Poor glycemic control may not be associated with increased outpatient antibiotic prescription rates

1. HbA1C levels were not associated with the number of antibiotic prescriptions in type 2 diabetic  patients followed at primary care sites

Evidence Rating Level: 3 (Average)

Study Rundown: Diabetes is one of the most common medical conditions worldwide and affected 537 million people worldwide in 2021. Management of diabetes focuses on glycemic control through lifestyle interventions (diet and physical activity), oral antidiabetic treatments, insulin use, and the screening/management of microvascular and macrovascular complications. Recent meta-analyses suggest strict glycemic control does not effect the clinically relevant variables of micro- and macrovascular complications. Namely, myocardial infarction, stroke, amputation, renal failure, blindness, and neuropathic pain. The strict glycemic regiments can cause adverse effects such as hypoglycemia which carries its own complications. Therefore, there has been a discussion about “non-gluco-centric” management of type 2 diabetes mellitus (T2DM). Another complication in T2DM is the increased risk of infection, particularly lower respiratory, urinary tract, and skin/mucous membrane. There has yet to be consensus on the preventative role of long-term glycemic control on infectious risk. This retrospective observational multicenter cohort study aimed to evaluate the effect of glycemic control in T2DM with bacterial infectious risk.  No connection was found between the HbA1c levels and antibiotic prescription, suggesting diabetic control and infection risk are not linked in T2DM patients followed at primary care centers. They found COPD/asthma history and previous antibiotic prescriptions were associated with antibiotic prescription. A key limitation of the study is the lack of inclusion of patients followed as medical inpatients which could highlight the association of HbA1c and infectious risk in the most poorly controlled T2DM patients. Nonetheless, study findings do not appear to suggest that at least in an outpatient setting, that glycemic control is related to infection risk as measured by antibiotics prescription rates. 

Click to read the study in PLOS

Relevant Reading: Pharmacologic Approaches to Glycemic Treatment 

In-Depth [retrospective observational multicenter cohort study]: Diabetes is one of the most common medical conditions worldwide and affected 537 million people worldwide in 2021. Management of diabetes focuses on glycemic control through lifestyle interventions (diet and physical activity), oral antidiabetic treatments, insulin use, and the screening/management of microvascular and macrovascular complications. Recent meta-analyses suggest strict glycemic control does not effect the clinically relevant variables of micro- and macrovascular complications. Namely, myocardial infarction, stroke, amputation, renal failure, blindness, and neuropathic pain. The strict glycemic regiments can cause adverse effects such as hypoglycemia which carries its own complications. Therefore, there has been a discussion about “non-gluco-centric” management of type 2 diabetes mellitus (T2DM). Another complication in T2DM is the increased risk of infection, particularly lower respiratory, urinary tract, and skin/mucous membrane. There has yet to be consensus on the preventative role of long-term glycemic control on infectious risk. This retrospective observational multicenter cohort study aimed to evaluate the effect of glycemic control in T2DM with bacterial infectious risk. 

Primary care data extracted from the electronic medical records of 1959 patients with T2DM and at least 3 visits were included. Glycemic control was determined by HbA1c values. HbA1c levels were compared to mean antibiotic prescriptions per year. 90.71% of patients with T2Dm were on antidiabetic treatments (65.03% of patients (n = 1274) and insulin treatment in 25.68% (n = 503)). The mean HbA1c was 6.92%. 64% of patients received antibiotic treatments. The most common classes penicillins (51.57%), macrolides (12.46%), streptogramins (9.16%), quinolones (8.73%), and cephalosporins (5%). HbA1c levels were not associated with antibiotic prescriptions but in a multivariate analysis, COPD/asthma was (coefficient 0.60 95% CI [0.383, 0.813] p < 0.001). Cardiac history, the number of antidiabetics, malignancy history, and BMI were statistically independent of antibiotic prescriptions. The number and tupe of antidiabetic treatment also had no impact on antibiotic prescription. Therefore, there was an absence in association between HbA1c levels and antibiotic prescription suggesting diabetic control and infection risk are not linked in T2DM patients followed at primary care centers. Multivariate analysis showed factors that do increase infectious risk are COPD/asthma history and previous antibiotic prescriptions. To bolster this study, patients treated in as hospital inpatients should have been included as they represent patients with more serious infections and potentially more poorly controlled T2DM. 

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