Author Response: Cause of Death in Spontaneous Intracerebral Hemorrhage Survivors: Multistate Longitudinal Study

We thank Dr. Llamas-Nieves et al. for their interest in our article1 and recognize that coexisting diabetes, among other comorbidities, may influence infection-related mortality in ICH survivors. We hypothesized that the high proportion of deaths caused by infections may be due to the burden of disability in this population. Intracerebral hemorrhage (ICH) survivors often require chronic hospitalization and are prone to infections such as Clostridium difficile , urinary tract infections, and aspiration pneumonia. Our finding that older age was an independent risk factor for death caused by infection supports this hypothesis. However, we agree that increased susceptibility to infection in patients with diabetes should be considered as a potential driver of infection-related deaths in patients with ICH.2 Diabetes was included as a covariate in the adjusted multinomial logistic regression model of causes of death during follow-up in our study (table 3). Diabetes was not associated with increased odds of death caused by infection (odds ratio 1.16, 95% confidence interval 0.86–1.55), although diabetes did correlate with increased risk for death overall (hazard ratio 1.22, 95% confidence interval 1.17–1.27). The cause of elevated mortality after ICH in patients with diabetes is not clear, and our results are not conclusive regarding the potential association with infection. As Dr. Llama-Nieves et al. point out, future studies of the specific causes of infection-related morbidity and mortality are warranted and necessary to improve long-term outcomes after ICH.