title: Clinical and microbiological features of infection in alcoholic hepatitis: an international cohort study.
abstract: BACKGROUND
  Previous studies have described the clinical impact of infection in alcoholic hepatitis (AH) but none have comprehensively explored the aetiopathogenesis of infection in this setting. We examined the causes, consequences and treatment of infection in a cohort of patients with AH.
  
  
  METHODS
  We undertook a retrospective cohort study of patients with AH admitted between 2009 and 2014 to seven centres in Europe and the USA. Clinical and microbiological data were extracted from medical records. Survival was analysed with Kaplan-Meier analysis and Cox proportional hazards analysis to control the data for competing factors. Propensity score matching was used to examine the efficacy of prophylactic antibiotics administered in the absence of infection.
  
  
  RESULTS
  We identified 404 patients with AH. Of these, 199 (49%) showed clinical or culture evidence of infection. Gut commensal bacteria, particularly Escherichia coli and Enterobacter species, were most commonly isolated in culture. Fungal infection was rarely seen. Cultured organisms and antibiotic resistance differed markedly between centres. Infection was an independent risk factor for death (hazard ratio for death at 90 days 2.33, 95% confidence interval 1.63-3.35, p < 0.001). Initiation of antibiotic therapy on admission in the absence of infection did not reduce mortality or alter the incidence of subsequent infections. Corticosteroid use increased the incidence of infection but this did not impact on survival.
  
  
  CONCLUSIONS
  In this large real-world cohort of patients with AH, infection was common and was associated with reduced short-term survival. Gram-negative, gut commensal bacteria were the predominant infective organisms, consistent with increased translocation of gut bacteria in AH; however, the characteristics of infection differ between centres. Infection should be actively sought and treated, but we saw no benefits of prophylactic antibiotics.
authors.affiliation: Centre for Liver Research, Institute of Biomedical Research, College of Medical and Dental Sciences, University of Birmingham, 5th Floor, Birmingham, B15 2TT, UK. richardparker@nhs.net.|University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2TH, UK. richardparker@nhs.net.
authors.forename: Richard
authors.identifier: http://orcid.org/0000-0003-4888-8670
authors.initials: R
authors.lastname: Parker
authors.affiliation: Mount Sinai Medical Center, 1468 Madison Avenue, New York, NY 10029, USA.
authors.forename: Gene
authors.initials: G
authors.lastname: Im
authors.affiliation: Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland.
authors.forename: Fiona
authors.initials: F
authors.lastname: Jones
authors.affiliation: Hospital Universitario de Canarias Carretera de Ofra, 38320, San Cristóbal de La Laguna, Santa Cruz de Tenerife, Spain.
authors.forename: Onan Pérez
authors.initials: OP
authors.lastname: Hernández
authors.affiliation: Mount Sinai Medical Center, 1468 Madison Avenue, New York, NY 10029, USA.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Nahas
authors.affiliation: New Cross Hospital, Royal Wolverhampton NHS Trust, Wolverhampton Rd, Heath Town, Wolverhampton, WV10 0QP, UK.
authors.forename: Aditi
authors.initials: A
authors.lastname: Kumar
authors.affiliation: New Cross Hospital, Royal Wolverhampton NHS Trust, Wolverhampton Rd, Heath Town, Wolverhampton, WV10 0QP, UK.
authors.forename: Daniel
authors.initials: D
authors.lastname: Wheatley
authors.affiliation: University Hospitals Bristol NHS Foundation Trust, Marlborough Street, Bristol, BS1 3NU, UK.
authors.forename: Ashish
authors.initials: A
authors.lastname: Sinha
authors.affiliation: Hospital Universitario de Canarias Carretera de Ofra, 38320, San Cristóbal de La Laguna, Santa Cruz de Tenerife, Spain.
authors.forename: Emilio
authors.initials: E
authors.lastname: Gonzalez-Reimers
authors.affiliation: Hospital Universitario de Canarias Carretera de Ofra, 38320, San Cristóbal de La Laguna, Santa Cruz de Tenerife, Spain.
authors.forename: María
authors.initials: M
authors.lastname: Sanchez-Pérez
authors.affiliation: NIHR Nottingham Digestive Diseases Biomedical Research Unit, Queen's Medical Centre, E Floor, West Block, Nottingham, NG7 2UH, UK.
authors.forename: Antonella
authors.initials: A
authors.lastname: Ghezzi
authors.affiliation: University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2TH, UK.
authors.forename: Miruna Delia
authors.initials: MD
authors.lastname: David
authors.affiliation: New Cross Hospital, Royal Wolverhampton NHS Trust, Wolverhampton Rd, Heath Town, Wolverhampton, WV10 0QP, UK.
authors.forename: Christopher
authors.initials: C
authors.lastname: Corbett
authors.affiliation: New Cross Hospital, Royal Wolverhampton NHS Trust, Wolverhampton Rd, Heath Town, Wolverhampton, WV10 0QP, UK.
authors.forename: Anne
authors.initials: A
authors.lastname: McCune
authors.affiliation: NIHR Nottingham Digestive Diseases Biomedical Research Unit, Queen's Medical Centre, E Floor, West Block, Nottingham, NG7 2UH, UK.
authors.forename: Guruprasad Padur
authors.initials: GP
authors.lastname: Aithal
authors.affiliation: University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham, B15 2TH, UK.
authors.forename: Andrew
authors.initials: A
authors.lastname: Holt
authors.affiliation: Mater Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland.
authors.forename: Stephen
authors.initials: S
authors.lastname: Stewart
mesh_terms: D000305:Adrenal Cortex Hormones / Q000008:administration & dosage / Q000009:adverse effects; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D019072:Antibiotic Prophylaxis / Q000379:methods; D001419:Bacteria / Q000302:isolation & purification*; D001424:Bacterial Infections / Q000188:drug therapy / Q000453:epidemiology* / Q000517:prevention & control; D015331:Cohort Studies; D024881:Drug Resistance, Bacterial; D005060:Europe; D005260:Female; D006519:Hepatitis, Alcoholic / Q000382:microbiology* / Q000401:mortality; D006801:Humans; D015994:Incidence; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009181:Mycoses / Q000453:epidemiology; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D014481:United States
chemical_list: D000305:Adrenal Cortex Hormones; D000900:Anti-Bacterial Agents
keywords: Hepatitis, alcoholic; Infection; Liver diseases, alcoholic