Diabetes Not a Risk Factor for Septic Shock Among Patients With Ureteral Stone and UTI
Key findings
- This retrospective study compared infectious outcomes in 49 patients with diabetes mellitus and 138 without who presented to the emergency department with ureteral stone and presumed urinary tract infection and underwent emergent ureteral stent placement
- The rate of admission to the ICU, the rate of prolonged vasopressor use, the duration of ICU stay, and the duration of hospital stay were the same for patients with and without diabetes
- Patients with diabetes were not at increased risk of septic shock compared with patients who did not have diabetes
- Yet there was a nearly three-fold greater risk for patients with diabetes to meet the criteria of the quick Sequential Organ Failure Assessment (qSOFA) (adjusted OR, 2.90; P=0.038 compared with patients who did not have diabetes)
- Clinicians should be aware qSOFA may demonstrate false-positive results in predicting septic shock among patients with ureteral stones and presumed concomitant infection
Poor glycemic control is associated with impaired immune function. Patients with diabetes mellitus (DM) may be at increased risk of septic shock when they develop an obstructing ureteral stone and urinary tract infection (UTI).
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Now, however, Jason Lee, MD, a clinical fellow in surgery in the Department of Urology at Massachusetts General Hospital, Brian H. Eisner, MD, co-director of the Kidney Stone Program in the Department, and colleagues have published evidence that DM is not associated with an increased risk of sepsis under those circumstances. In fact, they report in the Canadian Urological Association Journal that patients without DM experienced certain other complications of stone disease and concomitant UTI just as often as those with DM.
Methods
The team retrospectively studied 187 patients from two academic medical centers who presented to the emergency department with at least one unilateral obstructing stone between July 2016 and April 2020, had documented concern for concomitant infection, and were taken directly to the operating room for stent placement.
The median patient age was 61 (range, 16–93), and the cohort was 60% female. 43% of patients were 65 or older. 23% were admitted to the ICU. 49 (26%) had DM, including 16 (33%) who had hemoglobin A1c ≥7%.
The primary outcome of interest was the development of postoperative septic shock as defined by the quick Sequential Organ Failure Assessment (qSOFA), which requires at least two of the following criteria: respiratory rate >22, altered mental status, systolic blood pressure <100 mmHg, and need for a vasopressor to maintain mean arterial pressure >65 mmHg.
DM vs. Non-DM Cohorts
24 patients (12.8%) met the qSOFA criteria:
- 11 patients with DM (22.4%)
- 13 patients without DM (9.5%; P=0.026)
There were no differences between the DM and non-DM cohorts in the following:
- Use of vasopressors
- ICU admission rate
- Length of ICU stay
- Length of hospital stay
Multivariate regression demonstrated significantly greater odds of positive qSOFA score in patients with DM (adjusted OR, 2.90; P=0.038) but not ICU admission or septic shock.
Takeaway Message
The qSOFA was designed to evaluate the risk of sepsis in medicine, and few studies have applied it to urologic conditions. These results emphasize clinicians should use care in applying qSOFA when evaluating patients with ureteral stones and presumed concomitant UTI.
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