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Suárez M, Martínez R, Gómez-Molina R, Mateo J. Infection risk and management in patients with cirrhosis: A critical overview. World J Hepatol 2025; 17:104468. [DOI: 10.4254/wjh.v17.i5.104468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2024] [Revised: 02/27/2025] [Accepted: 03/13/2025] [Indexed: 05/27/2025] Open
Abstract
In this paper, we analyze the article published by El Labban et al, which explores the impact of cirrhosis on patients with necrotizing fasciitis. The authors conclude that cirrhosis is a significant risk factor for increased in-hospital morbidity and mortality in this patient population. Building upon their final observation regarding the importance of understanding this association, we will delve into the topic of infections in patients with liver cirrhosis. These patients exhibit intrinsic characteristics that make them particularly susceptible to infections, both bacterial and fungal. This heightened risk not only increases the likelihood of severe infections but also makes them a common trigger for acute decompensations, including the development of acute-on-chronic liver failure, which markedly worsens prognosis and mortality. Infections in patients with cirrhosis often require a more aggressive and rapid diagnostic and therapeutic approach due to the higher risk of nosocomial infections, multidrug-resistant organisms, and atypical clinical presentations. Delayed or inadequate management can lead to unfavorable outcomes, further complicating the course of their underlying liver disease. The aim of this article is to emphasize the importance of early and appropriate management in patients with cirrhosis with infections. Evidence supports that timely and tailored interventions not only improve clinical outcomes but also reduce mortality. By raising awareness among clinicians about the complexity of these cases, we hope to contribute to optimizing the care of this high-risk population.
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Affiliation(s)
- Miguel Suárez
- Department of Gastroenterology, Virgen de la Luz Hospital, Cuenca 16002, Castille-La Mancha, Spain
- Medical Analysis Expert Group, Institute of Technology, Universidad de Castilla-La Mancha, Cuenca 16071, Castille-La Mancha, Spain
- Medical Analysis Expert Group, Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo 45071, Castille-La Mancha, Spain
| | - Raquel Martínez
- Department of Gastroenterology, Virgen de la Luz Hospital, Cuenca 16002, Castille-La Mancha, Spain
- Medical Analysis Expert Group, Institute of Technology, Universidad de Castilla-La Mancha, Cuenca 16071, Castille-La Mancha, Spain
- Medical Analysis Expert Group, Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo 45071, Castille-La Mancha, Spain
| | - Raquel Gómez-Molina
- Department of Laboratory Medicine, Virgen de la Luz Hospital, Cuenca 16002, Castille-La Mancha, Spain
| | - Jorge Mateo
- Medical Analysis Expert Group, Institute of Technology, Universidad de Castilla-La Mancha, Cuenca 16071, Castille-La Mancha, Spain
- Medical Analysis Expert Group, Instituto de Investigación Sanitaria de Castilla-La Mancha (IDISCAM), Toledo 45071, Castille-La Mancha, Spain
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Goran LG, Liţă (Cofaru) FA, Fierbinţeanu-Braticevici C. Acute-on-Chronic Liver Failure: Steps Towards Consensus. Diagnostics (Basel) 2025; 15:751. [PMID: 40150093 PMCID: PMC11941433 DOI: 10.3390/diagnostics15060751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2025] [Revised: 03/09/2025] [Accepted: 03/14/2025] [Indexed: 03/29/2025] Open
Abstract
Acute-on-chronic liver failure (ACLF) is a clinical syndrome characterized by organ failure and high short-term mortality. Since its first definition in 2013, many international organizations have defined this syndrome and, till now, there has been no agreement regarding definitions and diagnostic criteria. Although the precise mechanism of ACLF is unknown, precipitant factors and the systemic inflammation response play a major role. Specific management of this high-mortality syndrome is still under development, but a general consensus in the diagnosis and management of ACLF is needed.
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Affiliation(s)
- Loredana Gabriela Goran
- Emergency University Hospital Bucharest, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (F.A.L.); (C.F.-B.)
- Internal Medicine II and Gastroenterology Department, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Florina Alexandra Liţă (Cofaru)
- Emergency University Hospital Bucharest, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (F.A.L.); (C.F.-B.)
- Emergency Department, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
| | - Carmen Fierbinţeanu-Braticevici
- Emergency University Hospital Bucharest, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (F.A.L.); (C.F.-B.)
- Internal Medicine II and Gastroenterology Department, University Emergency Hospital Bucharest, 050098 Bucharest, Romania
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Karvellas CJ, Gustot T, Fernandez J. Management of the acute on chronic liver failure in the intensive care unit. Liver Int 2025; 45:e15659. [PMID: 37365997 PMCID: PMC11815614 DOI: 10.1111/liv.15659] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/01/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023]
Abstract
Acute on chronic liver failure (ACLF) reflects the development of organ failure(s) in a patient with cirrhosis and is associated with high short-term mortality. Given that ACLF has many different 'phenotypes', medical management needs to take into account the relationship between precipitating insult, organ systems involved and underlying physiology of chronic liver disease/cirrhosis. The goals of intensive care management of patients suffering ACLF are to rapidly recognize and treat inciting events (e.g. infection, severe alcoholic hepatitis and bleeding) and to aggressively support failing organ systems to ensure that patients may successfully undergo liver transplantation or recovery. Management of these patients is complex since they are prone to develop new organ failures and infectious or bleeding complications. ICU therapy parallels that applied in the general ICU population in some complications but differs in others. Given that liver transplantation in ACLF is an emerging and evolving field, multidisciplinary teams with expertise in critical care and transplant medicine best accomplish management of the critically ill ACLF patient. The focus of this review is to identify the common complications of ACLF and to describe the proper management in critically ill patients awaiting liver transplantation in our centres, including organ support, prognostic assessment and how to assess when recovery is unlikely.
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Affiliation(s)
- Constantine J. Karvellas
- Department of Critical Care MedicineUniversity of AlbertaEdmontonCanada
- Division of Gastroenterology (Liver Unit)University of AlbertaEdmontonCanada
| | - Thierry Gustot
- Department of Gastroenterology, Hepato‐Pancreatology and Digestive Oncology, H.U.B.CUB Hôpital ErasmeBrusselsBelgium
| | - Javier Fernandez
- Liver ICU, Liver Unit, Hospital ClinicUniversity of Barcelona, IDIBAPS and CIBERehdBarcelonaSpain
- EF CLIF, EASL‐CLIF ConsortiumBarcelonaSpain
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Kronsten VT, Shawcross DL. Clinical Implications of Inflammation in Patients With Cirrhosis. Am J Gastroenterol 2025; 120:65-74. [PMID: 39194320 PMCID: PMC11676607 DOI: 10.14309/ajg.0000000000003056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 08/19/2024] [Indexed: 08/29/2024]
Abstract
Cirrhosis-associated immune dysfunction refers to the concurrent systemic inflammation and immunoparesis evident across the disease spectrum of chronic liver disease, ranging from the low-grade inflammatory plasma milieu that accompanies compensated disease to the intense high-grade inflammatory state with coexistent severe immune paralysis that defines acute decompensation and acute-on-chronic liver failure. Systemic inflammation plays a crucial role in the disease course of cirrhosis and is a key driver for acute decompensation and the progression from compensated to decompensated cirrhosis. Severe systemic inflammation is fundamental to the development of organ dysfunction and failure and, in its most extreme form, acute-on-chronic liver failure. Systemic inflammation propagates the development of hepatic encephalopathy and hepatorenal syndrome-acute kidney injury. It may also be involved in the pathogenesis of further complications such as hepatocellular carcinoma and mental illness. Those patients with the most profound systemic inflammation have the worst prognosis. Systemic inflammation exerts its negative clinical effects through a number of mechanisms including nitric oxide-mediated increased splanchnic vasodilation, immunopathology, and metabolic reallocation.
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Affiliation(s)
- Victoria T. Kronsten
- Institute of Liver Studies, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London
- Institute of Liver Studies, King's College Hospital, Denmark Hill, London
| | - Debbie L. Shawcross
- Institute of Liver Studies, Department of Inflammation Biology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London
- Institute of Liver Studies, King's College Hospital, Denmark Hill, London
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Haedge F, Bruns T. Antibiotics in decompensated liver disease - who, when and for how long? Expert Rev Gastroenterol Hepatol 2025; 19:111-130. [PMID: 39921440 DOI: 10.1080/17474124.2025.2464044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2024] [Revised: 01/26/2025] [Accepted: 02/04/2025] [Indexed: 02/10/2025]
Abstract
INTRODUCTION Bacterial infections are a leading cause of hospitalization and mortality in patients with decompensated cirrhosis. Antibiotic prophylaxis in cirrhotic patients has demonstrated significant short-term reductions in bacterial infections in randomized controlled trials, but at the cost of drug resistance and with uncertain survival benefits. AREAS COVERED This review examines antibiotic use in cirrhosis, focusing on patients most likely to benefit from antibiotic prophylaxis, management strategies for infections through risk-based antibiotic selection and timely treatment initiation, challenges posed by the emergence of multidrug-resistant organisms, and principles of antimicrobial stewardship. EXPERT OPINION The efficacy of prophylaxis has decreased over time, and current registry data have questioned its use, emphasizing the need for better risk-based individualized strategies. When bacterial infections occur, the efficacy of antimicrobial therapies depends heavily on local epidemiological patterns and individual patient risk factors, necessitating tailored antibiotic selection based on regional resistance data and specific clinical scenarios. Nosocomial infections, colonization with multidrug-resistant organisms, and prior exposure to systemic antibiotics are key risk factors that should guide empirical therapy selection. Until evidence-based algorithms are available, clinicians should continue to adopt individualized approaches, guided by available evidence, local specificities, and antimicrobial stewardship principles to optimize patient outcomes.
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Affiliation(s)
- Frederic Haedge
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Tony Bruns
- Department of Internal Medicine III, University Hospital RWTH Aachen, Aachen, Germany
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Simonetto DA, Winder GS, Connor AA, Terrault NA. Liver transplantation for alcohol-associated liver disease. Hepatology 2024; 80:1441-1461. [PMID: 38889100 DOI: 10.1097/hep.0000000000000978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/31/2024] [Indexed: 06/20/2024]
Abstract
Alcohol-associated liver disease (ALD) is a major cause of morbidity and mortality worldwide, and a leading indication for liver transplantation (LT) in many countries, including the United States. However, LT for ALD is a complex and evolving field with ethical, social, and medical challenges. Thus, it requires a multidisciplinary approach and individualized decision-making. Short-term and long-term patient and graft survival of patients undergoing LT for ALD are comparable to other indications, but there is a continued need to develop better tools to identify patients who may benefit from LT, improve the pretransplant and posttransplant management of ALD, and evaluate the impact of LT for ALD on the organ donation and transplantation systems. In this review, we summarize the current evidence on LT for ALD, from alcohol-associated hepatitis to decompensated alcohol-associated cirrhosis. We discuss the indications, criteria, outcomes, and controversies of LT for these conditions and highlight the knowledge gaps and research priorities in this field.
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Affiliation(s)
- Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Ashton A Connor
- Department of Surgery, Houston Methodist Hospital, Houston, Texas, USA
| | - Norah A Terrault
- Division of Gastrointestinal and Liver Diseases, Department of Medicine, University of Southern California, Los Angeles, California, USA
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Acevedo-Haro JG, Mohamed W, Moodley P, Bendall O, Bennett K, Keelty N, Chan S, Waddy S, Hosking J, Thomas W, Tilley R. Sensitivity of diagnosis of spontaneous bacterial peritonitis is higher with the automated cell count method. World J Hepatol 2024; 16:1265-1281. [PMID: 39606172 PMCID: PMC11586750 DOI: 10.4254/wjh.v16.i11.1265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 09/09/2024] [Accepted: 09/25/2024] [Indexed: 11/06/2024] Open
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) is one of the most important complications of patients with liver cirrhosis entailing high morbidity and mortality. Making an accurate early diagnosis of this infection is key in the outcome of these patients. The current definition of SBP is based on studies performed more than 40 years ago using a manual technique to count the number of polymorphs in ascitic fluid (AF). There is a lack of data comparing the traditional cell count method with a current automated cell counter. Moreover, current international guidelines do not mention the type of cell count method to be employed and around half of the centers still rely on the traditional manual method. AIM To compare the accuracy of polymorph count on AF to diagnose SBP between the traditional manual cell count method and a modern automated cell counter against SBP cases fulfilling gold standard criteria: Positive AF culture and signs/symptoms of peritonitis. METHODS Retrospective analysis including two cohorts: Cross-sectional (cohort 1) and case-control (cohort 2), of patients with decompensated cirrhosis and ascites. Both cell count methods were conducted simultaneously. Positive SBP cases had a pathogenic bacteria isolated on AF and signs/symptoms of peritonitis. RESULTS A total of 137 cases with 5 positive-SBP, and 85 cases with 33 positive-SBP were included in cohort 1 and 2, respectively. Positive-SBP cases had worse liver function in both cohorts. The automated method showed higher sensitivity than the manual cell count: 80% vs 52%, P = 0.02, in cohort 2. Both methods showed very good specificity (> 95%). The best cutoff using the automated cell counter was polymorph ≥ 0.2 cells × 109/L (equivalent to 200 cells/mm3) in AF as it has the higher sensitivity keeping a good specificity. CONCLUSION The automated cell count method should be preferred over the manual method to diagnose SBP because of its higher sensitivity. SBP definition, using the automated method, as polymorph cell count ≥ 0.2 cells × 109/L in AF would need to be considered in patients admitted with decompensated cirrhosis.
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Affiliation(s)
- Juan G Acevedo-Haro
- South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth PL6 8DH, United Kingdom
- Peninsula Medical School, University of Plymouth, Plymouth PL6 8DH, United Kingdom.
| | - Waddah Mohamed
- South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth PL6 8DH, United Kingdom
| | - Prebashan Moodley
- South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth PL6 8DH, United Kingdom
| | - Oliver Bendall
- South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth PL6 8DH, United Kingdom
| | - Kris Bennett
- South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth PL6 8DH, United Kingdom
| | - Nigel Keelty
- South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth PL6 8DH, United Kingdom
| | - Sally Chan
- South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth PL6 8DH, United Kingdom
| | - Sam Waddy
- Intensive Care Unit, University Hospitals Plymouth NHS Trust, Plymouth PL6 8DH, United Kingdom
| | - Joanne Hosking
- Medical Statistics Group, Peninsula Clinical Trials Unit, University of Plymouth, Plymouth PL6 8DH, United Kingdom
| | - Wayne Thomas
- Haematology Service, University Hospitals Plymouth NHS Trust, Plymouth PL6 8DH, United Kingdom
| | - Robert Tilley
- Microbiology Service, University Hospitals Plymouth NHS Trust, Plymouth PL6 8DH, United Kingdom
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Marciano S, Piano S, Singh V, Caraceni P, Maiwall R, Alessandria C, Fernandez J, Kim DJ, Kim SE, Soares E, Marino M, Vorobioff J, Merli M, Elkrief L, Vargas V, Krag A, Singh S, Elizondo M, Anders MM, Dirchwolf M, Mendizabal M, Lesmana CRA, Toledo C, Wong F, Durand F, Gadano A, Giunta DH, Angeli P. Development and external validation of a model to predict multidrug-resistant bacterial infections in patients with cirrhosis. Liver Int 2024; 44:2915-2928. [PMID: 39148354 DOI: 10.1111/liv.16063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 06/11/2024] [Accepted: 07/28/2024] [Indexed: 08/17/2024]
Abstract
UNLABELLED With the increasing rate of infections caused by multidrug-resistant organisms (MDRO), selecting appropriate empiric antibiotics has become challenging. We aimed to develop and externally validate a model for predicting the risk of MDRO infections in patients with cirrhosis. METHODS We included patients with cirrhosis and bacterial infections from two prospective studies: a transcontinental study was used for model development and internal validation (n = 1302), and a study from Argentina and Uruguay was used for external validation (n = 472). All predictors were measured at the time of infection. Both culture-positive and culture-negative infections were included. The model was developed using logistic regression with backward stepwise predictor selection. We externally validated the optimism-adjusted model using calibration and discrimination statistics and evaluated its clinical utility. RESULTS The prevalence of MDRO infections was 19% and 22% in the development and external validation datasets, respectively. The model's predictors were sex, prior antibiotic use, type and site of infection, MELD-Na, use of vasopressors, acute-on-chronic liver failure, and interaction terms. Upon external validation, the calibration slope was 77 (95% CI .48-1.05), and the area under the ROC curve was .68 (95% CI .61-.73). The application of the model significantly changed the post-test probability of having an MDRO infection, identifying patients with nosocomial infection at very low risk (8%) and patients with community-acquired infections at significant risk (36%). CONCLUSION This model achieved adequate performance and could be used to improve the selection of empiric antibiotics, aligning with other antibiotic stewardship program strategies.
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Affiliation(s)
- Sebastián Marciano
- Liver Unit and Research Department, Hospital Italiano Buenos Aires, Buenos Aires, Argentina
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Virendra Singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Paolo Caraceni
- Unit of Semeiotics, Liver and Alcohol-related diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Rakhi Maiwall
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Javier Fernandez
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain
- Institut d'Investigacions Biomèdiques August-PiSunyer, Barcelona, Catalonia, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Catalonia, Spain
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Catalonia, Spain
| | - Dong Joon Kim
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Sung Eun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym Sacred Heart Hospital, College of Medicine, Hallym University, Anyang City, Republic of Korea
| | - Elza Soares
- Gastroenterology Division, Medicine Department, Faculty of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Mónica Marino
- Liver Unit, Hospital Dr. Carlos B. Udaondo, Buenos Aires, Argentina
| | | | - Manuela Merli
- Department of translation and precision medicine, University of Rome Sapienza, Rome, Italy
| | - Laure Elkrief
- Service de Transplantation, Service d'Hépato-gastroentérologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Victor Vargas
- Liver Unit, Department of Internal Medicine, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Shivaram Singh
- Department of Gastroenterology, S.C.B. Medical College, Cuttack, India
| | - Martín Elizondo
- Bi-Institutional Liver Transplant Unit Center (Hospital de Clínicas-Military Hospital), Montevideo, Uruguay
| | - Maria M Anders
- Liver Unit, Hospital Aleman Buenos Aires, Buenos Aires, Argentina
| | | | | | - Cosmas R A Lesmana
- Hepatobiliary Division, Department of Internal Medicine, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia
- Medical Faculty, Universitas Indonesia, Jakarta, Indonesia
- Digestive Disease & GI Oncology Centre, Medistra Hospital, Jakarta, Indonesia
| | - Claudio Toledo
- Gastroenterology Unit, Hospital Valdivia, Universidad Austral de Chile, Valdivia, Chile
| | - Florence Wong
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Francois Durand
- Hepatology & Liver Intensive Care, Hospital Beaujon, University Paris Diderot, Paris, France
| | - Adrián Gadano
- Liver Unit and Research Department, Hospital Italiano Buenos Aires, Buenos Aires, Argentina
| | - Diego H Giunta
- Hospital Italiano Buenos Aires University, Buenos Aires, Argentina
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
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Dibos M, Mayr U, Triebelhorn J, Schmid RM, Lahmer T. [Infections and liver cirrhosis]. Med Klin Intensivmed Notfmed 2024; 119:465-469. [PMID: 39120610 DOI: 10.1007/s00063-024-01168-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 07/10/2024] [Accepted: 07/10/2024] [Indexed: 08/10/2024]
Abstract
End-stage liver disease is a life-threatening clinical syndrome combined with a state of immune dysfunction. In this constellation patients are prone to bacterial, fungal and viral infections associated with markedly increased morbidity and mortality rates. Bacterial infections are the most prevalent kind of infection in patients with end-stage liver disease accounting for nearly 30%. The evolving rates of multidrug resistant organisms present enormous challenges in treatment strategies. Therefore, the urgent needs for prevention, early detection strategies and widespread treatment options are a necessity to handle the rising incidence of infection complications in end-stage liver disease.
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Affiliation(s)
| | | | | | | | - Tobias Lahmer
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, München, Deutschland.
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Lim J, Scott AM, Wig R, Tan RV, Harnois ER, Zangeneh TT, Al-Obaidi MM. Clinical Characteristics and Mortality Risks Among Patients With Culture-Proven Coccidioidomycosis Who Are Critically Ill: A Multicenter Study in an Endemic Region. Open Forum Infect Dis 2024; 11:ofae454. [PMID: 39189034 PMCID: PMC11346353 DOI: 10.1093/ofid/ofae454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 08/05/2024] [Indexed: 08/28/2024] Open
Abstract
Background Coccidioidomycosis is an endemic mycosis in the southwestern United States. While most infections are mild, severe cases can be devastating. We aimed to describe the clinical characteristics and mortality risks of patients in the intensive care unit (ICU) with culture-proven coccidioidomycosis. Methods We performed a retrospective chart review of patients in the ICU with positive Coccidioides spp culture in a large health care system in Arizona between 1 October 2017 and 1 July 2022. All data were entered into REDCap. Results An overall 145 patients were identified and included. The median age was 51 years, with the majority male (69%) and non-Hispanic White (39%). Most patients (n = 104, 72%) had pulmonary coccidioidomycosis, and 41 had extrapulmonary disease (17 meningitis, 13 fungemia, 10 musculoskeletal disease, and 4 pericardial or aortic involvement). Seventy patients (48%) died during hospitalization, and most (91%) received antifungal therapy during hospitalization. In the multivariate logistic regression model, age ≥60 years (odds ratio [OR], 7.0; 95% CI, 2.6-18.8), cirrhosis (OR, 13.1; 95% CI, 1.6-108.8), and mechanical ventilation or vasopressor support (OR, 15.4; 95% CI, 3.9-59.6) were independently associated with increased all-cause mortality, but pre-ICU antifungal use had a statistically insignificant mortality risk association (OR, 0.5; 95% CI, .2-1.2). Conclusions In our study of patients in the ICU with coccidioidomycosis and multiple comorbidities, the mortality rate was high. Older age, cirrhosis, and mechanical ventilation or vasopressor support were significantly associated with high mortality. Future studies are recommended to evaluate those risk factors and the efficacy of rapid diagnosis and early therapy in patients at high risk.
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Affiliation(s)
- James Lim
- Department of Internal Medicine, University of Arizona College of Medicine, Tucson, Arizona, USA
- Division of Infectious Diseases, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Ashley M Scott
- Department of Internal Medicine, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Rebecca Wig
- Department of Internal Medicine, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Rachel V Tan
- Department of Internal Medicine, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Emily R Harnois
- Department of Internal Medicine, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Tirdad T Zangeneh
- Department of Internal Medicine, University of Arizona College of Medicine, Tucson, Arizona, USA
- Division of Infectious Diseases, University of Arizona College of Medicine, Tucson, Arizona, USA
- Valley Fever Center for Excellence, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Mohanad M Al-Obaidi
- Department of Internal Medicine, University of Arizona College of Medicine, Tucson, Arizona, USA
- Division of Infectious Diseases, University of Arizona College of Medicine, Tucson, Arizona, USA
- Valley Fever Center for Excellence, University of Arizona College of Medicine, Tucson, Arizona, USA
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11
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Piano S, Bunchorntavakul C, Marciano S, Rajender Reddy K. Infections in cirrhosis. Lancet Gastroenterol Hepatol 2024; 9:745-757. [PMID: 38754453 DOI: 10.1016/s2468-1253(24)00078-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/04/2024] [Accepted: 03/04/2024] [Indexed: 05/18/2024]
Abstract
Cirrhosis is an immune dysfunction state, and as such, patients with cirrhosis are susceptible to bacterial, fungal, and viral infections. Because of infection, these patients have a propensity to develop multiorgan failure, which is associated with high mortality. Bacterial infections are the most prevalent type of infection in patients with cirrhosis, with the prevalence of bacterial infections in patients admitted for an acute decompensating event ranging from 24% to 29%. Together with invasive fungal infections, bacterial infections are the most severe. Multidrug-resistant organisms have been evolving at a rapid and alarming rate around the world, which presents enormous challenges. The development of effective measures for the prevention, early detection, and treatment of infections in patients with cirrhosis is challenging, given the rising incidence of infections in this patient population.
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Affiliation(s)
- Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, University and Hospital of Padova, Padova, Italy
| | | | - Sebastian Marciano
- Department of Clinical Investigation, Italian Hospital, Buenos Aires, Argentina
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, PA, USA.
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Kim A, Song BG, Kang W, Sinn DH, Gwak GY, Paik YH, Choi MS, Lee JH, Goh MJ. Prevalence and predictors of multidrug-resistant bacteremia in liver cirrhosis. Korean J Intern Med 2024; 39:448-457. [PMID: 38715233 PMCID: PMC11076886 DOI: 10.3904/kjim.2023.354] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/07/2023] [Accepted: 01/02/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND/AIMS Improved knowledge of local epidemiology and predicting risk factors of multidrug-resistant (MDR) bacteria are required to optimize the management of infections. This study examined local epidemiology and antibiotic resistance patterns of liver cirrhosis (LC) patients and evaluated the predictors of MDR bacteremia in Korea. METHODS This was a retrospective study including 140 LC patients diagnosed with bacteremia between January 2017 and December 2022. Local epidemiology and antibiotic resistance patterns and the determinants of MDR bacteremia were analyzed using logistic regression analysis. RESULTS The most frequently isolated bacteria, from the bloodstream, were Escherichia coli (n = 45, 31.7%) and Klebsiella spp. (n = 35, 24.6%). Thirty-four isolates (23.9%) were MDR, and extended-spectrum beta-lactamase E. coli (52.9%) and methicillin-resistant Staphylococcus aureus (17.6%) were the most commonly isolated MDR bacteria. When Enterococcus spp. were cultured, the majority were MDR (MDR 83.3% vs. 16.7%, p = 0.003), particularly vancomycin-susceptible Enterococcus faecium. Antibiotics administration within 30 days and/or nosocomial infection was a significant predictor of MDR bacteremia (OR: 3.40, 95% CI: 1.24-9.27, p = 0.02). MDR bacteremia was not predicted by sepsis predictors, such as positive systemic inflammatory response syndrome (SIRS) or quick Sequential Organ Failure Assessment (qSOFA). CONCLUSION More than 70% of strains that can be treated with a third-generation cephalosporin have been cultured. In cirrhotic patients, antibiotic administration within 30 days and/or nosocomial infection are predictors of MDR bacteremia; therefore, empirical administration of broad-spectrum antibiotics should be considered when these risk factors are present.
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Affiliation(s)
- Aryoung Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byeong Geun Song
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Wonseok Kang
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Dong Hyun Sinn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Geum-Youn Gwak
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong-Han Paik
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Moon Seok Choi
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon Hyeok Lee
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myung Ji Goh
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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13
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Khan S, Hong H, Bass S, Wang Y, Wang XF, Sims OT, Koval CE, Kapoor A, Lindenmeyer CC. Comparison of fungal vs bacterial infections in the medical intensive liver unit: Cause or corollary for high mortality? World J Hepatol 2024; 16:379-392. [PMID: 38577538 PMCID: PMC10989308 DOI: 10.4254/wjh.v16.i3.379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Revised: 01/17/2024] [Accepted: 02/26/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Due to development of an immune-dysregulated phenotype, advanced liver disease in all forms predisposes patients to sepsis acquisition, including by opportunistic pathogens such as fungi. Little data exists on fungal infection within a medical intensive liver unit (MILU), particularly in relation to acute on chronic liver failure. AIM To investigate the impact of fungal infections among critically ill patients with advanced liver disease, and compare outcomes to those of patients with bacterial infections. METHODS From our prospective registry of MILU patients from 2018-2022, we included 27 patients with culture-positive fungal infections and 183 with bacterial infections. We compared outcomes between patients admitted to the MILU with fungal infections to bacterial counterparts. Data was extracted through chart review. RESULTS All fungal infections were due to Candida species, and were most frequently blood isolates. Mortality among patients with fungal infections was significantly worse relative to the bacterial cohort (93% vs 52%, P < 0.001). The majority of the fungal cohort developed grade 2 or 3 acute on chronic liver failure (ACLF) (90% vs 64%, P = 0.02). Patients in the fungal cohort had increased use of vasopressors (96% vs 70%, P = 0.04), mechanical ventilation (96% vs 65%, P < 0.001), and dialysis due to acute kidney injury (78% vs 52%, P = 0.014). On MILU admission, the fungal cohort had significantly higher Acute Physiology and Chronic Health Evaluation (108 vs 91, P = 0.003), Acute Physiology Score (86 vs 65, P = 0.003), and Model for End-Stage Liver Disease-Sodium scores (86 vs 65, P = 0.041). There was no significant difference in the rate of central line use preceding culture (52% vs 40%, P = 0.2). Patients with fungal infection had higher rate of transplant hold placement, and lower rates of transplant; however, differences did not achieve statistical significance. CONCLUSION Mortality was worse among patients with fungal infections, likely attributable to severe ACLF development. Prospective studies examining empiric antifungals in severe ACLF and associations between fungal infections and transplant outcomes are critical.
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Affiliation(s)
- Sarah Khan
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH 44195, United States.
| | - Hanna Hong
- Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Stephanie Bass
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Yifan Wang
- Department of Quantitative Health Sciences/Biostatistics Section, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Xiao-Feng Wang
- Department of Quantitative Health Sciences/Biostatistics Section, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Omar T Sims
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Christine E Koval
- Department of Infectious Disease, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Aanchal Kapoor
- Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Christina C Lindenmeyer
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH 44195, United States
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14
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Saner FH, Raptis DA, Alghamdi SA, Malagó MM, Broering DC, Bezinover D. Navigating the Labyrinth: Intensive Care Challenges for Patients with Acute-on-Chronic Liver Failure. J Clin Med 2024; 13:506. [PMID: 38256640 PMCID: PMC10816826 DOI: 10.3390/jcm13020506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/07/2024] [Accepted: 01/14/2024] [Indexed: 01/24/2024] Open
Abstract
Acute-on-chronic liver failure (ACLF) refers to the deterioration of liver function in individuals who already have chronic liver disease. In the setting of ACLF, liver damage leads to the failure of other organs and is associated with increased short-term mortality. Optimal medical management of patients with ACLF requires implementing complex treatment strategies, often in an intensive care unit (ICU). Failure of organs other than the liver distinguishes ACLF from other critical illnesses. Although there is growing evidence supporting the current approach to ACLF management, the mortality associated with this condition remains unacceptably high. In this review, we discuss considerations for ICU care of patients with ACLF and highlight areas for further research.
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Affiliation(s)
- Fuat H. Saner
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Dimitri A. Raptis
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Saad A. Alghamdi
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Massimo M. Malagó
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Dieter C. Broering
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Dmitri Bezinover
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA;
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15
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Chen G, To U. Inpatient management of bacterial infections in patients with cirrhosis: A clinical review. Clin Liver Dis (Hoboken) 2024; 23:e0214. [PMID: 38952696 PMCID: PMC11216674 DOI: 10.1097/cld.0000000000000214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 04/08/2024] [Indexed: 07/03/2024] Open
Affiliation(s)
- George Chen
- Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Uyen To
- Section of Digestive Diseases, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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16
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Sohail A, Naseem K, Khan A, Adhami T, Brown K. Predictors of inpatient outcomes of COVID-19 infection in patients with cirrhosis in the early pandemic phase: A nationwide survey. JGH Open 2023; 7:889-898. [PMID: 38162845 PMCID: PMC10757488 DOI: 10.1002/jgh3.12998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 08/25/2023] [Accepted: 10/25/2023] [Indexed: 01/03/2024]
Abstract
Background and Aim Previous studies conducted at single centers have suggested that patients with cirrhosis are at a greater risk for worse outcomes with COVID-19. However, there is limited data on a national level in the United States. We aimed to study hospital-related outcomes and identify the predictors of poor outcomes in patients with cirrhosis and concurrent COVID-19. Methods We queried 2020 National Inpatient and Readmission databases to identify all hospitalizations due to cirrhosis in adults with a diagnosis of COVID-19. Primary outcomes included inpatient mortality, mechanical ventilation (MV), and intensive care unit (ICU) utilization. Secondary outcomes included mean length of stay (LOS) and mean hospitalization costs. We classified cirrhosis into compensated (CC) and decompensated (DC) groups. Results We identified 25194 hospitalizations of adult patients due to cirrhosis with a concurrent diagnosis of COVID-19. These patients had higher mortality (19.50% vs 6.19%, P ≤ 0.01), MV (11.7% vs 2.8%, P ≤ 0.01), ICU utilization (17.3% vs 8.1%, P ≤ 0.01), LOS (8.89 days vs 6.16 days, P ≤ 0.01), and total hospitalization costs ($24 817 vs $18 505, P ≤ 0.01) than those without COVID-19. On subgroup analysis, patients in the DC group had higher mortality, LOS, and hospitalization costs compared to those in the CC group. On multivariate analysis, we also found that COVID-19 infection, age, Charlson Comorbidity Index ≥3, acute kidney injury, end-stage renal disease, septic shock, acute respiratory failure, MV, and ICU status were independent predictors for mortality. Conclusion Our study suggests that COVID-19 infection is an independent predictor of mortality in patients with cirrhosis, with threefold higher mortality and increased resource utilization. Early intervention through immunizations and advanced COVID-19 therapies can help improve these outcomes.
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Affiliation(s)
- Abdullah Sohail
- Department of Internal MedicineUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA
| | | | - Ahmad Khan
- Department of Gastroenterology and HepatologyCase Western Reserve UniversityClevelandOhioUSA
| | | | - Kyle Brown
- Department of Internal MedicineUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA
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17
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Surace M, Andria I, Valentini G. Renal dysfunctions and liver disease: a brief update on management with particular attention to hepatorenal syndrome. Minerva Gastroenterol (Torino) 2023; 69:412-422. [PMID: 33829727 DOI: 10.23736/s2724-5985.21.02816-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In 2015 the International Club of Ascites gave an accurate, exact and new definition of acute renal injury in cirrhotic patient, identifying objective criteria of severity and recoding hepatorenal syndrome as a particular form of renal dysfunction for which excessive renal vasoconstriction is one of the main, but not the only, pathophysiological mechanisms. In this review we tried to outline new pathophysiological and therapeutic insights, and to summarize the most recent recommendations. Vasopressor such as terlipressin and norepinephrine, in combination with albumin, still represent the first line therapy. However, the new discoveries in the pathophysiology of the disease have led the search for new pharmacological approaches, although, to date, the only definitive remedy is represented by liver (or simultaneous liver-kidney) transplantation.
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Affiliation(s)
- Monica Surace
- Unit of Gastroenterology, Hospital of Rivoli, Rivoli, Turin, Italy -
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18
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Dala Ali AHH, Harun SN, Othman N, Ibrahim B, Abdulbagi OE, Abdullah I, Ariffin IA. Determinants of Inadequate Empiric Antimicrobial Therapy in ICU Sepsis Patients in Al-Madinah Al-Munawwarah, Saudi Arabia: A Comparison of Artificial Neural Network and Regression Analysis. Antibiotics (Basel) 2023; 12:1305. [PMID: 37627725 PMCID: PMC10451895 DOI: 10.3390/antibiotics12081305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 06/15/2023] [Accepted: 06/20/2023] [Indexed: 08/27/2023] Open
Abstract
In the management of sepsis, providing adequate empiric antimicrobial therapy is one of the most important pillars of sepsis management. Therefore, it is important to evaluate the adequacy of empiric antimicrobial therapy (EAMT) in sepsis patients admitted to intensive care units (ICU) and to identify the determinants of inadequate EAMT. The aim of this study was to evaluate the adequacy of empiric antimicrobial therapy in patients admitted to the ICU with sepsis or septic shock, and the determinants of inadequate EAMT. The data of patients admitted to the ICU units due to sepsis or septic shock in two tertiary healthcare facilities in Al-Madinah Al-Munawwarah were retrospectively reviewed. The current study used logistic regression analysis and artificial neural network (ANN) analysis to identify determinants of inadequate empiric antimicrobial therapy, and evaluated the performance of these two approaches in predicting the inadequacy of EAMT. The findings of this study showed that fifty-three per cent of patients received inadequate EAMT. Determinants for inadequate EAMT were APACHE II score, multidrug-resistance organism (MDRO) infections, surgical history (lower limb amputation), and comorbidity (coronary artery disease). ANN performed as well as or better than logistic regression in predicating inadequate EAMT, as the receiver operating characteristic area under the curve (ROC-AUC) of the ANN model was higher when compared with the logistic regression model (LRM): 0.895 vs. 0.854. In addition, the ANN model performed better than LRM in predicting inadequate EAMT in terms of classification accuracy. In addition, ANN analysis revealed that the most important determinants of EAMT adequacy were the APACHE II score and MDRO. In conclusion, more than half of the patients received inadequate EAMT. Determinants of inadequate EAMT were APACHE II score, MDRO infections, comorbidity, and surgical history. This provides valuable inputs to improve the prescription of empiric antimicrobials in Saudi Arabia going forward. In addition, our study demonstrated the potential utility of applying artificial neural network analysis in the prediction of outcomes in healthcare research.
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Affiliation(s)
- Ahmad Habeeb Hattab Dala Ali
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia (USM), Penang 11800, Malaysia
- Department of Pharmacy Practice, College of Pharmacy, AlMaarefa University, Dariyah, Riyadh 13713, Saudi Arabia
| | - Sabariah Noor Harun
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia (USM), Penang 11800, Malaysia
| | - Noordin Othman
- Department of Clinical and Hospital Pharmacy, College of Pharmacy, Taibah University, Al-Madinah Al-Munawwarah 42353, Saudi Arabia
- School of Pharmacy, Management and Science University, University Drive, Off Persiaran Olahraga, Shah Alam 40100, Malaysia
| | - Baharudin Ibrahim
- Faculty of Pharmacy, University of Malaya, Wilayah Persekutuan Kuala Lumpur 50603, Malaysia
| | | | - Ibrahim Abdullah
- School of Pharmacy, Management and Science University, University Drive, Off Persiaran Olahraga, Shah Alam 40100, Malaysia
| | - Indang Ariati Ariffin
- Research Management Centre, Management and Science University, University Drive, Off Persiaran Olahraga, Section 13, Shah Alam 40100, Malaysia
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19
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Singh V, De A, Mehtani R, Angeli P, Maiwall R, Satapathy S, Singal AK, Saraya A, Sharma BC, Eapen CE, Rao PN, Shukla A, Shalimar, Choudhary NS, Alcantara-Payawal D, Arora V, Aithal G, Kulkarni A, Roy A, Shrestha A, Mamun Al Mahtab, Niriella MA, Siam TS, Zhang CQ, Huei LG, Yu ML, Roberts SK, Peng CY, Chen T, George J, Wong V, Yilmaz Y, Treeprasertsuk S, Kurniawan J, Kim SU, Younossi ZM, Sarin SK. Asia-Pacific association for study of liver guidelines on management of ascites in liver disease. Hepatol Int 2023; 17:792-826. [PMID: 37237088 DOI: 10.1007/s12072-023-10536-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 04/08/2023] [Indexed: 05/28/2023]
Affiliation(s)
- Virendra Singh
- Punjab Institute of Liver and Biliary Sciences, Mohali, Punjab, India.
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - Arka De
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rohit Mehtani
- Department of Hepatology, Amrita Institute of Medical Sciences and Research, Faridabad, India
| | - Paolo Angeli
- Department of Internal Medicine and Hepatology, University of Padova, Padua, Italy
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Sanjaya Satapathy
- Division of Hepatology, Sandra Atlas Bass Center for Liver Diseases and Transplantation, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Health, Manhasset, NY, USA
| | - Ashwini K Singal
- University of South Dakota Sanford School of Medicine, Sioux Falls, USA
| | - Anoop Saraya
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - B C Sharma
- Department of Gastroenterology, G.B. Pant Hospital, New Delhi, Delhi, India
| | - C E Eapen
- Department of Hepatology, Christian Medical College, Vellore, India
| | - P N Rao
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Akash Shukla
- Department of Gastroenterology, Lokmanya Tilak Municipal General Hospital and Lokmanya Tilak Municipal Medical College, Sion, Mumbai, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | | | | | - Vinod Arora
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guru Aithal
- Biomedical Research Unit, NIHR Nottingham Digestive Diseases, Nottingham, UK
| | - Anand Kulkarni
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Akash Roy
- Institute of Gastrosciences and Liver Transplantation, Apollo Multispeciality Hospitals, Kolkata, India
| | - Ananta Shrestha
- Department of Hepatology, The Liver Clinic, Liver Foundation, Kathmandu, Nepal
| | - Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Madunil A Niriella
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - Tan Soek Siam
- Department of Hepatology, Hospital Selayang, Selangor Darul Ehsan, Malaysia
| | - Chun-Qing Zhang
- Department of Gastroenterology, Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - Lee Guan Huei
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Ming-Lung Yu
- School of Medicine, College of Medicine and Center of Excellence for Metabolic Associated Fatty Liver Disease, National Sun Yat-Sen University, Kaohsiung, Taiwan
| | | | - Cheng-Yuan Peng
- Centre for Digestive Medicine, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Tao Chen
- Department of Infectious Diseases, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jacob George
- University of Sydney School of Medicine, Sydney, Australia
| | - Vincent Wong
- Mok Hing Yiu Professor of Medicine, Department of Medicine and Therapeutics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong, China
| | - Yusuf Yilmaz
- Liver Research Unit, Institute of Gastroenterology, Marmara University, Istanbul, Turkey
- Department of Gastroenterology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Turkey
| | | | - Juferdy Kurniawan
- Hepatobiliary Division, Department of Internal Medicine, Faculty of Medicine, Universitas Indonesia, Cipto Mangunkusumo Hospital Jakarta, Jakarta, Indonesia
| | - Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | | | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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20
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Moreau R, Tonon M, Krag A, Angeli P, Berenguer M, Berzigotti A, Fernandez J, Francoz C, Gustot T, Jalan R, Papp M, Trebicka J. EASL Clinical Practice Guidelines on acute-on-chronic liver failure. J Hepatol 2023; 79:461-491. [PMID: 37364789 DOI: 10.1016/j.jhep.2023.04.021] [Citation(s) in RCA: 105] [Impact Index Per Article: 52.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 04/19/2023] [Indexed: 06/28/2023]
Abstract
Acute-on-chronic liver failure (ACLF), which was described relatively recently (2013), is a severe form of acutely decompensated cirrhosis characterised by the existence of organ system failure(s) and a high risk of short-term mortality. ACLF is caused by an excessive systemic inflammatory response triggered by precipitants that are clinically apparent (e.g., proven microbial infection with sepsis, severe alcohol-related hepatitis) or not. Since the description of ACLF, some important studies have suggested that patients with ACLF may benefit from liver transplantation and because of this, should be urgently stabilised for transplantation by receiving appropriate treatment of identified precipitants, and full general management, including support of organ systems in the intensive care unit (ICU). The objective of the present Clinical Practice Guidelines is to provide recommendations to help clinicians recognise ACLF, make triage decisions (ICU vs. no ICU), identify and manage acute precipitants, identify organ systems that require support or replacement, define potential criteria for futility of intensive care, and identify potential indications for liver transplantation. Based on an in-depth review of the relevant literature, we provide recommendations to navigate clinical dilemmas followed by supporting text. The recommendations are graded according to the Oxford Centre for Evidence-Based Medicine system and categorised as 'weak' or 'strong'. We aim to provide the best available evidence to aid the clinical decision-making process in the management of patients with ACLF.
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21
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Mandorfer M, Aigner E, Cejna M, Ferlitsch A, Datz C, Gräter T, Graziadei I, Gschwantler M, Hametner-Schreil S, Hofer H, Jachs M, Loizides A, Maieron A, Peck-Radosavljevic M, Rainer F, Scheiner B, Semmler G, Reider L, Reiter S, Schoder M, Schöfl R, Schwabl P, Stadlbauer V, Stauber R, Tatscher E, Trauner M, Ziachehabi A, Zoller H, Fickert P, Reiberger T. Austrian consensus on the diagnosis and management of portal hypertension in advanced chronic liver disease (Billroth IV). Wien Klin Wochenschr 2023:10.1007/s00508-023-02229-w. [PMID: 37358642 DOI: 10.1007/s00508-023-02229-w] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/15/2023] [Indexed: 06/27/2023]
Abstract
The Billroth IV consensus was developed during a consensus meeting of the Austrian Society of Gastroenterology and Hepatology (ÖGGH) and the Austrian Society of Interventional Radiology (ÖGIR) held on the 26th of November 2022 in Vienna.Based on international recommendations and considering recent landmark studies, the Billroth IV consensus provides guidance regarding the diagnosis and management of portal hypertension in advanced chronic liver disease.
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Affiliation(s)
- Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
| | - Elmar Aigner
- First Department of Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Manfred Cejna
- Department of Radiology, LKH Feldkirch, Feldkirch, Austria
| | - Arnulf Ferlitsch
- Department of Internal Medicine I, KH Barmherzige Brüder Wien, Vienna, Austria
| | - Christian Datz
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Tilmann Gräter
- Department of Radiology, Medical University of Graz, Graz, Austria
| | - Ivo Graziadei
- Department of Internal Medicine, KH Hall in Tirol, Hall, Austria
| | - Michael Gschwantler
- Division of Gastroenterology and Hepatology, Department of Medicine IV, Klinik Ottakring, Vienna, Austria
| | - Stephanie Hametner-Schreil
- Department of Gastroenterology and Hepatology, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | - Harald Hofer
- Department of Internal Medicine I, Klinikum Wels-Grieskirchen, Wels, Austria
| | - Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Alexander Loizides
- Department of Radiology, Medical University of Innbsruck, Innsbruck, Austria
| | - Andreas Maieron
- Department of Internal Medicine II, University Hospital St. Pölten, St. Pölten, Austria
| | - Markus Peck-Radosavljevic
- Department of Internal Medicine and Gastroenterology, Hepatology, Endocrinology, Rheumatology and Nephrology, Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Florian Rainer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Georg Semmler
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lukas Reider
- Department of Interventional Radiology, Medical University of Vienna, Vienna, Austria
| | - Silvia Reiter
- Department of Internal Medicine and Gastroenterology and Hepatology, Kepler Universitätsklinikum, Linz, Austria
| | - Maria Schoder
- Department of Interventional Radiology, Medical University of Vienna, Vienna, Austria
| | - Rainer Schöfl
- Department of Gastroenterology and Hepatology, Ordensklinikum Linz Barmherzige Schwestern, Linz, Austria
| | - Philipp Schwabl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Vanessa Stadlbauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Rudolf Stauber
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Elisabeth Tatscher
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Alexander Ziachehabi
- Department of Internal Medicine and Gastroenterology and Hepatology, Kepler Universitätsklinikum, Linz, Austria
| | - Heinz Zoller
- Department of Internal Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Peter Fickert
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
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22
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Nanchal R, Subramanian R, Alhazzani W, Dionne JC, Peppard WJ, Singbartl K, Truwit J, Al-Khafaji AH, Killian AJ, Alquraini M, Alshammari K, Alshamsi F, Belley-Cote E, Cartin-Ceba R, Hollenberg SM, Galusca DM, Huang DT, Hyzy RC, Junek M, Kandiah P, Kumar G, Morgan RL, Morris PE, Olson JC, Sieracki R, Steadman R, Taylor B, Karvellas CJ. Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations. Crit Care Med 2023; 51:657-676. [PMID: 37052436 DOI: 10.1097/ccm.0000000000005824] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
OBJECTIVES To develop evidence-based recommendations for clinicians caring for adults with acute liver failure (ALF) or acute on chronic liver failure (ACLF) in the ICU. DESIGN The guideline panel comprised 27 members with expertise in aspects of care of the critically ill patient with liver failure or methodology. We adhered to the Society of Critical Care Medicine standard operating procedures manual and conflict-of-interest policy. Teleconferences and electronic-based discussion among the panel, as well as within subgroups, served as an integral part of the guideline development. INTERVENTIONS In part 2 of this guideline, the panel was divided into four subgroups: neurology, peri-transplant, infectious diseases, and gastrointestinal groups. We developed and selected Population, Intervention, Comparison, and Outcomes (PICO) questions according to importance to patients and practicing clinicians. For each PICO question, we conducted a systematic review and meta-analysis where applicable. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence to decision framework to facilitate recommendations formulation as strong or conditional. We followed strict criteria to formulate best practice statements. MEASUREMENTS AND MAIN RESULTS We report 28 recommendations (from 31 PICO questions) on the management ALF and ACLF in the ICU. Overall, five were strong recommendations, 21 were conditional recommendations, two were best-practice statements, and we were unable to issue a recommendation for five questions due to insufficient evidence. CONCLUSIONS Multidisciplinary, international experts formulated evidence-based recommendations for the management ALF and ACLF patients in the ICU, acknowledging that most recommendations were based on low quality and indirect evidence.
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Affiliation(s)
- Rahul Nanchal
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI
| | | | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Joanna C Dionne
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | - David T Huang
- University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | - Mats Junek
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Gagan Kumar
- Northeast Georgia Medical Center, Gainesville, GA
| | - Rebecca L Morgan
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Peter E Morris
- University of Kentucky College of Medicine, Lexington, KY
| | - Jody C Olson
- Kansas University Medical Center, Kansas City, KS
| | | | - Randolph Steadman
- University of California Los Angeles Medical Center, Los Angeles, CA
| | | | - Constantine J Karvellas
- Department of Critical Care Medicine and Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, AB, Canada
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23
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Reverter E, Toapanta D, Bassegoda O, Zapatero J, Fernandez J. Critical Care Management of Acute-on-Chronic Liver Failure: Certainties and Unknowns. Semin Liver Dis 2023; 43:206-217. [PMID: 37369227 DOI: 10.1055/s-0043-1769907] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Intensive care unit (ICU) admission is frequently required in patients with decompensated cirrhosis for organ support. This entity, known as acute-on-chronic liver failure (ACLF), is associated with high short-term mortality. ICU management of ACLF is complex, as these patients are prone to develop new organ failures and infectious or bleeding complications. Poor nutritional status, lack of effective liver support systems, and shortage of liver donors are also factors that contribute to increase their mortality. ICU therapy parallels that applied in the general ICU population in some complications but has differential characteristics in others. This review describes the current knowledge on critical care management of patients with ACLF including organ support, prognostic assessment, early liver transplantation, and futility rules. Certainties and knowledge gaps in this area are also discussed.
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Affiliation(s)
- Enric Reverter
- Liver ICU, Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - David Toapanta
- Liver ICU, Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Octavi Bassegoda
- Liver ICU, Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Juliana Zapatero
- Liver ICU, Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Javier Fernandez
- Liver ICU, Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
- European Foundation for the Study of Chronic Liver Failure, EASL-CLIF, Consortium, Barcelona, Spain
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24
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Dirchwolf M, Gomez Perdiguero G, Grech IM, Marciano S. Challenges and recommendations when selecting empirical antibiotics in patients with cirrhosis. World J Hepatol 2023; 15:377-385. [PMID: 37034233 PMCID: PMC10075007 DOI: 10.4254/wjh.v15.i3.377] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 12/28/2022] [Accepted: 03/10/2023] [Indexed: 04/11/2023] Open
Abstract
There is abundant evidence that bacterial infections are severe complications in patients with cirrhosis, being the most frequent trigger of acute-on-chronic liver failure and causing death in one of every four patients during hospitalization. For these reasons, early diagnosis and effective treatment of infections are mandatory to improve patient outcomes. However, treating physicians are challenged in daily practice since diagnosing bacterial infections is not always straightforward. This situation might lead to delayed antibiotic initiation or prescription of ineffective regimens, which are associated with poor outcomes. On the other hand, prescribing broad-spectrum antibiotics to all patients suspected of bacterial infections might favor bacterial resistance development. This is a significant concern given the alarming number of infections caused by multidrug-resistant microorganisms worldwide. Therefore, it is paramount to know the local epidemiology to propose tailored guidelines for empirical antibiotic selection in patients with cirrhosis in whom bacterial infections are suspected or confirmed. In this article, we will revise current knowledge in this area and highlight the importance of surveillance programs.
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Affiliation(s)
- Melisa Dirchwolf
- Liver Unit, Hospital Privado de Rosario, Rosario 2000, Santa Fe, Argentina
| | | | - Ingrid Mc Grech
- Liver Unit, Hospital Privado de Rosario, Rosario 2000, Santa Fe, Argentina
| | - Sebastian Marciano
- Liver Unit and Department of Research, Hospital Italiano de Buenos Aires, Buenos Aires 1181, Argentina
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25
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Terra C, de Mattos ÂZ, Chagas MS, Torres A, Wiltgen D, Souza BM, Perez RM. Impact of multidrug resistance on the management of bacterial infections in cirrhosis. World J Clin Cases 2023; 11:534-544. [PMID: 36793638 PMCID: PMC9923851 DOI: 10.12998/wjcc.v11.i3.534] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/22/2022] [Accepted: 01/05/2023] [Indexed: 01/23/2023] Open
Abstract
Patients with cirrhosis have an increased risk of infection and differently from other complications, that over the years are improving in their outcomes, infections in cirrhotic patients are still a major cause of hospitalization and death (up to 50% in-hospital mortality). Infections by multidrug-resistant organisms (MDRO) have become a major challenge in the management of cirrhotic patients with significant prognostic and cost-related impact. About one third of cirrhotic patients with bacterial infections is infected with MDR bacteria and their prevalence has increased in recent years. MDR infections have a worse prognosis compared to infections by non-resistant bacteria because they are associated with lower rate of infection resolution. An adequate management of cirrhotic patients with infections caused by MDR bacteria depends on the knowledge of some epidemiological aspects, such as the type of infection (spontaneous bacterial peritonitis, pneumonia, urinary tract infection and spontaneous bacteremia), bacteriological profile of antibiotic resistance at each health care unit and site of infection acquisition (community acquired, healthcare associated or nosocomial). Furthermore, regional variations in the prevalence of MDR infections determine that the choice of empirical antibiotic therapy must be adapted to the local microbiological epidemiology. Antibiotic treatment is the most effective measure to treat infections caused by MDRO. Therefore, optimizing antibiotic prescribing is critical to effectively treat these infections. Identification of risk factors for multidrug resistance is essential to define the best antibiotic treatment strategy in each case and the choice of an effective empirical antibiotic therapy and its early administration is cardinal to reduce mortality. On the other hand, the supply of new agents to treat these infections is very limited. Thus, specific protocols that include preventive measures must be implemented in order to limit the negative impact of this severe complication in cirrhotic patients.
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Affiliation(s)
- Carlos Terra
- Gastroenterology-Liver Unit, State University of Rio de Janeiro, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
- Liver Unit, Casa de Saúde São José-Rede Santa Catarina, Rio de Janeiro 22271-080, Rio de Janeiro, Brazil
- Alliance of Brazilian Centers for Cirrhosis Car, The ABC Group, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
- Liver Unit, Federal Hospital of Lagoa, Rio de Janeiro 22470-050, Rio de Janeiro, Brazil
| | - Ângelo Zambam de Mattos
- Alliance of Brazilian Centers for Cirrhosis Car, The ABC Group, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
- Graduate Program in Medicine: Hepatology, Federal University of Health Sciences of Porto Alegre, Porto Alegre 90020-090, Rio Grande do Sul, Brazil
- Gastroenterology and Hepatology Unit, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90020-090, Rio Grande do Sul, Brazil
| | - Marcelo Souza Chagas
- Gastroenterology-Liver Unit, State University of Rio de Janeiro, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
- Alliance of Brazilian Centers for Cirrhosis Car, The ABC Group, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
- Internal Medicine, Federal Hospital of Lagoa, Rio de Janeiro 22470-050, Rio de Janeiro, Brazil
| | - Andre Torres
- Gastroenterology-Liver Unit, State University of Rio de Janeiro, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
- Alliance of Brazilian Centers for Cirrhosis Car, The ABC Group, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
| | - Denusa Wiltgen
- Alliance of Brazilian Centers for Cirrhosis Car, The ABC Group, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
- Department of Internal Medicine, Federal University of Health Sciences of Porto Alegre, Porto Alegre 90020-090, Brazil
| | - Barbara Muniz Souza
- Gastroenterology-Liver Unit, State University of Rio de Janeiro, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
- Alliance of Brazilian Centers for Cirrhosis Car, The ABC Group, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
| | - Renata Mello Perez
- Alliance of Brazilian Centers for Cirrhosis Car, The ABC Group, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
- Hepatology Division, Federal University of Rio de Janeiro, Rio de Janeiro 21941-617, Rio de Janeiro, Brazil
- IDOR, D’Or Institute for Research and Education, Rio de Janeiro 22281-100, Rio de Janeiro, Brazil
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26
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Královcová M, Karvunidis T, Matějovič M. Critical care for multimorbid patients. VNITRNI LEKARSTVI 2023; 69:166-172. [PMID: 37468311 DOI: 10.36290/vnl.2023.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
Multimorbidity - the simultaneous presence of several chronic diseases - is very common in the critically ill patients. Its prevalence is roughly 40-85 % and continues to increase further. Certain chronic diseases such as diabetes, obesity, chronic heart, pulmonary, liver or kidney disease and malignancy are associated with higher risk of developing serious acute complications and therefore the possible need for intensive care. This review summarizes and discusses selected specifics of critical care for multimorbid patients.
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27
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Majeed A, Bailey M, Kemp W, Majumdar A, Bellomo R, Pilcher D, Roberts SK. Improved survival of cirrhotic patients with infections in Australian and New Zealand ICUs between 2005 and 2017. Liver Int 2023; 43:49-59. [PMID: 35532544 DOI: 10.1111/liv.15285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 03/22/2022] [Accepted: 04/23/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND & AIMS Changes in outcomes of cirrhotic patients admitted to intensive care units (ICUs) with infections are poorly understood. We aimed to describe changes over time in outcomes for such patients and to compare them to other ICU admissions. METHODS Analysis of consecutive admissions to 188 ICUs between 2005 and 2017 as recorded in the Australian and New Zealand Intensive Care Society Centre for Outcome and Research Evaluation Adult Patient Database. RESULTS Admissions for cirrhotic patients with infections accounted for 4645 (0.6%) of 813 189 non-elective ICU admissions. Hospital mortality rate (35.5%) was significantly higher compared with other cirrhotic patients' admissions (28.5%), and other ICU admissions for infection (17.1%, p < .0001), and increased to 52.2% in the presence of acute-on-chronic liver failure (ACLF). Hospital mortality in cirrhotic patients' ICU admissions for infection decreased significantly over time (annual decline odds ratio, 0.97; 95% CI, 0.95-0.99, p = .002). There was a comparable reduction in-hospital mortality rates over time in other ICU admissions for infections and other cirrhotic patients' ICU admissions. However, mortality rates did not change over time in the ACLF subgroup. Median hospital and ICU length of stays for cirrhotic patients' ICU admissions for infections were 12.1 and 3.5 days, respectively, and decreased significantly by 1 day every 4 years in-hospital survivors(p < .0001). CONCLUSION Hospital mortality in ICU admissions for cirrhotic patients with infection is double that of non-cirrhotic patients with infection but has declined significantly over time. Outcomes in the subgroup with ACLF remained poor without significant improvement over the study period.
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Affiliation(s)
- Ammar Majeed
- Department of Gastroenterology, The Alfred Hospital, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), Department of Epidemiology and Preventive Medicine, Monash University, Australia.,ANZICS Centre for Outcome and Resource Evaluation (CORE), Melbourne, Australia
| | - William Kemp
- Department of Gastroenterology, The Alfred Hospital, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - Avik Majumdar
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia.,Central Clinical School, The University of Sydney, Sydney, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), Department of Epidemiology and Preventive Medicine, Monash University, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), Department of Epidemiology and Preventive Medicine, Monash University, Australia.,ANZICS Centre for Outcome and Resource Evaluation (CORE), Melbourne, Australia.,Department of Intensive Care, The Alfred Hospital, Melbourne, Australia
| | - Stuart K Roberts
- Department of Gastroenterology, The Alfred Hospital, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
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28
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Kulkarni AV, Premkumar M, Arab JP, Kumar K, Sharma M, Reddy ND, Padaki NR, Reddy RK. Early Diagnosis and Prevention of Infections in Cirrhosis. Semin Liver Dis 2022; 42:293-312. [PMID: 35672014 DOI: 10.1055/a-1869-7607] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Strategies to prevent infection and improve outcomes in patients with cirrhosis. HAV, hepatitis A virus; HBV, hepatitis B virus; COVID-19, novel coronavirus disease 2019; NSBB, nonselective β-blocker; PPI, proton pump inhibitors.Cirrhosis is a risk factor for infections. Majority of hospital admissions in patients with cirrhosis are due to infections. Sepsis is an immunological response to an infectious process that leads to end-organ dysfunction and death. Preventing infections may avoid the downstream complications, and early diagnosis of infections may improve the outcomes. In this review, we discuss the pathogenesis, diagnosis, and biomarkers of infection; the incremental preventive strategies for infections and sepsi; and the consequent organ failures in cirrhosis. Strategies for primary prevention include reducing gut translocation by selective intestinal decontamination, avoiding unnecessary proton pump inhibitors' use, appropriate use of β-blockers, and vaccinations for viral diseases including novel coronavirus disease 2019. Secondary prevention includes early diagnosis and a timely and judicious use of antibiotics to prevent organ dysfunction. Organ failure support constitutes tertiary intervention in cirrhosis. In conclusion, infections in cirrhosis are potentially preventable with appropriate care strategies to then enable improved outcomes.
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Affiliation(s)
- Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Juan P Arab
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Karan Kumar
- Department of Hepatology, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
| | - Mithun Sharma
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Nageshwar D Reddy
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Nagaraja R Padaki
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Rajender K Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
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29
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Wong YJ, Kumar R. Follow-Up Paracentesis in Spontaneous Bacterial Peritonitis: Prognostic, but May Not Improve Survival. Clin Gastroenterol Hepatol 2022; 20:1615-1616. [PMID: 34371164 DOI: 10.1016/j.cgh.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 08/02/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore; Medicine Academic Clinical Programme, SingHealth Duke-National University of Singapore Academic Medical Centre, Singapore
| | - Rahul Kumar
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore; Medicine Academic Clinical Programme, SingHealth Duke-National University of Singapore Academic Medical Centre, Singapore
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30
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Tranah TH, Kronsten VT, Shawcross DL. Implications and Management of Cirrhosis-Associated Immune Dysfunction Before and After Liver Transplantation. Liver Transpl 2022; 28:700-716. [PMID: 34738724 DOI: 10.1002/lt.26353] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/18/2021] [Accepted: 10/27/2021] [Indexed: 12/28/2022]
Abstract
Cirrhosis-associated immune dysfunction (CAID) describes a panacea of innate and adaptive deficits that result from the sequelae of cirrhotic portal hypertension that is similar in its manifestations regardless of etiology of chronic liver injury. CAID is associated with synchronous observations of dysregulated priming of innate immune effector cells that demonstrate a proinflammatory phenotype but are functionally impaired and unable to adequately prevent invading pathogens. CAID is mainly driven by gut-barrier dysfunction and is associated with deficits of microbial compartmentalization and homeostasis that lead to tonic activation, systemic inflammation, and exhaustion of innate-immune cells. CAID leads to a high frequency of bacterial and fungal infections in patients with cirrhosis that are often associated with acute decompensation of chronic liver disease and acute-on-chronic liver failure and carry a high mortality rate. Understanding the deficits of mucosal and systemic immunity in the context of chronic liver disease is essential to improving care for patients with cirrhosis, preventing precipitants of acute decompensation of cirrhosis, and improving morbidity and survival. In this review, we summarize the detailed dynamic immunological perturbations associated with advanced chronic liver disease and highlight the importance of recognizing immune dysregulation as a sequela of cirrhosis. Furthermore, we address the role of screening, prevention, and early treatment of infections in cirrhosis in improving patient outcomes in transplant and nontransplant settings.
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Affiliation(s)
- Thomas H Tranah
- Institute of Liver Studies, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Institute of Liver Studies, King's College Hospital National Health Service Foundation Trust, London, UK
| | - Victoria T Kronsten
- Institute of Liver Studies, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Institute of Liver Studies, King's College Hospital National Health Service Foundation Trust, London, UK
| | - Debbie L Shawcross
- Institute of Liver Studies, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Institute of Liver Studies, King's College Hospital National Health Service Foundation Trust, London, UK
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31
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Maindad DG, Shenoy S, Shenoy S, Gopal S, Tantry BV. Treatment of Hospital-Acquired Infections in Patients with Cirrhosis - New Challenges. Infect Drug Resist 2022; 15:1039-1048. [PMID: 35313728 PMCID: PMC8934116 DOI: 10.2147/idr.s283723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 03/02/2022] [Indexed: 11/23/2022] Open
Abstract
Background Hospital acquired infections (HAI) in the cirrhotic patients contribute to hepatic decompensation. With emergence of bacterial drug resistance, designing the treatment protocol of HA infection has become the foremost challenge. Purpose To analyze the resistance pattern of organisms isolated from hospital-acquired (HA) infections and determine appropriate antibiotics treatment protocols for these infections. Study Design A prospective hospital based observational study was undertaken. Patients and Methods The present study was conducted over 18 months at Kasturba Medical College, Mangalore, Karnataka, India. Patients with suspected HA infections were subjected to clinical, hematological and microbiological evaluation. Antibiotic sensitivity evaluation was undertaken for the bacteria isolated from these patients. Results During the study period, 398 patients with cirrhosis were 472 times admitted to the hospital for treatment. Out of these patients, 40 patients were diagnosed with 50 HA infections. Fifty five different organisms were isolated from these infections. It was found that these 55 bacteria isolates comprised 30 (54.54%) gram-negative (GN) and 25 (45.45%) gram-positive (GP) bacteria. Quite seriously, extended-spectrum beta-lactamase (ESBL) producers and methicillin-resistant Staphylococcus aureus (MRSA) were detected in 40% and 58% of GN and GP infections respectively. A total of 36 (65.4%) and (14.5%) 8 out of 55 isolated organisms exhibited multi–drug resistance (MDR) and extensive drug resistance (XDR) behavior, respectively. Conclusion Cirrhosis patients with HA infection possess higher prevalence of MDR and XDR infections. In such sick patients, cephalosporin and quinolones are not the appropriate empirical antibiotics. Herein, we propose a tigecycline with carbapenem like meropenem and vancomycin based empirical antibiotics protocol to be prescribed for such patients. De-escalation is advised after the culture sensitivity report is obtained.
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Affiliation(s)
- Dadasaheb G Maindad
- Department of Medical Gastroenterology, Bharati Vidyapeeth University Medical College, Pune, India
| | - Suresh Shenoy
- Department of Gastroenterology, KMC Hospital, Mangalore, India
| | - Suchitra Shenoy
- Department of Microbiology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, India
| | - Sandeep Gopal
- Department of Gastroenterology, KMC Hospital, Mangalore, India
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32
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Simonetti RG, Perricone G, Gluud C. Albumin for people with liver cirrhosis and bacterial infections. Hippokratia 2021. [DOI: 10.1002/14651858.cd014636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Rosa G Simonetti
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research; Capital Region, Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
| | | | - Christian Gluud
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research; Capital Region, Rigshospitalet, Copenhagen University Hospital; Copenhagen Denmark
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33
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Piccolo Serafim L, Simonetto DA, Anderson AL, Choi DH, Weister TJ, Hanson AC, Kamath PS, Gajic O, Gallo de Moraes A. Clinical Effect of Systemic Steroids in Patients with Cirrhosis and Septic Shock. Shock 2021; 56:916-920. [PMID: 34132218 DOI: 10.1097/shk.0000000000001822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Evidence regarding the utility of systemic steroids in treating patients with cirrhosis and septic shock remains equivocal. This study aimed to evaluate and elucidate the association of steroid use with outcomes and adverse effects in a cohort of patients with cirrhosis and septic shock. PATIENTS AND METHODS Retrospective cohort study of patients with cirrhosis and septic shock admitted to a tertiary hospital intensive care unit (ICU) from January 2007 to May 2017, using a validated ICU Datamart. Patients who received vasopressors within 6 h of ICU admission were included in the multivariate analysis. The effect of steroids on outcomes was evaluated using multivariable regression, adjusting for confounding variables. RESULTS Out of 179 admissions of patients with cirrhosis and septic shock, 56 received steroids during the ICU admission. Patients who received steroids received a higher total dose of vasopressors (91.2 mg vs. 39.1 mg, P = 0.04) and had a lower initial lactate level (1.8 mmol/L vs. 2.6 mmol/L, P = 0.007). The multivariate analysis included 117 patients and showed no significant differences in mortality, length of ICU admission, or length of hospital stay. Bleeding events, delirium, and renal-replacement therapy requirements were also not associated with the use of steroids. CONCLUSION The use of systemic steroids was more prevalent in cirrhotic patients with higher vasopressor requirements. It was not associated with decreased mortality or increased ICU- and hospital-free days, or to adverse effects.
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Affiliation(s)
- Laura Piccolo Serafim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Group, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Alexandra L Anderson
- Division of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Dae Hee Choi
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
- Department of Internal Medicine, School of Medicine, Kangwon National University, Chuncheon-si, Gangwon-do, Republic of Korea
| | - Timothy J Weister
- Division of Anesthesiology and Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Andrew C Hanson
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Group, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
- Division of Biomedical Statistics and Informatics, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Group, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Alice Gallo de Moraes
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
- Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Group, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
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Mani I, Vrioni G, Hadziyannis E, Alexopoulos T, Vasilieva L, Tsiriga A, Tsiamis C, Tsakris A, Dourakis SP, Alexopoulou A. Bacterial DNA is a prognostic factor for mortality in patients who recover from spontaneous bacterial peritonitis. Ann Gastroenterol 2021; 34:852-861. [PMID: 34815652 PMCID: PMC8596224 DOI: 10.20524/aog.2021.0665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 05/26/2021] [Indexed: 11/13/2022] Open
Abstract
Background Spontaneous bacterial peritonitis (SBP) is associated with a high mortality. The aim was to investigate whether bacterial deoxyribonucleic acid (bactDNA) could offer an accurate identification of pathogens and to explore its prognostic role during and early after an SBP episode. Methods Consecutive patients with SBP (SBP-group) and patients with decompensated cirrhosis without SBP/bacterascites (control-group) were enrolled. Standard culture methodology was used to isolate and identify pathogens from blood and ascitic fluid (AF). The SeptiFast test was used to identify bactDNA directly from AF. Results Fifty-five patients, median age 60 (interquartile range [IQR] 53-74), model-for-end-stage liver disease (MELD) score 18 (IQR 13-29), with SBP were prospectively included. AF cultures were positive in 52.7% (17.2% drug-resistant bacteria) and bactDNA in 29.1% (58.2% combined sensitivity). BactDNA results were 84.6% concordant with AF cultures. Three patients had positive bactDNA in the culture-negative SBP-group. BactDNA was negative in all 36 of the control group (100% specificity). In multivariate analysis for 7-day survival, factors adversely affecting outcome were MELD (P=0.049) and C-reactive protein (P=0.012). After patients who died during the first week post-admission were excluded, patients with positive bactDNA had a poor prognosis compared to those with a negative test (log-rank P=0.005). Variables independently associated with 30-day mortality were neutrophil-to-lymphocyte ratio (P=0.011) and positive bactDNA (P=0.020). Conclusions No evidence was found for the usefulness of bactDNA to improve bacterial identification during an SBP episode. However, bactDNA was a predictor of 30-day mortality in the subset of patients who recovered from the infection episode.
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Affiliation(s)
- Iliana Mani
- 2 Department of Internal Medicine and Research Laboratory, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece (Iliana Mani, Emilia Hadziyannis, Theodoros Alexopoulos, Larisa Vasilieva, Athanasia Tsiriga, Spyros P. Dourakis, Alexandra Alexopoulou)
| | - Georgia Vrioni
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece (Georgia Vrioni, Constantinos Tsiamis, Athanasios Tsakris)
| | - Emilia Hadziyannis
- 2 Department of Internal Medicine and Research Laboratory, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece (Iliana Mani, Emilia Hadziyannis, Theodoros Alexopoulos, Larisa Vasilieva, Athanasia Tsiriga, Spyros P. Dourakis, Alexandra Alexopoulou)
| | - Theodoros Alexopoulos
- 2 Department of Internal Medicine and Research Laboratory, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece (Iliana Mani, Emilia Hadziyannis, Theodoros Alexopoulos, Larisa Vasilieva, Athanasia Tsiriga, Spyros P. Dourakis, Alexandra Alexopoulou)
| | - Larisa Vasilieva
- 2 Department of Internal Medicine and Research Laboratory, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece (Iliana Mani, Emilia Hadziyannis, Theodoros Alexopoulos, Larisa Vasilieva, Athanasia Tsiriga, Spyros P. Dourakis, Alexandra Alexopoulou)
| | - Athanasia Tsiriga
- 2 Department of Internal Medicine and Research Laboratory, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece (Iliana Mani, Emilia Hadziyannis, Theodoros Alexopoulos, Larisa Vasilieva, Athanasia Tsiriga, Spyros P. Dourakis, Alexandra Alexopoulou)
| | - Constantinos Tsiamis
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece (Georgia Vrioni, Constantinos Tsiamis, Athanasios Tsakris)
| | - Athanasios Tsakris
- Department of Microbiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece (Georgia Vrioni, Constantinos Tsiamis, Athanasios Tsakris)
| | - Spyros P Dourakis
- 2 Department of Internal Medicine and Research Laboratory, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece (Iliana Mani, Emilia Hadziyannis, Theodoros Alexopoulos, Larisa Vasilieva, Athanasia Tsiriga, Spyros P. Dourakis, Alexandra Alexopoulou)
| | - Alexandra Alexopoulou
- 2 Department of Internal Medicine and Research Laboratory, Medical School, National and Kapodistrian University of Athens, Hippokration Hospital, Athens, Greece (Iliana Mani, Emilia Hadziyannis, Theodoros Alexopoulos, Larisa Vasilieva, Athanasia Tsiriga, Spyros P. Dourakis, Alexandra Alexopoulou)
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Chebl RB, Tamim H, Sadat M, Qahtani S, Dabbagh T, Arabi YM. Outcomes of septic cirrhosis patients admitted to the intensive care unit: A retrospective cohort study. Medicine (Baltimore) 2021; 100:e27593. [PMID: 34797280 PMCID: PMC8601275 DOI: 10.1097/md.0000000000027593] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 10/04/2021] [Indexed: 01/05/2023] Open
Abstract
The aim of this study is to examine the outcome of septic patients with cirrhosis admitted to the intensive care unit (ICU) and predictors of mortality.Single center, retrospective cohort study.The study was conducted in Intensive care Department of King Abdulaziz Medical City, Riyadh, Saudi Arabia.Data was extracted from a prospectively collected ICU database managed by a full time data collector. All patients with an admission diagnosis of sepsis according to the sepsis-3 definition were included from 2002 to 2017. Patients were categorized into 2 groups based on the presence or absence of cirrhosis.The primary outcome of the study was in-hospital mortality. Secondary outcomes included ICU mortality, ICU and hospital lengths of stay and mechanical ventilation duration.A total of 7906 patients were admitted to the ICU with sepsis during the study period, of whom 497 (6.29%) patients had cirrhosis. 64.78% of cirrhotic patients died during their hospital stay compared to 31.54% of non-cirrhotic. On multivariate analysis, cirrhosis patients were at greater odds of dying within their hospital stay as compared to non-cirrhosis patients (Odds ratio {OR} 2.53; 95% confidence interval {CI} 2.04 - 3.15) independent of co-morbidities, organ dysfunction or hemodynamic status. Among cirrhosis patients, elevated international normalization ratio (INR) (OR 1.69; 95% CI 1.29-2.23), hemodialysis (OR 3.09; 95% CI 1.76-5.42) and mechanical ventilation (OR 2.61; 95% CI 1.60-4.28) were the independent predictors of mortality.Septic cirrhosis patients admitted to the intensive care unit have greater odds of dying during their hospital stay. Among septic cirrhosis patients, elevated INR and the need for hemodialysis and mechanical ventilation were associated with increased mortality.
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Affiliation(s)
- Ralphe Bou Chebl
- Department of Emergency Medicine, American University of Beirut, Lebanon
| | - Hani Tamim
- Department of Emergency Medicine, American University of Beirut, Lebanon
| | - Musharaf Sadat
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Saad Qahtani
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Tarek Dabbagh
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Yaseen M. Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
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Biggins SW, Angeli P, Garcia-Tsao G, Ginès P, Ling SC, Nadim MK, Wong F, Kim WR. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2021; 74:1014-1048. [PMID: 33942342 DOI: 10.1002/hep.31884] [Citation(s) in RCA: 438] [Impact Index Per Article: 109.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 12/13/2022]
Affiliation(s)
- Scott W Biggins
- Division of Gastroenterology and Hepatology, and Center for Liver Investigation Fostering discovEryUniversity of WashingtonSeattleWA
| | - Paulo Angeli
- Unit of Hepatic Emergencies and Liver TransplantationDepartment of MedicineDIMEDUniversity of PadovaPaduaItaly
| | - Guadalupe Garcia-Tsao
- Department of Internal MedicineSection of Digestive DiseasesYale UniversityNew HavenCT
- VA-CT Healthcare SystemWest HavenCT
| | - Pere Ginès
- Liver Unit, Hospital Clinic, and Institut d'Investigacions Biomèdiques August Pi i SunyerUniversity of BarcelonaBarcelonaSpain
- Centro de Investigación Biomèdica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD)MadridSpain
| | - Simon C Ling
- The Hospital for Sick Children, Division of Gastroenterology, Hepatology and Nutrition, and Department of PaediatricsUniversity of TorontoTorontoOntarioCanada
| | - Mitra K Nadim
- Division of NephrologyUniversity of Southern CaliforniaLos AngelesCA
| | - Florence Wong
- Division of Gastroenterology and HepatologyUniversity Health NetworkUniversity of TorontoTorontoOntarioCanada
| | - W Ray Kim
- Division of Gastroenterology and HepatologyStanford UniversityPalo AltoCA
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Abstract
Liver transplantation (LT) has revolutionized outcomes for cirrhotic patients. Current liver allocation policies dictate patients with highest short-term mortality receive the highest priority, thus, several patients become increasingly ill on the waitlist. Given cirrhosis is a progressive disease, it can be complicated by the occurrence of acute-on-chronic liver failure (ACLF), a syndrome defined by an acute deterioration of liver function associated with extrahepatic organ failures requiring intensive care support and a high short-term mortality. Successfully bridging to transplant includes accurate prognostication and prioritization of ACLF patients awaiting LT, optimizing intensive care support pre-LT, and tailoring immunosuppressive and anti-infective therapies post-LT. Furthermore, predicting futility (too sick to undergo LT) in ACLF is challenging. In this review, we summarize the role of LT in ACLF specifically highlighting (a) current prognostic scores in ACLF, (b) critical care management of the ACLF patient awaiting LT, (c) donor issues to consider in transplant in ACLF, and (d) exploring of recent post-LT outcomes in ACLF and potential opportunities to improve outcomes including current care gaps and unmet research needs.
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Gupta K, Bhurwal A, Law C, Ventre S, Minacapelli CD, Kabaria S, Li Y, Tait C, Catalano C, Rustgi VK. Acute kidney injury and hepatorenal syndrome in cirrhosis. World J Gastroenterol 2021; 27:3984-4003. [PMID: 34326609 PMCID: PMC8311533 DOI: 10.3748/wjg.v27.i26.3984] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 03/19/2021] [Accepted: 06/22/2021] [Indexed: 02/06/2023] Open
Abstract
Acute kidney injury (AKI) in cirrhosis, including hepatorenal syndrome (HRS), is a common and serious complication in cirrhotic patients, leading to significant morbidity and mortality. AKI is separated into two categories, non-HRS AKI and HRS-AKI. The most recent definition and diagnostic criteria of AKI in cirrhosis and HRS have helped diagnose and prognosticate the disease. The pathophysiology behind non-HRS-AKI and HRS is more complicated than once theorized and involves more processes than just splanchnic vasodilation. The common biomarkers clinicians use to assess kidney injury have significant limitations in cirrhosis patients; novel biomarkers being studied have shown promise but require further studies in clinical settings and animal models. The overall management of non-HRS AKI and HRS-AKI requires a systematic approach. Although pharmacological treatments have shown mortality benefit, the ideal HRS treatment option is liver transplantation with or without simultaneous kidney transplantation. Further research is required to optimize pharmacologic and nonpharmacologic approaches to treatment. This article reviews the current guidelines and recommendations of AKI in cirrhosis.
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Affiliation(s)
- Kapil Gupta
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, United States
| | - Abhishek Bhurwal
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, United States
| | - Cindy Law
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, United States
| | - Scott Ventre
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, United States
| | - Carlos D Minacapelli
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, United States
| | - Savan Kabaria
- Department of Internal Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, United States
| | - You Li
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, United States
| | - Christopher Tait
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, United States
| | - Carolyn Catalano
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, United States
| | - Vinod K Rustgi
- Division of Gastroenterology and Hepatology, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, United States
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Fernández J, Piano S, Bartoletti M, Wey EQ. Management of bacterial and fungal infections in cirrhosis: The MDRO challenge. J Hepatol 2021; 75 Suppl 1:S101-S117. [PMID: 34039482 DOI: 10.1016/j.jhep.2020.11.010] [Citation(s) in RCA: 91] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 12/12/2022]
Abstract
Bacterial infections are frequent in cirrhotic patients with acute decompensation or acute-on-chronic liver failure and can complicate the clinical course. Delayed diagnosis and inappropriate empirical treatments are associated with poor prognosis and increased mortality. Fungal infections are much less frequent, usually nosocomial and associated with extremely high short-term mortality. Early diagnosis and adequate empirical treatment of infections is therefore key in the management of these patients. In recent decades, antibiotic resistance has become a major worldwide problem in patients with cirrhosis, warranting a more complex approach to antibiotic treatment that includes the use of broad-spectrum antibiotics, new administration strategies, novel drugs and de-escalation policies. Herein, we review epidemiological changes, the main types of multidrug-resistant organisms, mechanisms of resistance, new rapid diagnostic tools and currently available therapeutic options for bacterial and fungal infections in cirrhosis.
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Affiliation(s)
- Javier Fernández
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain; European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain.
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Michele Bartoletti
- Infectious Disease Unit- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Emmanuel Q Wey
- ILDH, Division of Medicine, University College London Medical School, London, United Kingdom; Centre for Clinical Microbiology, Division of Infection & Immunity, UCL, London, United Kingdom; Department of Infection, Royal Free London NHS Trust London, United Kingdom
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Piano S, Tonon M, Angeli P. Changes in the epidemiology and management of bacterial infections in cirrhosis. Clin Mol Hepatol 2021; 27:437-445. [PMID: 33504138 PMCID: PMC8273641 DOI: 10.3350/cmh.2020.0329] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/07/2021] [Accepted: 01/25/2021] [Indexed: 12/15/2022] Open
Abstract
Patients with cirrhosis are susceptible to develop infections because of immune dysfunction, changes in microbiome and increase in bacterial translocation from the gut to systemic circulation. Bacterial infections can worse the clinical course of the disease, triggering the development of complications such as acute kidney injury, hepatic encephalopathy, organ failures and acute on chronic liver failure. In recent years, the spread of multi drug resistant bacteria made more challenging the management of infections in patients with cirrhosis. Hence, the mortality rate associated to sepsis is increasing in these patients. Therefore, the optimization of the management of infections has a high priority in cirrhosis. Herein we reviewed the recent changes in the epidemiology and the management of bacterial infections in patients with liver cirrhosis.
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Affiliation(s)
- Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Marta Tonon
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
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Bernal W, Karvellas C, Saliba F, Saner FH, Meersseman P. Intensive care management of acute-on-chronic liver failure. J Hepatol 2021; 75 Suppl 1:S163-S177. [PMID: 34039487 DOI: 10.1016/j.jhep.2020.10.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 02/07/2023]
Abstract
The syndrome of acute-on-chronic liver failure combines deterioration of liver function in a patient with chronic liver disease, with the development of extrahepatic organ failure and high short-term mortality. Its successful management demands a rapid and coherent response to the development of dysfunction and failure of multiple organ systems in an intensive care unit setting. This response recognises the features that distinguish it from other critical illness and addresses the complex interplay between the precipitating insult, the many organ systems involved and the disordered physiology of underlying chronic liver disease. An evidence base is building to support the approaches currently adopted and outcomes for patients with this condition are improving, but mortality remains unacceptably high. Herein, we review practical considerations in critical care management, as well as discussing key knowledge gaps and areas of controversy that require further focussed research.
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Affiliation(s)
- William Bernal
- Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, Denmark Hill, London SE5 9RS, United Kingdom.
| | - Constantine Karvellas
- Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, 1-40 Zeidler Ledcor Building, Edmonton, Alberta T6G-2X8, Canada
| | - Faouzi Saliba
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris SACLAY, INSERM Unit 1193, Villejuif, France
| | - Fuat H Saner
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum Essen Hufelandstr. 55 45 147, Essen, Germany
| | - Philippe Meersseman
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium
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Miranda-Zazueta G, León-Garduño LAPD, Aguirre-Valadez J, Torre-Delgadillo A. Bacterial infections in cirrhosis: Current treatment. Ann Hepatol 2021; 19:238-244. [PMID: 32317149 DOI: 10.1016/j.aohep.2019.09.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 08/28/2019] [Accepted: 09/03/2019] [Indexed: 02/08/2023]
Abstract
Bacterial infections frequently cause decompensating events in cirrhotic patients and are also the most common factor identified for the development of acute-on-chronic liver failure (ACLF). The increase in the prevalence of infections caused by multidrug-resistant (MDR) microorganisms has resulted in the reduced effectiveness of empiric antimicrobial treatment. We conducted a PubMed search from the last 20 years using the Keywords cirrhosis; multidrug-resistant; infections; diagnosis; treatment; prophylaxis; monitoring; sepsis; nutrition and antibiotic resistant. We made a review about bacterial infections among cirrhotic patients; we mainly focus on the description of diagnostic tools; biomarkers; clinical scores for diagnosis and prognosis also; we made an analysis concerning the monitoring of cirrhotic patients with sepsis and finally made some recommendations about the treatment; prophylaxis and prevention.
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Affiliation(s)
- Godolfino Miranda-Zazueta
- Hepatology and Liver Transplantation Unit, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | - Luis A Ponce de León-Garduño
- Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico
| | | | - Aldo Torre-Delgadillo
- Hepatology and Liver Transplantation Unit, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán", Mexico City, Mexico.
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Yang YY, Hsu YC. Effectiveness of sepsis bundle application and outcomes predictors to cirrhotic patients with septic shock. BMC Infect Dis 2021; 21:483. [PMID: 34039297 PMCID: PMC8157624 DOI: 10.1186/s12879-021-06194-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 05/17/2021] [Indexed: 12/29/2022] Open
Abstract
Introduction Cirrhotic patients with septic shock have a poorer prognosis compared with the general population. Our study aimed to investigate the survival benefit of the implementation of hour-1 bundle proposed by Surviving Sepsis Campaign, and to analyze the predictors associated with short-term mortality of these patients. Methods A single-center, retrospective case-control study was conducted among adult patients who visited the emergency department between January 1, 2018 and December 31, 2019. All patients with a diagnosis of liver cirrhosis and septic shock were enrolled. Their baseline characteristics, laboratory results, source of sepsis, and sepsis bundle management were recorded. We further divided the patients into survivor and non-survivor groups to identify independent prognostic factors. Results A total of 88 patients were eligible for this study. The overall 30-day mortality rate was 53.4% (47/88). The proportion of hour-1 bundle achievement was 30.7% (27/88). There were no significant mortality differences between the hour-1 bundle achievement and non-achievement groups (44.4% vs. 57.4%, p = 0.35). Compared with the patients in the survivor group, patients in the non-survivor group had significantly more advanced stage of cirrhosis and a lower proportion of receiving source control (4.3% vs. 22.0%, p = 0.02). The chronic liver failure-sequential organ failure assessment (CLIF-SOFA) score (adjusted hazard ratio [AHR] =1.52, p < 0.01), serum lactate (AHR =1.03, p < 0.01), and source control (AHR =0.54, p = 0.02) were identified as independent prognostic factors in the multivariate regression model. Furthermore, the CLIF-SOFA score (area under curve [AUC]: 0.81) and lactate levels (AUC: 0.77) revealed good mortality discrimination ability in cirrhotic patients with septic shock. Conclusions The application of the hour-1 bundle did not reveal a significant survival benefit to cirrhotic patients with septic shock. Clinicians could utilize CLIF-SOFA scores and lactate levels for mortality risk stratification and put more emphasis on the feasibility of source control to improve their prognosis.
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Affiliation(s)
- Yong-Ye Yang
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, No.1, Yida Road, Jiao-su Village, Yan-chao District, Kaohsiung City, 82445, Taiwan
| | - Yin-Chou Hsu
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, No.1, Yida Road, Jiao-su Village, Yan-chao District, Kaohsiung City, 82445, Taiwan. .,School of Medicine for International Student, I-Shou University, Kaohsiung, Taiwan.
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Adenote A, Dumic I, Madrid C, Barusya C, Nordstrom CW, Rueda Prada L. NAFLD and Infection, a Nuanced Relationship. Can J Gastroenterol Hepatol 2021; 2021:5556354. [PMID: 33977096 PMCID: PMC8087474 DOI: 10.1155/2021/5556354] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 03/30/2021] [Accepted: 04/05/2021] [Indexed: 02/06/2023] Open
Abstract
The prevalence of nonalcoholic fatty liver disease (NAFLD) has increased significantly over the last few decades mirroring the increase in obesity and type II diabetes mellitus. NAFLD has become one of the most common indications for liver transplantation. The deleterious effects of NAFLD are not isolated to the liver only, for it has been recognized as a systemic disease affecting multiple organs through protracted low-grade inflammation mediated by the metabolic activity of excessive fat tissue. Extrahepatic manifestations of NAFLD such as cardiovascular disease, polycystic ovarian syndrome, chronic kidney disease, and hypothyroidism have been well described in the literature. In recent years, it has become evident that patients suffering from NAFLD might be at higher risk of developing various infections. The proposed mechanism for this association includes links through hyperglycemia, insulin resistance, alterations in innate immunity, obesity, and vitamin D deficiency. Additionally, a risk independent of these factors mediated by alterations in gut microbiota might contribute to a higher burden of infections in these individuals. In this narrative review, we synthetize current knowledge on several infections including urinary tract infection, pneumonia, Helicobacter pylori, coronavirus disease 2019, and Clostridioides difficile as they relate to NAFLD. Additionally, we explore NAFLD's association with hidradenitis suppurativa.
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Affiliation(s)
- Abimbola Adenote
- Division of Hospital Internal Medicine, Mayo Clinic Health System, Eau Claire, WI, USA
- Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Igor Dumic
- Division of Hospital Internal Medicine, Mayo Clinic Health System, Eau Claire, WI, USA
- Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Cristian Madrid
- Division of Hospital Internal Medicine, Mayo Clinic Health System, Eau Claire, WI, USA
- Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Christopher Barusya
- Division of Hospital Internal Medicine, Mayo Clinic Health System, Eau Claire, WI, USA
- Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Charles W. Nordstrom
- Division of Hospital Internal Medicine, Mayo Clinic Health System, Eau Claire, WI, USA
- Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Libardo Rueda Prada
- Division of Hospital Internal Medicine, Mayo Clinic Health System, Eau Claire, WI, USA
- Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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Magro B, Mazzola A, Munteanu M, Goumard C, Martinez V, Bernard D, Scatton O, Battaglia S, Celsa C, Cammà C, Conti F. Consequences of Extended Spectrum Beta-Lactamase-Producing Enterobacteriaceae and Methicillin-Resistant Staphylococcus aureus Carriage in Awaiting Liver Transplant Patients. Liver Transpl 2021; 27:43-54. [PMID: 32955790 DOI: 10.1002/lt.25897] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 07/03/2020] [Accepted: 07/23/2020] [Indexed: 01/13/2023]
Abstract
Infections in patients with cirrhosis are associated with liver-related complications (LRCs), especially in patients awaiting liver transplantation (LT). The aim of this study was to evaluate the impact of methicillin-resistant Staphylococcus aureus (MRSA) and extended spectrum beta-lactamase colonization on infections and LRCs for patients on the wait list and on infections after LT. We retrospectively included 250 of 483 patients with cirrhosis who were placed on the wait list for LT from December 2015 to January 2018. These patients were screened for MRSA or extended spectrum beta-lactamase-producing Enterobacteriaceae (ESBLE) at the time of wait-list placement and after LT. Of the patients, 76% were male with a mean age of 57.5 ± 10 years, and the most frequent cause of liver disease was alcohol (39%). Median Model for End-Stage Liver Disease (MELD) score was 19 (12-28). Only 1 patient was positive for MRSA; 19% of patients (n = 47) had ESBLE fecal carriage at the time of wait-list placement and 15% (n = 37) had it after LT. Infection-free survival on the wait list and after LT, according to fecal carriage status, was not statistically different between 2 groups. LRC-free survival at 6 and 12 months was significantly lower in ESBLE fecal carriage (HR, 1.6; P = 0.04). MELD score >19 (HR, 3.0; P = 0.01) and occurrence of infection during the first 3 months on the wait list (HR, 4.13; P < 0.001) were independent risk factors for LRC occurrence in the multivariate analysis. Our study is the first showing that in a cohort of patients with cirrhosis waiting for LT LRC-free survival was lower in patients with ESBLE fecal carriage but that infection-free survival was not different between the 2 groups.
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Affiliation(s)
- Bianca Magro
- Liver Transplantation Unit, Hôpital Pitié-Salpêtrière, APHP, Paris, France.,Section of Gastroenterology and Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Alessandra Mazzola
- Liver Transplantation Unit, Hôpital Pitié-Salpêtrière, APHP, Paris, France.,Research Center of Saint-Antoine, INSERM U938, Sorbonne Université, Paris, France
| | - Mona Munteanu
- Nutrition Institute, INSERM, Sorbonne Université, Paris, France
| | - Claire Goumard
- Hepato-Biliary and Liver Transplantation Surgical Unit, Hôpital Pitié-Salpêtrière, APHP, Paris, France
| | - Valerie Martinez
- Infectious Diseases Unit, Hôpital Pitié-Salpêtrière, APHP, Paris, France
| | - Denis Bernard
- Intensive Care Unit, Hôpital Pitié-Salpêtrière, APHP, Paris, France
| | - Olivier Scatton
- Hepato-Biliary and Liver Transplantation Surgical Unit, Hôpital Pitié-Salpêtrière, APHP, Paris, France
| | - Salvatore Battaglia
- Department of Economics, Business and Statistics, University of Palermo, Palermo, Italy
| | - Ciro Celsa
- Section of Gastroenterology and Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy.,Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Calogero Cammà
- Section of Gastroenterology and Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, University of Palermo, Palermo, Italy
| | - Filomena Conti
- Liver Transplantation Unit, Hôpital Pitié-Salpêtrière, APHP, Paris, France.,Research Center of Saint-Antoine, INSERM U938, Sorbonne Université, Paris, France.,Nutrition Institute, INSERM, Sorbonne Université, Paris, France
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Bhattacharya C, Das-Mondal M, Gupta D, Sarkar AK, Kar-Purkayastha S, Konar A. Infection in cirrhosis: A prospective study. Ann Hepatol 2020; 18:862-868. [PMID: 31635968 DOI: 10.1016/j.aohep.2019.07.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 07/02/2019] [Accepted: 07/02/2019] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Multidrug-resistant (MDR) infections in cirrhosis are associated with poor outcomes. We attempted a prospective study on infections in patients with cirrhosis evaluating microbiology of these infections and how outcomes depended on factors like bacterial resistance, appropriate antibiotics, stage of liver disease and whether outcomes were significantly different from patients who did not have infections. MATERIALS AND METHODS This was a prospective evaluation involving one hundred and fifty nine patients with cirrhosis who were admitted at Peerless Hospitex Hospital and Research Center, Kolkata, West Bengal, India, during a 24 month period. One hundred and nineteen of these patients either had an infection at the time of admission or developed infection during hospitalization. Forty patients did not have an infection at admission and did not acquire infection while admitted. Data was collected about demographics, etiology of cirrhosis, liver and renal function and microbiology. RESULTS Infections were community acquired in 27.7% of patients, healthcare associated in 52.9% and nosocomial in 19.3%. Gram negative bacilli (Escherichia coli 47.4% Klebsiella pneumoniae 23%) were common. 84.9% of enterobacteriaceae produced ESBL, AmpC or Carbapenemases. Spontaneous bacteria peritonitis (SBP) and urinary tract infection (UTI) were the most common sites of infection. In hospital mortality was 21.9%. Non-survivors had higher MELD (26 vs 19, p<0.001) and CTP scores (11.7 vs 10.3, p<0.001). The control group had lower MELD (16.65 vs. 20.8, p<0.001) and CTP scores (9.25 vs 10.59, p<0.001). CONCLUSIONS MDR infections are common in patients with cirrhosis and have serious implications for treatment and outcomes.
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Affiliation(s)
- Chandramouli Bhattacharya
- Department of General Medicine, Peerless Hospitex Hospital and Research Center, Kolkata, West Bengal, India.
| | - Manisha Das-Mondal
- Department of Gastroenterology, Peerless Hospitex Hospital and Research Center, Kolkata, West Bengal, India
| | - Debkishore Gupta
- Department of Microbiology, Peerless Hospitex Hospital and Research Center, Kolkata, West Bengal, India
| | - Ajoy K Sarkar
- Department of General Medicine, Peerless Hospitex Hospital and Research Center, Kolkata, West Bengal, India
| | - Sujit Kar-Purkayastha
- Department of Gastroenterology, Peerless Hospitex Hospital and Research Center, Kolkata, West Bengal, India
| | - Asokananda Konar
- Department of Gastroenterology, Peerless Hospitex Hospital and Research Center, Kolkata, West Bengal, India
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Mattos AA, Wiltgen D, Jotz RF, Dornelles CMR, Fernandes MV, Mattos ÂZ. Spontaneous bacterial peritonitis and extraperitoneal infections in patients with cirrhosis. Ann Hepatol 2020; 19:451-457. [PMID: 32533951 DOI: 10.1016/j.aohep.2020.04.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 03/22/2020] [Accepted: 04/07/2020] [Indexed: 02/04/2023]
Abstract
Infections are a frequent complication and a major cause of death among patients with cirrhosis. The important impact of infections in general and especially spontaneous bacterial peritonitis on the course of disease and prognosis of patients with cirrhosis has been recognized for many years. Nevertheless, such importance has recently increased due to the comprehension of infection as one of the most prominent risk factors for patients to develop acute-on-chronic liver failure. Furthermore, the issue of infections in cirrhosis is a focus of increasing attention because of the spreading of multidrug resistant bacteria, which is an emerging concern among physicians assisting patients with cirrhosis. In the present paper, we will review the current epidemiology of infections in patients with cirrhosis and particularly that of infections caused by resistant bacteria, demonstrating the relevance of the subject. Besides, we will discuss the current recommendations on diagnosis and treatment of different kinds of infections, including spontaneous bacterial peritonitis, and we will highlight the importance of knowing local microbiological profiles and choosing empirical antibiotic therapy wisely. Finally, we will debate the existing evidences regarding the role of volume expansion with albumin in patients with cirrhosis and extraperitoneal infections, and that of antibiotic prophylaxis of spontaneous bacterial peritonitis.
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Affiliation(s)
- Angelo A Mattos
- Federal University of Health Sciences of Porto Alegre, Graduate Program in Medicine: Hepatology, Brazil; Irmandade Santa Casa de Misericórdia de Porto Alegre, Brazil
| | - Denusa Wiltgen
- Irmandade Santa Casa de Misericórdia de Porto Alegre, Brazil; Federal University of Health Sciences of Porto Alegre, Brazil
| | - Raquel F Jotz
- Federal University of Health Sciences of Porto Alegre, Brazil
| | | | | | - Ângelo Z Mattos
- Federal University of Health Sciences of Porto Alegre, Graduate Program in Medicine: Hepatology, Brazil; Irmandade Santa Casa de Misericórdia de Porto Alegre, Brazil.
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Allaire M, Cadranel JF, Nguyen TTN, Garioud A, Zougmore H, Heng R, Perignon C, Ollivier-Hourmand I, Dao T. Management of infections in patients with cirrhosis in the context of increasing therapeutic resistance: A systematic review. Clin Res Hepatol Gastroenterol 2020; 44:264-274. [PMID: 31706985 DOI: 10.1016/j.clinre.2019.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 09/23/2019] [Accepted: 10/04/2019] [Indexed: 02/04/2023]
Abstract
Patients with cirrhosis are prone to develop bacterial infections, which consist in one of the major precursors of Acute-on-Chronic Liver Failure (ACLF) and are responsible for a high mortality rate. In recent years, the management of bacterial infections in patients with cirrhosis has become increasingly complicated due to a change in bacterial ecology associated with a higher rate of cocci gram positive bacteria in Europe and America along with the emergence of a multidrug-resistant (MDR) and extensively drug-resistant (XDR) bacteria leading to a decrease in the efficacy of empirical strategies based on the administration of third-generation cephalosporins. MDR and XDR now account for about 40% of the infections worldwide, and up to 70% in India. Among them, the most common ones are extended-spectrum beta-lactamase producing (ESBL-P) bacteria, carbapenem-resistant enterobacteriaceae (CRE), Methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant enterococci (VRE). An early diagnosis associated to an empirical antibiotic adapted to the site of infection and potential bacterial resistance is now crucial in order to improve the chances of survival and contain the resistance phenomenon. Moreover, a fungal infection must always be discussed in these high-risks patients, especially in the absence of clinical improvement under appropriate antibiotic treatment. In this review, we will focus on the emerging threat of MDR and XDR organisms, as well as fungal infections, in order to better adapt the therapeutic management of cirrhotic patients with infections.
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Affiliation(s)
- Manon Allaire
- Service d'hépato-gastro-entérologie et nutrition, CHU Côte de Nacre, 14000 Caen, France; Unité Inserm-U1149, Centre de recherche sur l'inflammation, 75018 Paris, France.
| | - Jean-François Cadranel
- Service d'hépato-gastro-entérologie de nutrition et d'alcoologie, GHPSO, 60100 Creil, France
| | - Thi Thu Nga Nguyen
- Service d'hépato-gastro-entérologie et nutrition, CHU Côte de Nacre, 14000 Caen, France
| | - Armand Garioud
- Service d'hépato-gastro-entérologie de nutrition et d'alcoologie, GHPSO, 60100 Creil, France
| | - Honore Zougmore
- Service d'hépato-gastro-entérologie de nutrition et d'alcoologie, GHPSO, 60100 Creil, France
| | - Ratmony Heng
- Service d'hépato-gastro-entérologie de nutrition et d'alcoologie, GHPSO, 60100 Creil, France
| | - Claire Perignon
- Service d'hépato-gastro-entérologie et nutrition, CHU Côte de Nacre, 14000 Caen, France
| | | | - Thông Dao
- Service d'hépato-gastro-entérologie et nutrition, CHU Côte de Nacre, 14000 Caen, France
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49
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Management of liver failure in general intensive care unit. Anaesth Crit Care Pain Med 2020; 39:143-161. [PMID: 31525507 DOI: 10.1016/j.accpm.2019.06.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 06/30/2019] [Indexed: 12/11/2022]
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50
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Sutherland AK, Berman AR. Management of Acute and Acute on Chronic Liver Failure in the Intensive Care Unit Setting. LIVER FAILURE 2020:143-166. [DOI: 10.1007/978-3-030-50983-5_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2025]
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