title: Bacterial Infections Change Natural History of Cirrhosis Irrespective of Liver Disease Severity.
abstract: We assessed the prognostic significance of infections in relation to current prognostic scores and explored if infection could be considered per se a distinct clinical stage in the natural history of cirrhosis.
  
  
  
  We included consecutive patients with cirrhosis admitted to a tertiary referral liver unit for at least 48 h over a 2-year period. Diagnosis of infection was based on positive cultures or strict established criteria. We used competing risk analysis and propensity score matching for data analysis.
  
  
  
  501 patients (63% male, 48% alcoholic liver disease, median Model of End-stage Liver Disease (MELD)=17) underwent 781 admissions over the study period. Portal hypertensive bleeding and complicated ascites were the commonest reasons of admission. The incidence of proven bacterial infection was 25.6% (60% community acquired and 40% nosocomial). Survival rates at 3, 6, 12, and 30 months were 83%, 77%, 71%, and 62% in patients without diagnosis of infection, vs. 50%, 46%, 41%, and 34% in patients with diagnosis of infection. Overall survival was independently associated with MELD score (hazards ratio (HR) 1.099), intensive care (ITU) stay (HR 1.967) and bacterial infection (HR 2.226). Bacterial infection was an independent predictor of survival even when patients who died within the first 30 days were excluded from the analysis in Cox regression (HR 2.013) and competing risk Cox models in all patients (HR 1.46) and propensity risk score-matched infected and non-infected patients (HR 1.67).
  
  
  
  Infection most likely represents a distinct prognostic stage of cirrhosis, which affects survival irrespective of disease severity, even after recovery from the infective episode.
authors.affiliation: UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK.|Unità di Gastroenterologia, Azienda Ospedaliera di Melegnano, Vizzolo Predabissi, Italy.
authors.forename: Elena
authors.initials: E
authors.lastname: Dionigi
authors.affiliation: UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK.
authors.forename: Matteo
authors.initials: M
authors.lastname: Garcovich
authors.affiliation: Unità di Gastroenterologia, Azienda Ospedaliera di Melegnano, Vizzolo Predabissi, Italy.
authors.forename: Mauro
authors.initials: M
authors.lastname: Borzio
authors.affiliation: National Institute of Gastroenterology, "S. de Bellis" Research Hospital, Castellana Grotte, Italy.
authors.forename: Gioacchino
authors.initials: G
authors.lastname: Leandro
authors.affiliation: UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK.
authors.forename: Avik
authors.initials: A
authors.lastname: Majumdar
authors.affiliation: UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK.
authors.forename: Aikaterini
authors.initials: A
authors.lastname: Tsami
authors.affiliation: UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK.
authors.forename: Vasiliki
authors.initials: V
authors.lastname: Arvaniti
authors.affiliation: UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK.
authors.forename: Davide
authors.initials: D
authors.lastname: Roccarina
authors.affiliation: UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK.
authors.forename: Massimo
authors.initials: M
authors.lastname: Pinzani
authors.affiliation: UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK.
authors.forename: Andrew K
authors.initials: AK
authors.lastname: Burroughs
authors.affiliation: UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK.
authors.forename: James
authors.initials: J
authors.lastname: O'Beirne
authors.affiliation: UCL Institute for Liver and Digestive Health and Sheila Sherlock Liver Unit, Royal Free Hospital and UCL, London, UK.
authors.forename: Emmanuel A
authors.initials: EA
authors.lastname: Tsochatzis
mesh_terms: D000328:Adult; D000368:Aged; D001201:Ascites / Q000453:epidemiology / Q000209:etiology; D001424:Bacterial Infections / Q000453:epidemiology*; D015331:Cohort Studies; D017714:Community-Acquired Infections / Q000453:epidemiology; D003428:Cross Infection / Q000453:epidemiology; D018450:Disease Progression; D058625:End Stage Liver Disease; D004932:Esophageal and Gastric Varices / Q000453:epidemiology / Q000209:etiology; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000453:epidemiology; D006801:Humans; D006975:Hypertension, Portal / Q000209:etiology; D015994:Incidence; D008103:Liver Cirrhosis / Q000150:complications / Q000453:epidemiology* / Q000401:mortality / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012720:Severity of Illness Index; D015996:Survival Rate