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 Table of Contents  
Year : 2017  |  Volume : 45  |  Issue : 2  |  Page : 68-72

Epidemiology of infection as a precipitating factor for diabetic ketoacidosis at Tanta University Hospital

1 Department of Internal Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt
2 Department of Public Health and Community Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt

Date of Submission07-Feb-2017
Date of Acceptance18-Jun-2017
Date of Web Publication13-Oct-2017

Correspondence Address:
Zeinab Shafeek Shafeek Hamed
Department of Internal Medicine, Faculty of Medicine Tanta University, Mitt Haway, Elsanta, Elgharbiya, 31746
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tmj.tmj_10_17

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Diabetic ketoacidosis (DKA) is one of the life-threatening sequels in diabetes mellitus. Nonadherence to treatment, infections, psychological troubles, and comorbid diseases were the main precipitating factors that trigger DKA.
Evaluate infection as a precipitating factor of DKA and its correction may contribute to improve outcome and decrease recurrence.
Patients and methods
This descriptive, cross-sectional study was conducted on 200 patients with DKA admitted to the Internal Medicine Department, Tanta University Hospital. All patients were subjected to history taking, clinical examination, routine investigations, glycosylated hemoglobin, and albumin–creatinine ratio.
Our study included 86 men and 114 women. Of these, 113 patients were of type 2 diabetes, 83 patients were of type 1 diabetes, two patients were of secondary diabetes, and two patients were having gestational diabetes. Infection was the main precipitating factor of DKA (46.5%). The most common source of infections was urinary tract infections and respiratory tract infections (31.2, 26.8%, respectively). Infection was the precipitating cause in 38.5% of type 1 diabetes and 53.9% of type 2 diabetes with P value was 0.033. DKA was the first presentation of diabetes in 18.5% of patients. Stress, dietary errors, pregnancy, and nonidentified causes were 19%.
Infection is the main precipitating factor of DKA in patients of Tanta University Hospital.

Keywords: diabetes mellitus, diabetic ketoacidosis, infection

How to cite this article:
Hamed ZS, Gawaly AM, Abbas KM, El Ahwal LM. Epidemiology of infection as a precipitating factor for diabetic ketoacidosis at Tanta University Hospital. Tanta Med J 2017;45:68-72

How to cite this URL:
Hamed ZS, Gawaly AM, Abbas KM, El Ahwal LM. Epidemiology of infection as a precipitating factor for diabetic ketoacidosis at Tanta University Hospital. Tanta Med J [serial online] 2017 [cited 2023 Nov 30];45:68-72. Available from: http://www.tdj.eg.net/text.asp?2017/45/2/68/216685

  Introduction Top

Diabetic ketoacidosis (DKA) is a metabolic derangement with three main presentations, hyperglycemia, ketosis, and acidosis, which occurs in the presence of low effective insulin. It is one of the common emergencies in patients with diabetes mellitus (DM) [1].

DKA affects more than 8 per 1000 diabetics annually. It is associated with significant morbidity and mortality, with a worldwide mortality rate of 2–10% [1]. DKA frequently occurs in type 1 diabetes as this type of diabetes is presented with an absolute lack of insulin production by the  Islets of Langerhans More Details. In type 2 diabetes, the production of insulin is insufficient to meet the body’s requirements due to insulin resistance leading to activation of lipid metabolism with production of acidic ketone bodies that cause most of the symptoms and complications [2].

Many cases of DKA are triggered by insulin cessation due to social, psychological, and economic reasons especially in developing countries. Infection, new onset of diabetes, and other comorbid states such as stroke, acute pancreatitis, and chronic renal failure are implicated in the development of DKA [3].

Appropriate management of the precipitating factors of DKA decreases the mortality rate and days of hospitalizations [4].

Patient education programs should be implemented especially during travel and sick days to prevent DKA. In addition, the relevant authorities should ensure that insulin is available to all patients [5].

  Patients and methods Top

This descriptive, cross-sectional study included 200 diabetic patients with DKA based on increased random blood glucose of more than 250 mg/dl, metabolic acidosis pH of less than 7.35 in arterial blood gases, and presence of ketone bodies on urine analysis. Patients were recruited from Tanta University Hospitals, Internal Medicine Department, ICU during the period from July 2014 to January 2015.

All participants provided informed written consent and the study was approved by Tanta Faculty of Medicine Ethical Committee.

All patients of the study were subjected to history taking with stress on age, sex, marital state, level of education, employment, duration of diabetes, type of therapy whether oral or insulin and co-morbidities. Besides, accurate history about diet control was taken.

History of manifestation of DKA that made them seek medical advice such as altered mental state, abdominal pain, vomiting, polyuria, polydipsia, and fever was taken. Accurate history about compliance to therapy was taken.

Full clinical examination and assessment of mental state and body temperature were done, searching for the source of infection such as chest infection, urinary tract infections, gastroenteritis, ENT infections, infected diabetic foot, and skin infections. ECG was done to exclude silent myocardial infarction.

Laboratory investigations

  1. To diagnose DKA, tests such as random blood glucose level, arterial blood gases, and urine dipstick test for ketone bodies were performed.
  2. Routine laboratory investigations were done including: complete blood count, renal function tests, electrolytes, c-reactive protein, lipid profile, and urine analysis and culture.
  3. Glycosylated hemoglobin.
  4. Albumin–creatinine ratio.

Radiological investigations: chest radiography and pelviabdominal ultrasound (for any hidden source of infection).

Statistical analysis

The data were analyzed with the SPSS version 20 software package (SPSS Inc., Chicago, Illinois, USA). Quantitative variables were presented as mean±SD and range. Qualitative variables were presented as number of frequency and percentage. Comparisons between two groups of qualitative variables were done by χ2-test. Independent t-test was used for comparison between two groups of quantitative variables. Analysis of variance test was used for comparison between more than two groups of quantitative variables. A P value of less than 0.05 was considered statistically significant [6].

  Results Top

The mean age of patients was 39.92±16.83. It included 86 (43%) men and 114 (57%) women. Of these, 61 (30%) patients were single, 131 (66%) patients were married, and eight (4%) patients were divorced; 124 (62%) patients were from the rural area and 76 (38%) patients from the urban area; 34 (17%) patients had higher education; 80 (40%) patients had secondary school; 17 (8%) patients can read and write; and 69 (35%) patients were illiterate. Totally, 134 (67%) patients were unemployed (including farmers, housewives, and hand workers); 33 (16.5%) patients were employed; and 33 (16.5%) were students as in [Table 1].
Table 1 Demographic data of the studied patients

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In this study, 33 (16.5%) patients were anemic (hemoglobin level <10 g/dl), 40 (20%) patient had hypercholesterolemia (cholesterol >200 mg/dl); 80 (40%) patients had hypertriglyceridemia (triglyceride >150 mg/dl); 46 (23%) patients had renal impairment (serum creatinine >1.3 and/or blood urea >40 mg/dl); 41 (20.5%) patients had microalbuminuria (albumin–creatinine ratio: 30–300 mg/mmol); 187 (93.5%) patients were suffering from uncontrolled diabetics (HbA1c >7%) as given in [Table 2].
Table 2 Laboratory investigations of the studied patients

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There were 56.5% of patients with type 2 diabetes, 41.5% with type 1 diabetes, 1% had secondary diabetes due to thalassemia major, and 1% of patients had gestational DM as shown in [Figure 1].
Figure 1 Pie chart of percentage of different types of diabetes mellitus in studied cases. DM, diabetes mellitus

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The most common presentation was gastrointestinal symptoms (abdominal pain and vomiting) in 94 (47%) patients; 60 (30%) patients presented with altered mental state; 27 (13%) patients presented with polyuria and polydipsia; and 20 (10%) patients presented with fever ([Figure 2]).
Figure 2 Clinical presentation of diabetic ketoacidosis in the studied patients

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The main precipitating factor was infections in 93 (46.5%) patients, nonadherence to therapy in 61 (30.5%) patients, first presentation of DM in 37 (18.5%) patients, and other causes in 38 (19%) patients such as stress, dietary factors, pregnancy, and not identified causes [Figure 3].
Figure 3 Precipitating factors of diabetic ketoacidosis in the studied patients. DM, diabetes mellitus

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The most common infection was urinary tract infection in 29 (31.2%) patients; respiratory tract infection was the precipitating factor in 25 (26.8%) patients; gastrointestinal tract infections in 13 (13.9%) patients; skin and subcutaneous tissue infections in four (4.3%) patients, diabetic foot in two (2.1%) patients; ENT infections in eight (8.6%) patients; and mixed infection in 12 (12.9%) patients as in [Figure 4].
Figure 4 Types of different infections precipitating diabetic ketoacidosis. GIT, gastrointestinal tract; RTI, respiratory tract infection; UTI, urinary tract infection

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Dietary factors were the precipitating factor in nine (4.5%) patients, stress in 13 (6.5%) patients, pregnancy in four (2%) patients, and not identified causes in 12 (6%) patients as in [Figure 5].
Figure 5 Other precipitating factors of diabetic ketoacidosis

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Infection was the main precipitating cause in 61 (53.9%) patients of type 2 diabetes and 32 (38.5%) patients of type 1 diabetes with statistically significant difference as in [Table 3].
Table 3 Infections as the precipitating factor of diabetic ketoacidosis in type 1 and 2 diabetes mellitus

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Infections were the precipitating factor in 67 (60.3%) patients treated by premixed insulin, 11 (32.4%) patients treated by basal bolus, and in 10 (55.5%) patients treated by oral treatment with statistically significant difference as in [Table 4].
Table 4 Infections as the precipitating factor of diabetic ketoacidosis at different types of therapy

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  Discussion Top

DKA is one of the common emergencies of DM [1]. There were few studies in Egypt on incidence, precipitating factors, and outcome of DKA, so we aimed to evaluate infection as an important precipitating factor of DKA in order to prevent it and improve the outcome.

In the present study, women were predominant (n=114) than men (n=86). Elmehdawi and Elmagerhei [7] found the predominance of women (n=71) than men (n=29). On the other hand, Qari [8] found that n=40 in men and n=28 in women. Urinary tract infection explains female predominance as it is the most common type of infection in women.

In this study, we found predominance of type 2 diabetes in patients with DKA episodes. Huiwen et al. [9] found more than 65% of patients with type 2 diabetes as most of the inpatients in our hospitals were adults and most of the type 1 diabetic onset develops in the pediatric period.

Abdominal pain and vomiting appeared to be the most common presenting symptoms in the present study which accounted for 47% of patients followed by altered mental state in 30% of patients. Polyuria, polydipsia, and fever were rare presentations.

Qari [10] found that gastrointestinal symptoms and altered mental state were the commonest presentations of DKA. Elmehdawi et al. [11] found polyuria, polydipsia, and weakness were the most common presentation (100% each), followed by vomiting (54.6%), abdominal pain (7.5%), headache and dizziness (4.5%), hematemesis (1.8%) and convulsion (1.7%); while 3.5% of patients were in coma at presentation. This may be due to negligence in seeking medical advice. Polydipsia and polyuria do not bring people to medical attention.

The present study suggests infection as a principal precipitating factor for DKA in 93 (46.5%) patients. The most common source of infections was urinary tract infections (31.2%) and respiratory tract infections (26.8%).

The study by Amol et al. [12] found that infection was the major precipitating factor in 40%. On the other hand, Bassyouni et al. [13] found that nonadherence to therapy in 45.5% and infection in 27.2%.

In the present study; 37 (18.5%) patients presented with DKA as initial presentation of diabetes. Gavrielatos et al. [14] found 18.2% of the patients had DKA as their first presentation.

Leonid et al. [15] found new onset DM only in 8.6% of all DKA cases and explained this by better identification of new onset DM and improved screening procedures in the last decade.

In this study, we found stress as a precipitating factor in 13 (6.5%) patients. Pregnancy was present in four (2%) patients and dietary errors in nine (4.5%) patients. Huiwen [9] reported pregnancy, trauma, tumors, steroid, and alcohol abuse to be other precipitating factors for DKA.

In the present study, 12 (6%) patients had no obvious precipitating factor. Amol [12] found similar results.

In the present study, infection was the main precipitating factor in type 2 diabetes (53.9%) patients, but in 38.5% of patients of type 1 diabetes (P=0.033). Systemic infections were also the major precipitating factors for DKA in type 2 diabetic patients in Husain et al. [16] study.

Infections were the precipitating factor in 60.3% of whom on premixed insulin, 55.5% of whom on oral treatment, 32.4% of whom on basal bolus with P value less than 0.001. This result supports the role of basal bolus insulin to be the best regimen of insulin in the control of blood glucose during periods of stress and illness.

  Conclusion Top

Infection is the main precipitating factor for DKA in this study, followed by urinary tract infections by nonadherence to therapy. Other causes were implicated in the development of DKA such as pregnancy, psychological troubles, dietary errors, and nonidentified causes.


The authorities should ensure availability of insulin to all patients. Education of patients as to how to manage their diabetes during stress or infection, that is ‘sick-day management’.


The authors acknowledge all participants for their help during the study, particularly Dr Yasser Mostafa Hafez, Lecturer of Internal Medicine, Tanta University for his precious effort and great support during this work.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Wolfsdorf J, Craig M, Daneman D, Dunger D, Edge J, Lee W. ISPAD Clinical Practice Consensus Guidelines 2009 Compendium: diabetic ketoacidosis in children and adolescents with diabetes. Pediatr Diabetes 2009; 10:118–133.  Back to cited text no. 1
Zargar A, Wani A, Masoodi S, Bashir M, Laway B, Gupta V et al. Causes of mortality in diabetes mellitus. Data from a tertiary teaching hospital in India. Postgrad Med J 2009; 85:227–232.  Back to cited text no. 2
Azevedo L, Choi H, Simmonds K, Davidow J, Bagshaw S. Incidence and long-term outcomes of critically ill adult patients with moderate-to-severe diabetic ketoacidosis. J Crit Care 2014; 29:971–977.  Back to cited text no. 3
Hara J, Rahbar A, Jeffres M, Izuora K. Impact of a hyperglycemic crises protocol. Endocr Pract 2013; 19:953–962.  Back to cited text no. 4
Zafar S, Khan H, Ahmed F. Precipitating factors for Diabetic Ketoacidosis. Med Channel 2004; 10:48–50.  Back to cited text no. 5
Bhattacharya Br, Habtzghi D. Median of the p value under the alternative hypothesis. Am Stat 2002; 56:202–206.  Back to cited text no. 6
Elmehdawi R, Elmagerhei H. Profile of diabetic ketoacidosis at a teaching hospital in Benghazi, Libyan Arab Jamahiriya. East Mediterr Health J 2010; 16:292–299.  Back to cited text no. 7
Qari F. Precipitating factors for diabetic ketoacidosis. Saudi Med J 2002; 23:173–176.  Back to cited text no. 8
Huiwen T, Yunxia Z, Yerong Y. Characteristics of diabetic ketoacidosis in Chinese adults and adolescents – teaching hospital-based analysis. Diabetes Res Clin Pract 2012; 97:306–312.  Back to cited text no. 9
Qari F. Clinical characteristics of patients with diabetic ketoacidosis at the Intensive Care Unit of a University Hospital. Pak J Med Sci 2015; 31:1463–1466.  Back to cited text no. 10
Elmehdawi R, Ehmida M, Elmagerhei H, Alaysh A. Incidence and mortality of diabetic ketoacidosis in Benghazi-Libya in 2007. Oman Med J 2013; 28:178–183.  Back to cited text no. 11
Amol H, Sheetal H, Krithika P, Bhola N. Profile of precipitating factors in Diabetic Ketoacidosis: data from a rural teaching hospital. J Prev Med Holistic Health 2015; 1:92–95.  Back to cited text no. 12
Bassyouni A, El Ebrashy I, El Hefnawy H. Epidemiology of diabetic ketoacidosis in National Institute of Diabetes and Endocrinology (NIDE). Endocr Abstracts 2012; 29:659.  Back to cited text no. 13
Gavrielatos G, Ioannidis I, Lionakis N, Avramidis D, Komitopoulos N, Varsamis E. Clinical and laboratory characteristics of diabetic ketoacidosis in adult diabetic patients. Internet J Endocrinol 2006; 3:1–7.  Back to cited text no. 14
Leonid B, Roman N, Elena R, Alan J, Miri Z, Lior Z. Diabetic ketoacidosis: clinical characteristics, precipitating factors and outcomes of care. Isr Med Assoc J 2012; 14:299–303.  Back to cited text no. 15
Husain S, Javed M, Ali S. Diabetic ketoacidosis: the precipitating entities in patients with type 2 diabetes mellitus. Professional Med J 2011; 18:80–82.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2], [Table 3], [Table 4]

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