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in Trauma Patients
Pablo E Serrano, MD, MPH, MSBS, Sadik A Khuder, PhD, MPH, John J Fath, MD, MPH, FACS, FCCM
Obesity, like multiple trauma, is associated with an inflammatory condition that leads to an
immunodeficient state. Obese trauma patients are thus thought to be at higher risk of infection
compared to patients of normal body mass. Despite this risk, studies to date have not defined
obesity as an independent risk factor for infection in trauma patients.
STUDY DESIGN: Retrospective data were collected on 1,024 patients admitted to a Level I trauma center
during a 12-month period. Obesity was defined as a body mass index (BMI) 30 kg/m2.
Outcomes analyzed included urinary tract infection, pneumonia, septicemia, and wound
infection and Clostridium difficile infection. Multiple logistic regression was used to evaluate the contribution of each BMI category to infection while adjusting for comorbidities,
age, gender, Injury Severity Score (ISS), hospital and ICU lengths of stay, and number of
ventilator days.
RESULTS:
Obesity prevalence was 30.6%. Obese patients had longer hospital length of stay, with
similar ISS, number of ventilator days, and ICU length of stay. The overall rate of infections
was 8.7%. Variables independently associated with increased risk of infections were BMI,
age, ISS, ICU length of stay, hospital length of stay, and multiple comorbidities. The risks
of infections according to each BMI category were: BMI 25 kg/m2, 4.2%, BMI 25 to 29
kg/m2, 9.5%, odds ratio (OR) 2.65 (CI 0.72 to 5.72); BMI 30 to 39 kg/m2, 12%, OR 4.69
(CI 2.18 to 10.08); and BMI 40 kg/m2, 20.3%, OR 5.91 (CI 2.18 to 16.01). Pulmonary
and wound infections were significantly more frequent in obese patients.
CONCLUSIONS: In this retrospective study, obesity was shown to be an independent risk factor for nosocomial
infection after trauma. Prospective studies would clarify the reasons associated with this increased risk of infections in obese trauma patients. (J Am Coll Surg 2010;211:6167. 2010
by the American College of Surgeons)
BACKGROUND:
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ISSN 1072-7515/10/$36.00
doi:10.1016/j.jamcollsurg.2010.03.002
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METHODS
Data on body mass index in kg/m2 body surface area (BMI)
were prospectively collected and retrospectively reviewed
using the trauma service registry at the University of Toledo
Medical Center. The Medical Center is an American College of Surgeons verified Level I Trauma Center. From
January 1, 2008 to December 31, 2008, 1,294 patients
were included in the study. This period was chosen in order
to obtain the minimum number of obese patients (n
275) required to obtain an 80% power in order to detect a
10% difference in the infection rate between the subjects
(obese patients) and the controls (nonobese individuals).
Patients less than 18 years of age and pregnant or postpartum patients were excluded because the BMI in these
populations is not reflective of their degree of obesity. Patients admitted to the hospital for short observation and
transferred or discharged in less than 24 hours were also
excluded from the study because the actual origin of the
infection could not be assessed. This study focused on the
nosocomial infection rates. Postdischarge evaluation was
RESULTS
Complete data were available for 1,024 patients. There
were 382 (37.3%) normal weight patients, 328 (32.01%)
overweight, 250 (24.44%) obese, and 64 (16%) morbidly
obese patients. There were 392 (38.3%) women and 632
(61.7%) men. There was no difference in the obesity rate
between men and women. Average age was 48.8 years, with
a range from 18 to 102 years. BMI ranged from 14.8 to
66.4 kg/m2, with an average of 27.97 kg/m2. The overall
infection rate for the population was 8.78%. A total of 104
nosocomial infections were identified in 90 patients, distributed as 55 pulmonary infections, 14 wound infections
or SSIs, 27 UTIs, 5 bloodstream infections, and 3 cases of
Clostridium difficile colitis.
Multivariate analyses showed that obese and morbidly
obese patients had a higher rate of nosocomial infections
compared with normal weight patients. Significant differences were found in pulmonary and wound infections (p
0.01) (Figs. 1, 2, and 3).
Obese patients had higher rate of multiple comorbidi-
BMI
CAD
CHF
DM
ICU
IL
ISS
OR
SSI
TNF
UTI
Serrano et al
63
n
COPD, %
Coronary disease, %
Chronic renal failure, %
Hypertension, %*
Asthma, %*
Heart failure, %*
Diabetes, %*
History of stroke, %*
Injury Severity Score
ICU length of stay, d
Ventilator, d
Hospital length of
stay, d*
Figure 3. Percentage of wound infections based on body mass
index (BMI).
382
6.8
14.1
2.1
23.3
6.3
3.9
6.5
3.9
6.35
4.85
4.1
328
5.8
12.5
3
29.9
5.2
5.2
11
5.2
7.52
5.38
4.26
250
3.2
15.2
1.6
38.8
7.6
3.6
17.2
2.8
6.66
5.67
6.31
64
9.4
21.9
3.1
48.4
18.8
14.1
29.7
10.9
6.70
5.40
3.20
3.71
3.75
3.99
5.75
ICU length of stay and ventilator days reported only for patients requiring
those services.
*p 0.05.
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Serrano et al
J Am Coll Surg
Odds ratio
Obesity*
Age*
Injury Severity Score*
ICU length of stay*
Hospital length of stay*
Gender
Ventilator days
Diabetes
Congestive heart failure
Coronary artery disease
COPD
Hypertension
Chronic renal failure
History of stroke
Comorbidities
combined*
4.69
1.02
1.12
1.15
1.19
1.25
0.99
1.39
3.62
2.32
3.25
2.12
2.82
3.11
2.1810.1
1.011.03
1.091.16
1.041.28
1.131.26
0.722.19
0.841.17
0.712.59
0.657.43
0.343.93
0.546.45
0.333.35
0.818.09
0.326.71
CI
p Value
0.03
0.0072
0.01
0.008
0.01
0.43
0.93
0.36
0.1
0.07
0.45
0.4
0.62
0.48
1.26
1.051.51
0.01
*p 0.05.
DISCUSSION
Obesity worldwide has reached epidemic proportions. In
the United States, which has one of the highest rates of
obesity among developed countries, the prevalence of obesity has increased among all ages, gender, racial, and ethnic
groups.1 From 1960 to 2004, the prevalence of overweight
individuals increased from 44.8% to 66% in US adults
older than 20 years of age. The prevalence of obesity during
this same time period doubled from 13.3% to 32.1%.2
Nosocomial infections are complications that severely
affect outcomes and that increase costs to all hospitalized
patients. They increase the hospital length of stay and place
a burden on hospital resources.29 Risk factors that increase
the likelihood of nosocomial infections should be identified and prevented (eg, central lines, urinary catheters, ventilator days).
Studies performed on severely injured trauma patients
(ISS 16) have suggested that obesity is associated with an
increased risk of mortality and morbidity (including infections) in the ICU.8,30 Despite these findings, obesity is not
recognized as a risk factor for infection in the general
trauma population, perhaps because until now, there has
been no study to evaluate this problem.
Newell and colleagues8 established a relationship between obesity and increased risk of UTIs and pneumonia.
Similarly, Dossett and associates9 found an association with
catheter and bloodstream infections in the critically ill
obese trauma patient. In the surgical patient, obesity is
associated with an increased risk of SSI.31-33 In this study,
obesity was associated with an overall increased risk of nosocomial infections. Infections that had a statistically signif-
tion correlates with the degree of obesity. Adipocytes secrete large amounts of proinflammatory (leptin, IL-6,
C-reactive protein, TNF-, IL-1)46 and anti-inflammatory
mediators (adiponectin),47 which eventually lead to an altered immune response with impaired numbers of natural
killer (NK), B and T cells, and neutrophils.48,49 This loss of
balance in the immune system and the impaired inflammatory immune response may also play a role in the increased
risk of infections in obese patients.47
The chronic inflammation found in states of obesity is
considered to be the basis for the multiple associated comorbidities of the obese patient, including DM, hypertension, CAD, and asthma.48-50 As previously indicated, this
study found that obese patients had higher rates of multiple
comorbidities.4,51 Individual comorbidities did not show
an increased risk of infections; however, when combined as
a single factor, there was a statistically significant increased
risk of nosocomial infections. Previous reports have not
shown individual comorbidities to be associated with an
increased risk of nosocomial infections. Hyperglycemia,
the presence of urinary or central line catheters, ICU and
hospital length of stay, and number of ventilator days have
been linked to nosocomial infections.52,53 The minimum
number of comorbidities associated with an increased risk
of infection was 4, particularly DM, CHF, COPD, and
CAD. Other comorbidities included in the model that
were not statistically significant were: asthma, chronic renal
failure, history of stroke, and hypertension.
There was no difference in the number of ventilator days
or the ICU length of stay among the 4 BMI categories.
Although when considering only 2 groups, obese and
nonobese individuals, there was a statistically significant
increase in the number of ventilator days and ICU length of
stay, consistent with the current literature on obesity and
critical care.12
In our series, obesity was associated with an increased
risk of infections after trauma, even after adjusting for
known risk factors of infection, suggesting that the chronic
inflammation found in obese trauma patients may have
clinical consequences. Because obesity is a factor that cannot be modified in trauma patients, research should focus
on the etiology of the association between obesity and
infection.
Limitations of the study are mostly related to the retrospective review of data, which limits the variables that can
be included in the model. For example, we were unable to
assess the effectiveness of glycemic control efforts because
that information is not included in the Trauma Registry.
Factors not included that may have had an impact on the
results include glycemic level, Abbreviated Injury Score,
degree of mobility, and psychological factors after trauma.
Serrano et al
65
Author Contributions
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50. Chinn S. Obesity and asthma: evidence for and against a causal
relation. J Asthma 2003;40:116.
51. Haslam DW, James WP. Obesity. Lancet 2005;366:11971209.
52. Doshi RK, Patel G, Mackay R, Wallach F. Healthcare-associated
infections: epidemiology, prevention, and therapy. Mt Sinai
J Med 2009;76:8494.
53. Bochicchio GV, Joshi M, Bochicchio KM, et al. Early hyperglycemic control is important in critically injured trauma patients.
J Trauma 2007;63:13531358; discussion 13581359.