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In the Clinic |


Adam Gilden Tsai, MD, MSCE; and Thomas A. Wadden, PhD
Ann Intern Med. 2013;159(5):ITC3-1. doi:10.7326/0003-4819-159-5-201309030-01003
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An estimated 36% of adults and 17% of children and adolescents in the United States are obese. Obesity is a serious health problem that has physical and psychosocial consequences. It increases health care costs to employers and reduces productivity. Rates of obesity in the United States and throughout the world have increased dramatically over the past 40 years and continue to rise in many countries.

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Obesity and Serious Infections
Posted on September 18, 2013
Dimitrios Farmakiotis, MD
Baylor College of Medicine
Conflict of Interest: None Declared
In their recent review, Tsai and Wadden include increased susceptibility to influenza as well as skin and soft tissue infections in their comprehensive list of obesity-associated health consequences (1). I would like to highlight some additional issues of potential clinical significance, regarding the well-described but often under-recognized association between obesity and infection (2).
In several studies, obesity has been identified as a significant risk factor for higher incidence of and worse outcomes from surgical wound, respiratory, periodontal, and urinary tract infections (2-4). Those associations are definitely influenced by comorbid conditions and management pitfalls that are more frequently encountered in the obese, such as mobility problems and imaging difficulties. However, there is also substantial evidence linking excess adiposity with immune system dysfunction, specifically phagocytosis, cytokine production, as well as T-cell number and activation (2). Thus, prompt initiation of appropriate antibacterials when there is clinical suspicion for infection is paramount in this patient population, in order to prevent hospitalization and unfavorable outcomes.
Nevertheless, the findings from a recent report suggest that obesity is also independently associated with higher risk for Clostridium difficile infection (5). The exact underlying mechanisms remain to be investigated, but adiposity-related changes in the intestinal microbiome might be one of the most important contributors to this association (2, 5). Therefore, administration of broad-spectrum antibiotics and duration of therapy should be judicious, as obese patients might be at increased risk for C. diffcile colitis.
Tsai and Wadden (1) mention the association between increased body weight and severity of influenza, as well. In a Canadian cohort study over twelve influenza seasons, severe obesity was an independent risk factor for respiratory hospitalizations (3). Even in the absence of comorbidities, patients with a BMI >35 kg/m2 should be approached as a high-risk group, with emphasis on yearly immunization. Furthermore, empiric administration of oseltamivir should be strongly considered for obese patients, as early as possible in the course of respiratory tract infections, during influenza season (3, 4).
In conclusion, primary care providers should be aware of and consider counseling their patients about the increased risk for serious infections being an important health problem associated with obesity. Such information could serve as an additional motive for weight loss.


1. Tsai AG, Walden TA. Obesity. Ann Intern Med. 2013;159:ITC3-1.
2. Falagas ME, Kompoti M. Obesity and infection. Lancet Infect Dis. 2006;6:438-46.
3. Kwong JC, Kampitelli MA, Rosella LC. Obesity and respiratory hospitalizations during influenza seasons in Ontario, Canada: A cohort study. Clin Infect Dis 2011;53:413-421.
4. Almond MH, Edwards MR, Barclay WS, Johnston SL. Obesity and susceptibility to severe outcomes following respiratory viral infection. Thorax. 2013;68:684-6.
5. Bishara J, Farah R, Mograbi J, Khalaila W, Abu-Elheja O, Mahamid M, Nseir W. Obesity as a risk factor for Clostridium difficile infection. Clin Infect Dis 2013;57:489-93.
Author's Response
Posted on October 17, 2013
Adam Gilden Tsai, MD, MSCE, FACP, Thomas A. Wadden, PhD
University of Colorado, University of Pennsylvania
Conflict of Interest: None Declared
Dr. Farmakiotis’ thoughtful letter remind us about other infectious consequences of obesity, particularly moderate to severe obesity (BMI ≥ 35 kg/m2), that should concern internal medicine physicians. As with other body systems, both physical factors (immobility) as well as biochemical factors (impaired immune system function) increase the risk of these complications. We thank Dr. Farmakiotis for reminding Annals readers of these additional risks faced by patients with obesity.

Adam Gilden Tsai, MD, MSCE, FACP
University of Colorado School of Medicine

Thomas A. Wadden, PhD
Perelman School of Medicine, University of Pennsylvania
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