Published online Mar 26, 2020. doi: 10.12998/wjcc.v8.i6.1042
Peer-review started: December 10, 2019
First decision: December 30, 2019
Revised: January 7, 2020
Accepted: March 5, 2020
Article in press: March 5, 2020
Published online: March 26, 2020
Hepatitis B virus (HBV) related acute-on-chronic liver failure (ACLF) is a complicated syndrome with a high short-term mortality rate that develops in patients with HBV related chronic liver disease (CLD) regardless of the presence of cirrhosis and is characterized by acute deterioration of liver function and hepatic and/or extrahepatic organ failure. Bacterial infections (BIs) trigger ACLF and play pivotal roles in the deterioration of clinical course.
The Chinese Group on the Study of Severe Hepatitis B (COSSH) has recently developed a new criterion for HBV-ACLF. However, the clinical characteristics, survival rates, and prognostic effects of BIs in the COSSH definition for patients with HBV-ACLF are unclear. Patients with COSSH-HBV-ACLF combined with first BIs were selected for this study.
This study aimed to investigate the clinical characteristics, the site of BIs, bacterial detection, 28-d outcomes, and independent predictors of outcomes of first BIs either at admission or during hospitalization in patients with HBV-ACLF as defined by the COSSH.
A total of 159 patients with HBV-ACLF and 40 patients with acute decompensation of HBV-CLD combined with first BIs were selected for a retrospective analysis between October 2014 and March 2016. The characteristics of BIs, the site of BIs, and bacterial detection were evaluated. Cumulative survival probability curves of the 28-d transplant-free survival rates were calculated by Kaplan–Meier method and compared by log-rank test. COX proportional hazard regression analysis was used to screen the independent predictors of 28-d outcomes.
A total of 194 episodes of BIs occurred in 159 patients with HBV-ACLF. Among the episodes, 13.4% were community-acquired, 46.4% were healthcare-associated, and 40.2% belonged to nosocomial BIs. Pneumonia (40.7%), spontaneous bacterial peritonitis (SBP) (34.5%), and bloodstream infection (BSI) (13.4%) were the most prevalent. As the ACLF grade increased, the incidence of SBP showed a downward trend (P = 0.021). Sixty-one strains of bacteria, including 83.6% of Gram-negative bacteria and 29.5% of multidrug-resistant organisms (MDROs), were cultivated from 50 patients with ACLF. E. coli (44.3%) and K. pneumoniae (23.0%) were the most common bacteria. As the ACLF grade increased, the 28-d transplant-free survival rates showed a downward trend (ACLF-1, 55.7%; ACLF-2, 29.3%; ACLF-3, 5.4%; P < 0.001). The independent predictors of the 28-d outcomes of patients with HBV-ACLF were COSSH-ACLF score (hazard ratio [HR] = 1.371), acute kidney injury (AKI) (HR = 2.187), BSI (HR = 2.339), prothrombin activity (PTA) (HR = 0.967), and invasive catheterization (HR = 2.173).
For patients with COSSH-HBV-ACLF combined with first BIs, pneumonia is the most common, and the incidence of SBP decreases with increasing ACLF grade. Gram-negative bacteria account for the majority of cultured bacteria, and MDROs are common. The 28-d transplant-free survival rate of patients is very low and decreases with increasing ACLF grade. The independent predictors of the 28-d outcomes are COSSH-ACLF score, AKI, BSI, PTA, and invasive catheterization.
The clinical characteristics, the site of BIs, bacterial detection, 28-d outcomes and independent predictors of outcomes of first BIs in patients with COSSH-HBV-ACLF were described in detail in this study. However, this single-center retrospective study had a small sample size. Hence, additional multi-center prospective randomized study studies should be conducted to reveal the role of BIs in the deterioration of clinical course in patients with COSSH-HBV-ACLF in the future.