title: Community-acquired pneumonia in patients with liver cirrhosis: clinical features, outcomes, and usefulness of severity scores.
abstract: We performed an observational analysis of a prospective cohort of nonimmunocompromised hospitalized adults with community-acquired pneumonia (CAP) to determine the epidemiology, clinical features, and outcomes of patients with liver cirrhosis. We also analyzed the prognostic value of several severity scores. Of 3420 CAP episodes, 90 occurred in patients with liver cirrhosis. The median value of the Model for End-Stage Liver Disease (MELD) was 14 (range, 6-36). On the Child-Pugh (CP) score, 56% of patients were defined as grade B and 22% as grade C. Patients with liver cirrhosis were younger (61.8 vs. 66.8 yr; p = 0.001) than patients without cirrhosis, more frequently presented impaired consciousness at admission (33% vs. 14%; p < 0.001) and septic shock (13% vs. 6%; p = 0.011), and were more commonly classified in high-risk Pneumonia Severity Index (PSI) classes (classes IV-V) (74% vs. 58%; p = 0.002). Streptococcus pneumoniae (47% vs. 33%; p = 0.009) and Pseudomonas aeruginosa (4.4% vs. 0.9%; p = 0.001) were more frequently documented in patients with cirrhosis. Bacteremia was also more common in these patients (22% vs. 13%; p = 0.023). Areas under the curve (AUCs) from disease-specific scores (MELD, CP, PSI, and CURB-65 [confusion, urea, respiratory rate, blood pressure, and age ≥65 yr]) were comparable in predicting severe disease (30-d mortality and intensive care unit [ICU] admission). A new score based on MELD, multilobar pneumonia, and septic shock at admission (MELD-CAP) had an AUC of 0.945 (95% confidence interval [CI], 0.872-0.983) for predicting severe disease and was significantly different from other scores. Early (5.6% vs. 2.1%; p = 0.048) and overall (14.4% vs. 7.4%; p < 0.024) mortality rates were higher in cirrhotic patients than in patients without cirrhosis. Factors associated with mortality were impaired consciousness, multilobar pneumonia, ascites, acute renal failure, bacteremia, ICU admission, and MELD score. Among the severity scores, MELD-CAP was the only score associated with severe disease (odds ratio [OR], 1.33; 95% CI, 1.09-1.52) and mortality (OR, 1.21; 95% CI, 1.03-1.42). In conclusion, CAP in patients with liver cirrhosis presents a distinctive clinical picture and is associated with higher mortality than is found in patients without cirrhosis. The severity of hepatic dysfunction plays an important role in the development of adverse events. Cirrhosis-specific scores may be useful for predicting and stratifying cirrhotic patients with CAP who have a high risk of severe disease.
authors.affiliation: From Departments of Infectious Diseases (DV, CG, JA, FG, J. Carratalà), Hepatology and Liver Transplant (J. Castellote), Microbiology (RV), and Respiratory Medicine (JD, FM), Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), University of Barcelona. L'Hospitalet de Llobregat, Barcelona, Spain.
authors.forename: Diego
authors.initials: D
authors.lastname: Viasus
authors.forename: Carolina
authors.initials: C
authors.lastname: Garcia-Vidal
authors.forename: Jose
authors.initials: J
authors.lastname: Castellote
authors.forename: Jordi
authors.initials: J
authors.lastname: Adamuz
authors.forename: Ricard
authors.initials: R
authors.lastname: Verdaguer
authors.forename: Jordi
authors.initials: J
authors.lastname: Dorca
authors.forename: Frederic
authors.initials: F
authors.lastname: Manresa
authors.forename: Francesc
authors.initials: F
authors.lastname: Gudiol
authors.forename: Jordi
authors.initials: J
authors.lastname: Carratalà
mesh_terms: D000367:Age Factors; D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D017714:Community-Acquired Infections / Q000150:complications / Q000188:drug therapy / Q000453:epidemiology; D005260:Female; D006746:Hospital Bed Capacity, 500 and over; D006785:Hospitals, University; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications* / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D018410:Pneumonia, Bacterial / Q000150:complications* / Q000188:drug therapy / Q000453:epidemiology; D011446:Prospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents