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2018, Number 6

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Ann Hepatol 2018; 17 (6)

Infection and Predictors of Outcome of Cirrhotic Patients after Emergency Care Hospital Admission

Safi W, Elnegouly M, Schellnegger R, Umgelter K, Geisler F, Reindl W, Saugel B, Hapfelmeier A, Umgelter A

Language: English
References: 47
Page: 948-958
PDF size: 269.45 Kb.


ABSTRACT

Introduction and aims. We aimed to explore the impact of infection diagnosed upon admission and of other clinical baseline parameters on mortality of cirrhotic patients with emergency admissions. Material and methods. We performed a prospective observational monocentric study in a tertiary care center. The association of clinical parameters and established scoring systems with short-term mortality up to 90 days was assessed by univariate and multivariable Cox regression analysis. Akaike’s Information Criterion (AIC) was used for automated variable selection. Statistical interaction effects with infection were also taken into account. Results. 218 patients were included. 71.2% were male, mean age was 61.1 ± 10.5 years. Mean MELD score was 16.2 ± 6.5, CLIF-consortium Acute on Chronic Liver Failure-score was 34 ± 11. At 28, 90 and 365 days, 9.6%, 26.0% and 40.6% of patients had died, respectively. In multivariable analysis, respiratory organ failure [Hazard Ratio (HR) = 0.15], albumin substitution (HR = 2.48), non-HCC-malignancy (HR = 4.93), CLIF-C-ACLF (HR = 1.10), HCC (HR = 3.70) and first episode of ascites (HR = 0.11) were significantly associated with 90-day mortality. Patients with infection had a significantly higher 90-day mortality (36.3 vs. 20.1%, p = 0.007). Cultures were positive in 32 patients with resistance to cephalosporins or quinolones in 10, to ampicillin/sulbactam in 14 and carbapenems in 6 patients. Conclusion. Infection is common in cirrhotic ED admissions and increases mortality. The proportion of resistant microorganisms is high. The predictive capacity of established scoring systems in this setting was low to moderate.


REFERENCES

  1. Jalan R, Fernández J, Wiest R, Schnabl B, Moreau R, Angeli P, Stadlbauer V, et al. Bacterial infections in cirrhosis: a position statement based on the EASL Special Conference 2013. J Hepatol 2014; 60: 1310-24.

  2. Gustot T, Durand F, Lebrec D, Vincent J-L, Moreau R. Severe sepsis in cirrhosis. Hepatology 2009; 50: 2022-33.

  3. Wiest R, Lawson M, Geuking M. Pathological bacterial translocation in liver cirrhosis. J Hepatol 2014; 60: 197-209.

  4. Singal AK, Salameh H, Kamath PS. Prevalence and in-hospital mortality trends of infections among patients with cirrhosis: a nationwide study of hospitalised patients in the United States. Aliment Pharmacol Ther 2014; 40: 105-12.

  5. Cholongitas E, Betrosian A, Senzolo M, Shaw S, Patch D, Manousou P, O’Beirne J, et al. Prognostic models in cirrhotics admitted to intensive care units better predict outcome when assessed at 48 h after admission. J Gastroenterol Hepatol 2008; 23: 1223-7.

  6. Wehler M, Kokoska J, Reulbach U, Hahn EG, Strauss R. Short-term prognosis in critically ill patients with cirrhosis assessed by prognostic scoring systems. Hepatology 2001; 34: 255-61.

  7. Cholongitas E, Senzolo M, Patch D, Kwong K, Nikolopoulou V, Leandro G, Shaw S, et al. Risk factors, sequential organ failure assessment and model for end-stage liver disease scores for predicting short term mortality in cirrhotic patients admitted to intensive care unit. Aliment Pharmacol Ther 2006; 23: 883-93.

  8. Jalan R, Saliba F, Pavesi M, Amorós À, Moreau R, Ginès P, Levesque E, et al. Development and validation of a prognostic score to predict mortality in patients with acute-on-chronic liver failure. J Hepatol 2014; 61: 1038-47.

  9. Bernardi M, Moreau R, Angeli P, Schnabl B, Arroyo V. Mechanisms of Decompensation and Organ Failure in Cirrhosis: From Peripheral arterial Vasodilation to Systemic Inflammation Hypothesis. J Hepatol 2015.

  10. Clària J, Stauber RE, Coenraad MJ, Moreau R, Jalan R, Pavesi M, Amorós À, et al. Systemic inflammation in decompensated cirrhosis: Characterization and role in acute-on-chronic liver failure. Hepatology (Baltimore, Md) 2016; 64: 1249-64.

  11. Fischer J, Silva TE, Soares E, Silva PE, Colombo BS, Silva MC, Wildner LM, et al. From stable disease to acute-onchronic liver failure: Circulating cytokines are related to prognosis in different stages of cirrhosis. Cytokine 2017; 91: 162-9.

  12. Nahon P, Lescat M, Layese R, Bourcier V, Talmat N, Allam S, Marcellin P, et al. Bacterial infection in compensated viral cirrhosis impairs 5-year survival (ANRS CO12 CirVir prospective cohort). Gut 2017; 66: 330-41.

  13. Vincent J-L, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, Reinhart CK, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 1996; p. 707-10.

  14. Moreau R, Jalan R, Gines P, Pavesi M, Angeli P, Cordoba J, Durand F, et al. Acute-on-Chronic Liver Failure Is a Distinct Syndrome That Develops in Patients With Acute Decompensation of Cirrhosis. Gastroenterology 2013; 144: 1426- 37.e9.

  15. Stekhoven DJ: missForest. Nonparametric Missing Value Imputation using Random Forest. R package version 1.4. 2013.

  16. Peduzzi P, Concato J, Feinstein AR, Holford TR. Importance of events per independent variable in proportional hazards regression analysis. II. Accuracy and precision of regression estimates. J Clin Epidemiol 1995; 48: 1503-10.

  17. ACCP/SCCM: American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 1992; p. 864-74.

  18. Fernandez J NM, Gomez J, Colmenero J, Vila J, Arroyo V, Rodes J. Bacterial infections in cirrhosis: epidemiological changes with invasive procedures and norfloxacin prophylaxis. Hepatology 2002; 35: 140-8.

  19. Fernández J, Acevedo J, Castro M, Garcia O, de Lope CR, Roca D, Pavesi M, et al. Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study. Hepatology 2012; 55: 1551-61.

  20. Arvaniti V, D’Amico G, Fede G, Manousou P, Tsochatzis E, Pleguezuelo M, Burroughs AK. Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis. Gastroenterology 2010; 139: 1246-56, 56.e1-5.

  21. Sauneuf B, Champigneulle B, Soummer A, Mongardon N, Charpentier J, Cariou A, Chiche J-D, et al. Increased survival of cirrhotic patients with septic shock. Crit Care 2013; 17: R78.

  22. Gustot T, Felleiter P, Pickkers P, Sakr Y, Rello J, Velissaris D, Pierrakos C, et al. Impact of infection on the prognosis of critically ill cirrhotic patients: results from a large worldwide study. Liver Int 2014; 34: 1496-503.

  23. Cazzaniga M, Dionigi E, Gobbo G, Fioretti A, Monti V, Salerno F. The systemic inflammatory response syndrome in cirrhotic patients: relationship with their in-hospital outcome. J Hepatol 2009; 51: 475-82.

  24. Thabut D, Massard J, Gangloff A, Carbonell N, Francoz C, Nguyen-Khac E, Duhamel C, et al. Model for end-stage liver disease score and systemic inflammatory response are major prognostic factors in patients with cirrhosis and acute functional renal failure. Hepatology (Baltimore Md) 2007; 46: 1872-82.

  25. Sort P, Navasa M, Arroyo V, Aldeguer X, Planas R, Ruiz-del- Arbol L, Castells L, et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med 1999; 341: 403-9.

  26. Guevara M, Terra C, Nazar A, Solà E, Fernández J, Pavesi M, Arroyo V, et al. Albumin for bacterial infections other than spontaneous bacterial peritonitis in cirrhosis. A randomized, controlled study. J Hepatol 2012; 57: 759-65.

  27. Afinogenova Y, Tapper EB. The efficacy and safety profile of albumin administration for patients with cirrhosis at high risk of hepatorenal syndrome is dose dependent. Gastroenterol Rep (Oxf) 2015; 3: 216-21.

  28. Ortega R, Gines P, Uriz J, Cardenas A, Calahorra B, De Las Heras D, Guevara M, et al. Terlipressin therapy with and without albumin for patients with hepatorenal syndrome: results of a prospective, nonrandomized study. Hepatology 2002; 36: 941-8.

  29. Bernardi M, Caraceni P, Navickis RJ, Wilkes MM. Albumin infusion in patients undergoing large-volume paracentesis: a meta-analysis of randomized trials. Hepatology 2012; 55: 1172-81.

  30. Singh N WM, Gayowski T. Changing epidemiology and predictors of mortality in patients with spontaneous bacterial peritonitis at a liver transplant unit. Clin Microbiol Infect 2003; 9: 531-7.

  31. Heo J, Seo YS, Yim HJ, Hahn T, Park SH, Ahn SH, Park JY, et al. Clinical features and prognosis of spontaneous bacterial peritonitis in korean patients with liver cirrhosis: a multicenter retrospective study. Gut Liver 2009; 3: 197-204.

  32. Umgelter A, Reindl W, Miedaner M, Schmid RM, Huber W. Failure of current antibiotic first-line regimens and mortality in hospitalized patients with spontaneous bacterial peritonitis. Infection 2009; 37: 2-8.

  33. Merli M, Lucidi C, Giannelli V, Giusto M, Riggio O, Falcone M, Ridola L, et al. Cirrhotic patients are at risk for health careassociated bacterial infections. Clin Gastroenterol Hepatol 2010; 8: 979-85.

  34. Yakar T, Güçlü M, Serin E, Aliskan H, Husamettin E. A recent evaluation of empirical cephalosporin treatment and antibiotic resistance of changing bacterial profiles in spontaneous bacterial peritonitis. Dig Dis Sci 2010; 55: 1149-54.

  35. Piroth L, Pechinot A, Di Martino V, Hansmann Y, Putot A, Patry I, Hadou T, et al. Evolving epidemiology and antimicrobial resistance in spontaneous bacterial peritonitis: a two-year observational study. BMC Infect Dis 2014; 14: 287.

  36. Tandon P, Delisle A, Topal JE, Garcia-Tsao G. High prevalence of antibiotic-resistant bacterial infections among patients with cirrhosis at a US liver center. Clin Gastroenterol Hepatol 2012; 10: 1291-8.

  37. Ye C, Kumar D, Carbonneau M, Keough A, Ma M, Tandon P. Asymptomatic bacteriuria is an independent predictor of urinary tract infections in an ambulatory cirrhotic population: a prospective evaluation. Liv Int 2014; 34: e39-e44.

  38. Reuken PA, Stallmach A, Bruns T. Mortality after urinary tract infections in patients with advanced cirrhosis - Relevance of acute kidney injury and comorbidities. Liv Int 2013; 33: 220-30.

  39. Han D, Wang R, Yu Y, Yang S-S, Mueller S, Romeiro FG, Song T, et al. Impact of elevated urine leukocyte and bacteria count per high-power field on the in-hospital outcome of patients with liver cirrhosis. J Public Health and Emergency 2017; 1: 73.

  40. Borzio M, Salerno F, Piantoni L, Cazzaniga M, Angeli P, Bissoli F, Boccia S, et al. Bacterial infection in patients with advanced cirrhosis: a multicentre prospective study. Digestive and Liver Disease 2001; 33: 41-8.

  41. Gerbes AL, Gülberg V, Sauerbruch T, Wiest R, Appenrodt B, Bahr MJ, Dollinger MM, et al. German S 3-guideline “ascites, spontaneous bacterial peritonitis, hepatorenal syndrome”. Z Gastroenterol 2011; 49: 749-79.

  42. Sersté T, Melot C, Francoz C, Durand F, Rautou P-E, Valla D, Moreau R, et al. Deleterious effects of beta-blockers on survival in patients with cirrhosis and refractory ascites. Hepatology 2010; 52: 1017-22.

  43. Mandorfer M, Bota S, Schwabl P, Bucsics T, Pfisterer N, Kruzik M, Hagmann M, et al. Nonselective β blockers increase risk for hepatorenal syndrome and death in patients with cirrhosis and spontaneous bacterial peritonitis. Gastroenterology 2014; 146: 1680-90.e1.

  44. Bang UC, Benfield T, Hyldstrup L, Jensen J-EB, Bendtsen F. Effect of propranolol on survival in patients with decompensated cirrhosis: A nationwide study based Danish patient registers. Liver Int 2016: n/a-n/a.

  45. Theocharidou E, Pieri G, Mohammad AO, Cheung M, Cholongitas E, Agarwal B, Banwari A, et al. The Royal Free Hospital score: a calibrated prognostic model for patients with cirrhosis admitted to intensive care unit. Comparison with current models and CLIF-SOFA score. Am J Gastroenterol 2014; 109: 554-62.

  46. Pan H-C, Jenq C-C, Tsai M-H, Fan P-C, Chang C-H, Chang MY, Tian Y-C, et al. Scoring systems for 6-month mortality in critically ill cirrhotic patients: a prospective analysis of chronic liver failure - sequential organ failure assessment score (CLIF-SOFA). Aliment Pharmacol Ther 2014; 40: 1056-65.

  47. Silva PESE, Fayad L, Lazzarotto C, Ronsoni MF, Bazzo ML, Colombo BS, Dantas-Correa EB, et al. Single-centre validation of the EASL-CLIF consortium definition of acute-onchronic liver failure and CLIF-SOFA for prediction of mortality in cirrhosis. Liver Int 2015; 35: 1516-23.




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