Diabetes and infections: towards an optimal treatment strategy in primary care

Context. Almost 90% of the people with diabetes have DM2 and most of them are treated in primary care. Current evidence of the association between diabetes and infections is not clear. A complicated course of infections may influence the diabetes-related burden of people with DM2. However, since there is a lack of data on prognostic factors for complications from infections of the urinary (UTI) and lower respiratory tract (LRTI), related health care cannot be tailored to the individual needs of patients with diabetes. Research questions. 1. What is the risk of common infections among patients with DM1 and DM2 and which prognostic factors are associated with a complicated course? 2. What knowledge, health beliefs and intentions do patients with type 2 diabetes have concerning the management of common infections? 3. What is the effect of an educational program on health seeking behavior in case of LRTI and UTI in patients with type 2 diabetes? Methods. Q1. In a prospective cohort study we compared patients with diabetes with patients who had hypertension. Furthermore, we developed prediction rules for complicated UTI and LRTI in patients with diabetes. Q2. We conducted focus group interviews with DM2 patients. Additional quantitative information was obtained by a questionnaire study. Q3. We developed a health educational program on common infections for DM2 patients, based on the results of the focus group interviews and questionnaires. We assessed its short-term effects on health seeking behavior in 1124 patients with DM2 in 101 general practices in a randomized controlled trial. Results. Patients with diabetes had a higher risk of LRTI (adj. OR for DM1 1.42 and for DM2 1.32) and UTI (1.96 and 1.24). Risks increased with recurrences of common infections. Upper RTI were equally common in patients with diabetes compared with controls. Predictors for complicated UTI in DM2 patients were increasing age, male gender, number of physician contacts, urinary incontinence, cerebrovascular disease, dementia and renal disease. Predictors for complicated LRTI in diabetes were type of LRTI diagnosis, age, heart failure, hospitalization in previous year, use of antibiotics in previous month, use of prednisone. The majority of the DM2 patients lacked knowledge and proper health beliefs about UTI and LRTI. After the educational program, compared to controls, knowledge about symptoms of UTI and LRTI in participants of the intervention group increased (increase 11% versus 0% and 31% versus 4%). Moreover bronchitis and cystitis were perceived by more patients as dangerous (increase 21% versus 5% and 22% versus 4%, respectively). Diaries showed that, compared to controls, there was a trend of intervention group patients visiting their GP more often in cases of symptoms about which they had been advised during the educational meetings. Conclusion. Diabetes increases the risk of (recurrence of) common infections, except for those of the upper respiratory tract. Education of patients with DM2 and diabetes care providers about infections is necessary. Our educational program positively influenced determinants of health seeking behavior in cases of symptoms of infections. Making education about infections an integrated part of regular diabetes check-ups, little effort might have large effects. Whether or not the physician should treat with wide spectrum antibiotics or for a longer period of time should be established in further studies