title: Impact of chronic liver disease in intensive care unit acquired pneumonia: a prospective study.
abstract: OBJECTIVE
  To assess the impact of chronic liver disease (CLD) on ICU-acquired pneumonia.
  
  
  METHODS
  This was a prospective, observational study of the characteristics, microbiology, and outcomes of 343 consecutive patients with ICU-acquired pneumonia clustered according to the presence of CLD.
  
  
  RESULTS
  Sixty-seven (20%) patients had CLD (67% had liver cirrhosis, LC), MELD score 26 ± 9, 20% Child-Pugh class C). They presented higher severity scores than patients without CLD both on admission to the ICU (APACHE II, LC 19 ± 6 vs. other CLD 18 ± 6 vs. no CLD 16 ± 6; p < 0.001; SOFA, 10 ± 3 vs. 8 ± 4 vs. 7 ± 3; p < 0.001) and at onset of pneumonia (APACHE II, 19 ± 6 vs. 17 ± 6 vs. 16 ± 5; p = 0.001; SOFA, 11 ± 4 vs. 9 ± 4 vs. 7 ± 3; p < 0.001). Levels of CRP were lower in patients with LC than in the other two groups (day 1, 6.5 [2.5-11.5] vs. 13 [6-23] vs. 15.5 [8-24], p < 0.001, day 3, 6 [3-12] vs. 16 [9-21] vs. 11 [5-20], p = 0.001); all the other biomarkers were higher in LC and other CLD patients. LC patients had higher 28- and 90-day mortality (63 vs. 28%, p < 0.001; 72 vs. 38%, p < 0.001, respectively) than non-CLD patients. Presence of LC was independently associated with decreased 28- and 90-day survival (95% confidence interval [CI], 1.982-17.250; p = 0.001; 95% confidence interval [CI], 2.915-20.699, p = 0.001, respectively).
  
  
  CONCLUSIONS
  In critically ill patients with ICU-acquired pneumonia, CLD is associated with a more severe clinical presentation and poor clinical outcomes. Moreover, LC is independently associated with 28- and 90-day mortality. The results of this study are important for future trials focused on mortality.
authors.affiliation: Servei de Pneumologia, Institut del Torax, Hospital Clinic, IDIBAPS, Universitat de Barcelona, Barcelona, Spain, marta.dipasquale@unimi.it.
authors.forename: Marta
authors.initials: M
authors.lastname: Di Pasquale
authors.forename: Mariano
authors.initials: M
authors.lastname: Esperatti
authors.forename: Ernesto
authors.initials: E
authors.lastname: Crisafulli
authors.forename: Miquel
authors.initials: M
authors.lastname: Ferrer
authors.forename: Gianluigi Li
authors.initials: GL
authors.lastname: Bassi
authors.forename: Mariano
authors.initials: M
authors.lastname: Rinaudo
authors.forename: Angels
authors.initials: A
authors.lastname: Escorsell
authors.forename: Javier
authors.initials: J
authors.lastname: Fernandez
authors.forename: Antoni
authors.initials: A
authors.lastname: Mas
authors.forename: Francesco
authors.initials: F
authors.lastname: Blasi
authors.forename: Antoni
authors.initials: A
authors.lastname: Torres
mesh_terms: D018806:APACHE; D016638:Critical Illness; D003428:Cross Infection / Q000209:etiology / Q000382:microbiology / Q000401:mortality*; D018432:Drug Resistance, Multiple; D058625:End Stage Liver Disease / Q000209:etiology / Q000382:microbiology / Q000401:mortality*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D015337:Multicenter Studies as Topic; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data; D011014:Pneumonia / Q000209:etiology / Q000382:microbiology / Q000401:mortality*; D011446:Prospective Studies; D012720:Severity of Illness Index; D013030:Spain / Q000453:epidemiology; D016019:Survival Analysis
references.citation: Crit Care Med. 2011 Oct;39(10):2211-7
references.pmid: 21705887
references.citation: Am J Med. 1993 Mar;94(3):281-8
references.pmid: 8452152
references.citation: Can J Gastroenterol. 2004 Jun;18(6):405-6
references.pmid: 15190398
references.citation: Clin Infect Dis. 2010 Aug 1;51 Suppl 1:S29-35
references.pmid: 20597668
references.citation: Chest. 2009 Sep;136(3):823-831
references.pmid: 19363212
references.citation: Hepatology. 2002 Jan;35(1):140-8
references.pmid: 11786970
references.citation: Am J Gastroenterol. 1999 Aug;94(8):2193-7
references.pmid: 10445549
references.citation: J Hepatol. 1993 Jul;18(3):353-8
references.pmid: 8228129
references.citation: Crit Care Med. 1985 Oct;13(10):818-29
references.pmid: 3928249
references.citation: Crit Care Med. 2003 Mar;31(3):676-82
references.pmid: 12626968
references.citation: Crit Care Med. 2004 Apr;32(4):938-45
references.pmid: 15071382
references.citation: Chest. 2001 Feb;119(2 Suppl):373S-384S
references.pmid: 11171773
references.citation: Gastroenterology. 2010 Oct;139(4):1246-56, 1256.e1-5
references.pmid: 20558165
references.citation: Circulation. 2003 Oct 21;108(16):1930-2
references.pmid: 14530191
references.citation: Am J Gastroenterol. 2000 May;95(5):1290-3
references.pmid: 10811341
references.citation: Hepatology. 2001 Aug;34(2):255-61
references.pmid: 11481609
references.citation: Intensive Care Med. 2010 Jun;36(6):971-8
references.pmid: 20309520
references.citation: Semin Liver Dis. 2008 Feb;28(1):26-42
references.pmid: 18293275
references.citation: Curr Opin Pulm Med. 2012 May;18(3):187-93
references.pmid: 22366995
references.citation: Thorax. 1999 Oct;54(10):867-73
references.pmid: 10491448
references.citation: Am J Respir Crit Care Med. 2002 Apr 1;165(7):867-903
references.pmid: 11934711
references.citation: Hepatology. 2012 May;55(5):1551-61
references.pmid: 22183941
references.citation: Am J Respir Crit Care Med. 1994 Mar;149(3 Pt 1):818-24
references.pmid: 7509706
references.citation: Chest. 2001 May;119(5):1489-97
references.pmid: 11348958
references.citation: J Lab Clin Med. 2005 Dec;146(6):347-51
references.pmid: 16310518
references.citation: J Clin Gastroenterol. 1998 Jan;26(1):44-9
references.pmid: 9492863
references.citation: Crit Care Med. 2008 Jan;36(1):296-327
references.pmid: 18158437
references.citation: JAMA. 1993 Dec 22-29;270(24):2957-63
references.pmid: 8254858
references.citation: N Engl J Med. 2001 Feb 15;344(7):481-7
references.pmid: 11172189
references.citation: Chest. 2005 Sep;128(3):1650-6
references.pmid: 16162771
references.citation: Clin Infect Dis. 2010 Aug 1;51 Suppl 1:S81-7
references.pmid: 20597676
references.citation: Biochem J. 1997 Oct 15;327 ( Pt 2):425-9
references.pmid: 9359411
references.citation: Brain Res. 2000 Dec 22;887(1):80-9
references.pmid: 11134592