title: Infection in patients with severe alcoholic hepatitis treated with steroids: early response to therapy is the key factor.
abstract: OBJECTIVE
  In severe (Maddrey score >or=32) alcoholic hepatitis (AH), infection is classically viewed as a contraindication for corticosteroids, although specific data are lacking. This study's aims were (1) to evaluate the incidence of infection in patients with severe AH before and after corticosteroid treatment; (2) to determine whether infection contraindicates corticosteroids; and (3) to focus on predictive factors of development of infection.
  
  
  METHODS
  At admission, systematic screening of infection consisted of chest x-ray and blood, ascites, and urinary cultures. All patients were treated with prednisolone. Response to steroids was defined using the Lille model.
  
  
  RESULTS
  Two hundred forty-six patients with severe AH were prospectively included. Infections at admission were as follows: 63 infections (25.6%) were diagnosed: 28 (44.4%) spontaneous bacterial peritonitis or bacteremia, 8 (12.7%) pulmonary infections, 20 (31.7%) urinary tract infections, and 7 (11.2%) other infections. Patients infected before using corticosteroids had 2-month survival similar to that of others: 70.9% +/- 6.1% vs 71.6% +/- 3.4%, respectively, P = .99. Development of infection after steroids: 57 patients (23.7%) developed infection: 16 (28.1%) spontaneous bacterial peritonitis or bacteremia, 23 (40.3%) pulmonary, 10 (17.5%) urinary tract, and 8 (14.1%) other infections. Infection occurred more frequently in nonresponders than in responders: 42.5% vs 11.1%, respectively, P < .000001. In multivariate analysis, only the Lille model (P = .0002) independently predicted infection upon steroids use. The Lille model (P = .000001) and Model for End-Stage Liver Disease score (P = .006) were independently associated with survival, whereas infection was not (P = .52).
  
  
  CONCLUSIONS
  Severe AH is associated with high risk of infection. Infection screening is warranted but should not contraindicate steroids. In terms of mechanisms, nonresponse to steroids is the key factor in development of infection and prediction of survival.
authors.affiliation: Service des Maladies de l'Appareil digestif, Hôpital Huriez, Lille, France. p-mathurin@chru-lille.fr
authors.forename: Alexandre
authors.initials: A
authors.lastname: Louvet
authors.forename: Faustine
authors.initials: F
authors.lastname: Wartel
authors.forename: Hélène
authors.initials: H
authors.lastname: Castel
authors.forename: Sébastien
authors.initials: S
authors.lastname: Dharancy
authors.forename: Antoine
authors.initials: A
authors.lastname: Hollebecque
authors.forename: Valérie
authors.initials: V
authors.lastname: Canva-Delcambre
authors.forename: Pierre
authors.initials: P
authors.lastname: Deltenre
authors.forename: Philippe
authors.initials: P
authors.lastname: Mathurin
mesh_terms: D000305:Adrenal Cortex Hormones / Q000627:therapeutic use*; D017677:Age Distribution; D000368:Aged; D000704:Analysis of Variance; D001424:Bacterial Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000382:microbiology; D001707:Biopsy, Needle; D001774:Blood Chemical Analysis; D015331:Cohort Studies; D042241:Early Diagnosis; D005500:Follow-Up Studies; D006519:Hepatitis, Alcoholic / Q000188:drug therapy* / Q000401:mortality* / Q000473:pathology; D006801:Humans; D015994:Incidence; D053208:Kaplan-Meier Estimate; D008111:Liver Function Tests; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011336:Probability; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D017678:Sex Distribution; D018709:Statistics, Nonparametric; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000305:Adrenal Cortex Hormones