Second infections independently increase mortality in hospitalized patients with cirrhosis: the North American consortium for the study of end-stage liver disease (NACSELD) experience.
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.


CONCLUSIONS
Potentially preventable second infections are predictors of mortality independent of liver disease severity in this multicenter cirrhosis cohort.
Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA 23249, USA. jsbajaj@vcu.edu
Jasmohan S
JS
Bajaj
Jacqueline G
JG
O'Leary
K Rajender
KR
Reddy
Florence
F
Wong
Jody C
JC
Olson
Ram M
RM
Subramanian
Geri
G
Brown
Nicole A
NA
Noble
Leroy R
LR
Thacker
Patrick S
PS
Kamath
D001424:Bacterial Infections / Q000150:complications / Q000382:microbiology* / Q000401:mortality*; D002177:Candidiasis / Q000382:microbiology / Q000401:mortality; D055499:Catheter-Related Infections / Q000382:microbiology; D016360:Clostridioides difficile; D017714:Community-Acquired Infections / Q000382:microbiology / Q000401:mortality; D003428:Cross Infection / Q000382:microbiology / Q000401:mortality; D058625:End Stage Liver Disease / Q000150:complications / Q000401:mortality; D004761:Enterocolitis, Pseudomembranous / Q000382:microbiology / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D008103:Liver Cirrhosis / Q000150:complications* / Q000401:mortality*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D063305:Organ Dysfunction Scores; D011446:Prospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index