By Stan Deresinski, MD, FACP, FIDSA
Clinical Professor of Medicine, Stanford University
SYNOPSIS: Infections in patients with cirrhosis are frequent and potentially lethal, with pneumonia associated with the highest risk for mortality.
SOURCES: Choudry N, Sasso R, Rockey DC. Infection in hospitalized cirrhosis patients: Changing epidemiology and clinical features. Am J Med Sci 2022;363:114-121.
Choudry and colleagues performed a retrospective observational cohort study examining infections in all adult inpatients with cirrhosis at the Medical University of South Carolina from 2011 through 2016. The cohort included 877 patients who had 1,208 admissions for infection, with 108 of these having more than one such admission. In addition, 180 individual admissions were associated with one or more infections.
The mean age of the patients was 56 ± 12 years, and 44% were women. Nonalcoholic steatohepatitis was the most common cause of cirrhosis, accounting for 39% of cases, followed by hepatitis C virus infection in 32% and alcoholic cirrhosis in 23%. The mean Model for End-Stage Liver Disease (MELD) score was 12 ± 1.
At the time of admission, only 5% had a temperature > 38.6°C, but 29% had clinical features of sepsis, 9% of the cohort had a mean arterial blood pressure < 60 mmHg, and 11% received vasopressors. Almost one-half of the cohort received intensive care.
The most frequent infection involved the urinary tract (33%), followed by pneumonia in 23%, spontaneous bacterial peritonitis in 14%, and bacteremia in 11%. Smaller proportions had cellulitis (6%), with endocarditis in 5% and biliary tract infection in 4%. Bacteremia was most often caused by staphylococci, with coagulase-negative staphylococci identified more than twice as frequently as Staphylococcus aureus. Escherichia coli and Candida spp. were recovered with approximately equal frequency from blood cultures. Gram-positive bacteria were recovered from ascitic fluid in patients with spontaneous bacterial peritonitis (SBP) more frequently than were gram-negative bacteria (15 vs. 8), while Candida was isolated from five patients.
The in-hospital mortality was 20%, but an additional 8% were discharged to hospice care, and the in-hospital mortality associated with readmissions was 30%. Independent risk factors for mortality based on multivariate analysis were pneumonia (odds ratio [OR], 4.2; 95% confidence interval [CI], 1.6 to 11.5), a pressor requirement (OR, 13.7; 95% CI, 5.6 to 33.3), and higher MELD score (OR, 2.2; 95% CI, 1.3 to 3.8).
COMMENTARY
Patients with cirrhosis are at great risk of infection and mortality. This results from multiple deficits, especially in the innate immune system, together with the frequent presence of ascites and factors such as portasystemic shunting.1 Ascites provides an effective culture medium for bacterial and yeast growth and may be seeded through the bloodstream or by intestinal translocation. Portasystemic shunting allows intestinal bacteria to bypass the protective reticuloendothelial system of the liver.
This large retrospective study confirms known factors about infections in cirrhosis while identifying an apparent shift in etiologic agents toward gram-positive organisms, a finding that others have noted recently.2 The authors speculated that this may be due, at least in part, to the use of antibiotic prophylaxis in many cirrhotic patients, but they appear to provide no data to confirm this. Also of note in this study was the finding that only 5% of patients had temperatures > 38.6°C on admission, a factor that could delay the suspicion of sepsis in initiation of empiric therapy.
Choudry et al found that pneumonia was the type of infection associated with the greatest risk of mortality. This also was found in a recent large study, although the overall mortality of spontaneous bacterial peritonitis and of Clostridioides difficile infections was close behind on univariate analyses.2 In the study reviewed here, this infection is not mentioned.
REFERENCES
- Van der Merwe S, Chokshi S, Bernsmeier C, Albillos A. The multifactorial mechanisms of bacterial infection in decompensated cirrhosis. J Hepatol 2021;75(Suppl 1):S82-S100.
- Atteberry P, Biederman B, Jesudian A, et al. Mortality, sepsis, and organ failure in hospitalized patients with cirrhosis vary by type of infection. J Gastroenterol Hepatol 2021;36:3363-3370.
