Second infections independently increase mortality in hospitalized patients With cirrhosis: the north american consortium for the study of end-stage liver disease (NACSELD) experience

• Published in: Hepatology (Baltimore, Md.) Vol. 56; no. 6; pp. 2328 - 2335
• Main Authors: Bajaj, Jasmohan S., O'Leary, Jacqueline G., Reddy, K. Rajender, Wong, Florence, Olson, Jody C., Subramanian, Ram M., Brown, Geri, Noble, Nicole A., Thacker, Leroy R., Kamath, Patrick S.
• Format: Journal Article
• Language: English
• Published: Hoboken Wiley Subscription Services, Inc., A Wiley Company 01.12.2012; Wiley; Wolters Kluwer Health, Inc
• Subjects: Bacterial Infections - complications; Bacterial Infections - microbiology; Bacterial Infections - mortality; Biological and medical sciences; Candidiasis - microbiology; Candidiasis - mortality; Catheter-Related Infections - microbiology; Clostridium difficile; Community-Acquired Infections - microbiology; Community-Acquired Infections - mortality; Cross Infection - microbiology; Cross Infection - mortality; End Stage Liver Disease - complications; End Stage Liver Disease - mortality; Enterocolitis, Pseudomembranous - microbiology; Enterocolitis, Pseudomembranous - mortality; Fatalities; Female; Gastroenterology. Liver. Pancreas. Abdomen; Hepatology; Hospital Mortality; Humans; Infections; Length of Stay; Liver cirrhosis; Liver Cirrhosis - complications; Liver Cirrhosis - mortality; Liver diseases; Liver. Biliary tract. Portal circulation. Exocrine pancreas; Logistic Models; Male; Medical sciences; Middle Aged; Mortality; Multivariate Analysis; Organ Dysfunction Scores; Other diseases. Semiology; Prospective Studies; Risk Factors; Severity of Illness Index; Human; Infection; Cirrhosis; Prognosis; Mortality; Gastroenterology; Digestive diseases; Hepatic disease; Terminal stage; Epidemiology
• ISSN: 0270-9139; 1527-3350; 1527-3350
• DOI: 10.1002/hep.25947

Bacterial infections are an important cause of mortality in cirrhosis, but there is a paucity of multicenter studies. The aim was to define factors predisposing to infection‐related mortality in hospitalized patients with cirrhosis. A prospective, cohort study of patients with cirrhosis with infections was performed at eight North American tertiary‐care hepatology centers. Data were collected on admission vitals, disease severity (model for endstage liver disease [MELD] and sequential organ failure [SOFA] scores), first infection site, type (community‐acquired, healthcare‐associated [HCA] or nosocomial), and second infection occurrence during hospitalization. The outcome was mortality within 30 days. A multivariate logistic regression model predicting mortality was created. 207 patients (55 years, 60% men, MELD 20) were included. Most first infections were HCA (71%), then nosocomial (15%) and community‐acquired (14%). Urinary tract infections (52%), spontaneous bacterial peritonitis (SBP, 23%) and spontaneous bacteremia (21%) formed the majority of the first infections. Second infections were seen in 50 (24%) patients and were largely preventable: respiratory, including aspiration (28%), urinary, including catheter‐related (26%), fungal (14%), and Clostridium difficile (12%) infections. Forty‐nine patients (23.6%) who died within 30 days had higher admission MELD (25 versus 18, P < 0.0001), lower serum albumin (2.4 g/dL versus 2.8 g/dL, P = 0.002), and second infections (49% versus 16%, P < 0.0001) but equivalent SOFA scores (9.2 versus 9.9, P = 0.86). The case fatality rate was highest for C. difficile (40%), respiratory (37.5%), and spontaneous bacteremia (37%), and lowest for SBP (17%) and urinary infections (15%). The model for mortality included admission MELD (odds ratio [OR]: 1.12), heart rate (OR: 1.03) albumin (OR: 0.5), and second infection (OR: 4.42) as significant variables. Conclusion: Potentially preventable second infections are predictors of mortality independent of liver disease severity in this multicenter cirrhosis cohort. (HEPATOLOGY 2012;56:2328–2335)