title: Epidemiology and outcomes of bloodstream infection in patients with cirrhosis.
abstract: OBJECTIVE
  Bloodstream infections (BSIs) in cirrhotic patients are 10-fold more common than in non-cirrhotic patients and increasingly caused by resistant pathogens. We examined 162 BSI episodes in cirrhotic patients to describe the etiology and risk factors for 30-day mortality.
  
  
  METHODS
  We retrospectively analyzed all consecutive BSIs in patients with liver cirrhosis at our 1350-bed teaching hospital (January 2008 to June 2012). Cox-proportional hazard regression was used to analyze the impact of disease and treatment-related variables on the crude 30-day mortality.
  
  
  RESULTS
  BSI episodes were identified in 162 patients, including 29 mixed infections. Most of episodes were classified as hospital acquired or healthcare associated (93%). Gram-negative bacteria (GNB), Gram-positive bacteria and Candida spp. caused 64%, 38%, and 10% of episodes, respectively. GNB were classified as multi-drug resistant (MDR) and extensively drug resistant (XDR) in 25% and 21% of cases, respectively. The overall crude 30-day mortality rate was 29%. Four risk factors were independently associated with 30-day crude mortality: worsening of MELD score from baseline (the last MELD score available in the 2 weeks prior BSI) to that at BSI onset (HR 1.11 per point increase, 95% CI 1.07-1.15, p<0.0001), spontaneous bacterial peritonitis as BSI source (HR 4.42, 2.04-9.54, p=0.002), sepsis grading (HR 2.18, 1.39-3.43, p=0.0007), and inappropriate antibiotic therapy within 24h from blood cultures (HR 2.82, 1.50-5.41, p=0.002).
  
  
  CONCLUSIONS
  An increasing proportion of BSIs in cirrhotic patients are caused by resistant GNB and Candida spp. Accurate evaluation of risk factors for mortality may improve early appropriate therapeutic management.
authors.affiliation: Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Bartoletti
authors.affiliation: Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
authors.forename: Maddalena
authors.initials: M
authors.lastname: Giannella
authors.affiliation: Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Caraceni
authors.affiliation: Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Domenicali
authors.affiliation: Microbiology Unit, S. Orsola-Malpighi Hospital Bologna, Italy.
authors.forename: Simone
authors.initials: S
authors.lastname: Ambretti
authors.affiliation: Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
authors.forename: Sara
authors.initials: S
authors.lastname: Tedeschi
authors.affiliation: Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
authors.forename: Gabriella
authors.initials: G
authors.lastname: Verucchi
authors.affiliation: Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Badia
authors.affiliation: Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
authors.forename: Russell E
authors.initials: RE
authors.lastname: Lewis
authors.affiliation: Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
authors.forename: Mauro
authors.initials: M
authors.lastname: Bernardi
authors.affiliation: Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy. Electronic address: pierluigi.viale@unibo.it.
authors.forename: Pierluigi
authors.initials: P
authors.lastname: Viale
mesh_terms: D000368:Aged; D016470:Bacteremia / Q000150:complications; D058387:Candidemia / Q000150:complications; D003428:Cross Infection / Q000150:complications; D024901:Drug Resistance, Multiple, Bacterial; D058625:End Stage Liver Disease / Q000150:complications; D005260:Female; D016905:Gram-Negative Bacterial Infections / Q000150:complications; D016908:Gram-Positive Bacterial Infections / Q000150:complications; D006801:Humans; D007558:Italy / Q000453:epidemiology; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D012307:Risk Factors; D018805:Sepsis / Q000150:complications* / Q000453:epidemiology* / Q000401:mortality
keywords: Bloodstream infection; Candidemia; Extremely-drug resistance; Inappropriate empirical therapy; Liver cirrhosis; Mortality; Multi-drug resistance