Postoperative infections less frequent with insulin pump therapy for adults with diabetes
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Adults with diabetes who undergo surgery may be less likely to develop an infection and spend less time in the hospital after an operation if they are treated with continuous subcutaneous insulin infusion instead of insulin injection therapy, according to findings published in the Journal of Diabetes.
“Continuous subcutaneous insulin infusion has better control of glucose, lower risk of postoperative infection and shorter hospital stay, which suggests that continuous subcutaneous insulin infusion therapy might improve postoperative life quality of patients and their postoperative prognosis,” Xuefeng Yu, MD, PhD, of the division of endocrinology in the department of internal medicine at Tongji Hospital, Tongji Medical College and Huazhong University of Science and Technology in China, and colleagues wrote. “Continuous subcutaneous insulin infusion is, therefore, a good choice for perioperative patients, especially when blood glucose is severely elevated and difficult to control.”
Using medical records from January 2006 to March 2016 at Tongji Hospital, Yu and colleagues evaluated fasting and mean glucose levels across 8 days, with surgery performed on the third day, in 253 adults with diabetes who were treated with continuous subcutaneous insulin infusion (CSII; mean age, 58.7 years; 49.8% women) and 253 propensity-matched adults who were treated with insulin injection therapy (mean age, 58.49 years; 45.5% women). The researchers also assessed how often participants had fevers, whether they took antibiotics, their positive rates of bacterial cultures and how long they were in the hospital.
Average fasting glucose was 7.67 mmol/L among those on CSII and 8.34 mmol/L among those on insulin injection therapy (P < .001). Mean glucose was 9.22 mmol/L among those on CSII and 10.22 mmol/L among those on injections (P < .001).
Effect on infection factors
On the day of surgery, fevers occurred among 10.2% of those on CSII and 18.6% of those on injections (P = .014). On the day after surgery, fevers occurred among 34.7% of the CSII group and 55.1% of the injection group (P < .001).
The positive rate of secretion culture was 1.2% among those on CSII and 7.5% among those on injections (P = .001).
The CSII group required antibiotics for an average of 10.23 days total and 8.72 days after surgery vs. 12.46 days total (P = .002) and 10.34 days after surgery (P < .001) for the injection group.
It took 11 days on average before health care providers could take out the suture for the CSII group and 13.64 days for the injection group (P = .01).
“These results suggest that CSII therapy reduces the risk of postoperative infection,” the researchers wrote. “Furthermore, patients in the CSII group also needed fewer days until suture removal, which indicates that CSII therapy could shorten the time needed for surgical site healing and improve the prognosis of patients.”
Time, costs
Participants on CSII spent an average of 19.05 days in the hospital, including 10.7 days after surgery, whereas participants on insulin injection therapy spent an average of 21.83 days in the hospital, including 12.71 days after surgery (P < .001 for both). The researchers noted that those on CSII and those on insulin injection therapy spent similar amounts on medical expenses.
“Although the cost of CSII therapy was higher than other insulin treatments, we did not observe a significant difference in the total hospital expenditure between the CSII group and non-CSII group,” the researchers wrote. “A probable explanation is that CSII therapy reduced other medical costs via improved postoperative outcomes and shortened hospital stay.” – by Phil Neuffer
Disclosures: The authors report no relevant financial disclosures.
Perspective
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David Klonoff, MD
This study reported that during a surgical hospitalization, continuous subcutaneous insulin infusion (CSII), compared with other insulin regimens (non-CSII) reduces the risk of postoperative infection. The investigators conducted a retrospective propensity-matching real-world evidence study. They matched the two groups for risk factors affecting surgical outcomes. They did not attempt to match for type 1 diabetes compared with type 2 diabetes.
Preoperative HbA1c concentrations and various elements of perioperative care, which can be linked to better perioperative outcomes, were not reported. Furthermore, both patients with type 1 diabetes and type 2 diabetes were studied. CSII is used almost exclusively in type 1 diabetes. Thus, the study essentially compared outcomes for CSII in patients with type 1 diabetes against outcomes of a combined population of non-CSII-treated patients with type 1 diabetes and type 2 diabetes. Type 2 diabetes, present only in the non-CSII group, should have been excluded.
This study cannot be used to conclude that CSII is preferable to non-CSII insulin therapy for preoperative diabetes treatment to decrease the rate of postsurgical complications. Were better outcomes in the CSII group due to an inherent capability of this technology compared with other non-CSII insulin treatment regimens to deliver better control? An alternate explanation for this study’s outcomes could be that the two groups were not adequately matched and the CSII patients might have been at lower risk for infections irrespective of their method of insulin administration. In retrospective real-world evidence studies, it is difficult to control for all the greatest risks, such as perioperative care, especially after the patients have been matched.
This study suggests a hypothesis that surgical patients with diabetes on CSII, compared with other insulin regimens, prior to admission have fewer perioperative infections. This hypothesis can be appropriately tested with a prospective randomized trial in patients with type 1 diabetes controlled for similar risk factors for perioperative infections and similar perioperative treatments.
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