1
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Caccamo G, Franzè MS, Saffioti F, Pitrone C, Porcari S, Alibrandi A, Filomia R, Mondello P, Cacciola I, Saitta C, Squadrito G, Raimondo G, Maimone S. Cirrhotic Patients with Bacterial Infection and Negative Cultures Have a More Advanced Disease and an Increased Short-Term Mortality Rate. Dig Dis Sci 2022; 67:2655-2665. [PMID: 34041650 DOI: 10.1007/s10620-021-07047-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 05/09/2021] [Indexed: 12/09/2022]
Abstract
BACKGROUND The negative clinical impact of bacterial infections (BI) in patients with cirrhosis is well documented. In cirrhotic patients, failure to isolate the pathogen is a frequent event, occurring in 30-40% of cases. AIM The aim of this study was to compare the clinical characteristics, early (30-day) and short-term (90-day) mortality rates, in a cohort of cirrhotic patients with BI, between those with positive (C-pos) and those with negative (C-neg) microbiological cultures. METHODS We retrospectively enrolled 279 consecutive hospitalized cirrhotic patients with BI. Survival and predictors of 30-day and 90-day mortality were assessed by Kaplan-Meier curves and logistic regression analysis, respectively. RESULTS Cultures tested negative in 108/279 (38.7%) patients. C-neg patients were more frequently males (p = 0.035), had higher Child-Pugh-Turcotte (CPT; p = 0.007) and model for end-stage liver disease-sodium (MELD-Na; p = 0.043) scores, and had more frequently decompensated liver disease (p = 0.04). Mortality rate was higher in C-neg than in C-pos patients, both at 30 days (22.2% versus 11.7%, p = 0.024) and 90 days (46.3% versus 33.3%, p = 0.030). MELD-Na score and non-selective beta-blockers (NSBBs) were independent risk factors for 30-day and 90-day mortality. In particular, the use of NSBBs was independently associated with a lower 30-day and 90-day mortality risk (OR 0.41, CI95% 0.17-0.94, p = 0.040; and OR 0.43, CI95% 0.25-0.75, p = 0.003, respectively). CONCLUSIONS Cirrhotic patients with BI and negative microbiological cultures have significantly higher mortality compared to those with positive cultures. Early mortality and short-term mortality are mainly influenced by the underlying severity of liver disease. In this contest, therapy with NSBBs has a positive impact on short-term survival.
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Affiliation(s)
- Gaia Caccamo
- Division of Medicine and Hepatology, University Hospital of Messina "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy. .,Department of Medical Sciences, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy.
| | - Maria Stella Franzè
- Division of Medicine and Hepatology, University Hospital of Messina "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy.,Department of Medical Sciences, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy.,Department of Clinical and Experimental Medicine, University of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
| | - Francesca Saffioti
- Department of Gastroenterology and Hepatology, Oxford University Hospitals NHS Foundation Trust, Windmill Road, Heading, Oxford, OX1 HP, UK
| | - Concetta Pitrone
- Division of Medicine and Hepatology, University Hospital of Messina "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy.,Department of Medical Sciences, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy.,Department of Clinical and Experimental Medicine, University of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
| | - Serena Porcari
- Department of Medical Sciences, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy.,Division of Gastroenterology and Inflammatory Bowel Diseases, University Hospital of Messina, Via Consolare Valeria 1, 98124, Messina, Italy
| | - Angela Alibrandi
- Department of Economics Unit of Statistical and Mathematical Science, University of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
| | - Roberto Filomia
- Division of Medicine and Hepatology, University Hospital of Messina "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy.,Department of Medical Sciences, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
| | - Placido Mondello
- Department of Medical Sciences, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy.,Division of Infectious Diseases, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
| | - Irene Cacciola
- Division of Medicine and Hepatology, University Hospital of Messina "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy.,Department of Medical Sciences, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy.,Department of Clinical and Experimental Medicine, University of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
| | - Carlo Saitta
- Division of Medicine and Hepatology, University Hospital of Messina "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy.,Department of Medical Sciences, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
| | - Giovanni Squadrito
- Department of Medical Sciences, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy.,Department of Clinical and Experimental Medicine, University of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy.,Division of Internal Medicine, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
| | - Giovanni Raimondo
- Division of Medicine and Hepatology, University Hospital of Messina "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy.,Department of Medical Sciences, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy.,Department of Clinical and Experimental Medicine, University of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
| | - Sergio Maimone
- Division of Medicine and Hepatology, University Hospital of Messina "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy.,Department of Medical Sciences, University Hospital of Messina, "Policlinico G. Martino", Via Consolare Valeria 1, 98124, Messina, Italy
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2
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Dirchwolf M, Marciano S, Martínez J, Ruf AE. Unresolved issues in the prophylaxis of bacterial infections in patients with cirrhosis. World J Hepatol 2018; 10:892-897. [PMID: 30631393 PMCID: PMC6323518 DOI: 10.4254/wjh.v10.i12.892] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2018] [Revised: 09/05/2018] [Accepted: 10/11/2018] [Indexed: 02/06/2023] Open
Abstract
Bacterial infections are highly prevalent and a frequent cause of hospitalization and short-term mortality in patients with cirrhosis. Due to their negative impact on survival, antibiotic prophylaxis for bacterial infections in high-risk subgroups of patients with cirrhosis has been the standard of care for decades. Patients with prophylaxis indications include those at risk for a first episode of spontaneous bacterial peritonitis (SBP) due to a low ascitic fluid protein count and impaired liver and kidney function, patients with a prior episode of SBP and those with an episode of gastrointestinal bleeding. Only prophylaxis due to gastrointestinal bleeding has a known and short-time duration. All other indications imply long-lasting exposure to antibiotics - once the threshold requirement for initiating prophylaxis is met - without standardized criteria for re-assessing antibiotic interruption. Despite the fact that the benefit of antibiotic prophylaxis in reducing bacterial infections episodes and mortality has been thoroughly reported, the extended use of antibiotics in patients with cirrhosis has also had negative consequences, including the emergence of multi-drug resistant bacteria. Currently, it is not clear whether restricting the use of broad and fixed antibiotic regimens, tailoring the choice of antibiotics to local bacterial epidemiology or selecting non-antibiotic strategies will be the preferred antibiotic prophylaxis strategy for patients with cirrhosis in the future.
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Affiliation(s)
- Melisa Dirchwolf
- Unidad de Hígado, Hospital Privado de Rosario, Rosario 2000, Argentina
| | - Sebastián Marciano
- Unidad de Hígado, and Departamento de Investigación del Hospital Italiano de Buenos Aires, Buenos Aires 1424, Argentina
| | - José Martínez
- Unidad de Hígado, Hospital Privado de Rosario, Rosario 2000, Argentina
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3
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Kim SG, Larson JJ, Lee JS, Therneau TM, Kim WR. Beneficial and harmful effects of nonselective beta blockade on acute kidney injury in liver transplant candidates. Liver Transpl 2017; 23:733-740. [PMID: 28187503 PMCID: PMC5449204 DOI: 10.1002/lt.24744] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 01/04/2017] [Indexed: 02/06/2023]
Abstract
Nonselective beta-blockers (NSBBs) have played an important role in the prevention of portal hypertensive bleeding in patients with cirrhosis. However, recent studies have suggested that NSBBs may be harmful in some patients with end-stage liver disease. The purpose of this article is to evaluate the association between use of NSBB and the incidence of acute kidney injury (AKI). We conducted a nested case-control study in a cohort of liver transplant wait-list registrants. Each patient with AKI was matched to a control by the Model for End-Stage Liver Disease-Na score, age, serum creatinine, and follow-up duration. Out of a total of 2361 wait-list registrants, 205 patients developed AKI after a median follow-up duration of 18.2 months. When compared with matched controls, ascites (79.0% versus 51.7%) and non-Caucasian race (16.6% versus 7.8%) were more common among the cases. The frequency of NSBB use was higher among the cases than controls, albeit insignificantly (45.9% versus 37.1%; P = 0.08). In multivariate analyses, the impact of nonselective beta blockade on the development of AKI was dependent on the presence of ascites: nonselective beta blockade in patients with ascites significantly increased the risk of AKI (hazard ratio [HR], 3.31; 95% confidence interval [CI], 1.57-6.95), whereas in patients without ascites, NSBB use reduced it (HR, 0.19; 95% CI, 0.06-0.60). Potential benefits and harms of a NSBB in terms of AKI depend on the presence of ascites in liver transplant candidates. NSBB therapy in patients with cirrhosis may need to be individualized. Liver Transplantation 23 733-740 2017 AASLD.
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Affiliation(s)
- Sang Gyune Kim
- Digestive Disease Center and Research Institute, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Joseph J. Larson
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - Ji Sung Lee
- Clinical Research Center, Asan Medical Center, Seoul, Korea
| | - Terry M. Therneau
- Department of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | - W. Ray Kim
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, USA
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4
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Fernández J, Tandon P, Mensa J, Garcia-Tsao G. Antibiotic prophylaxis in cirrhosis: Good and bad. Hepatology 2016; 63:2019-31. [PMID: 26528864 DOI: 10.1002/hep.28330] [Citation(s) in RCA: 131] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 11/02/2015] [Indexed: 12/13/2022]
Abstract
UNLABELLED Patients with cirrhosis, particularly those with decompensated cirrhosis, are at increased risk of bacterial infections that may further precipitate other liver decompensations including acute-on-chronic liver failure. Infections constitute the main cause of death in patients with advanced cirrhosis, and strategies to prevent them are essential. The main current strategy is the use of prophylactic antibiotics targeted at specific subpopulations at high risk of infection: prior episode of spontaneous bacterial peritonitis, upper gastrointestinal bleeding, and low-protein ascites with associated poor liver function. Antibiotic prophylaxis effectively prevents not only the development of bacterial infections in all these indications but also further decompensation (variceal bleeding, hepatorenal syndrome) and improves survival. However, antibiotic prophylaxis is also associated with a clinically relevant and increasing drawback, the development of infections due to multidrug-resistant organisms. Several strategies have been suggested to balance the risks and benefits of antibiotic prophylaxis. CONCLUSION Antibiotic stewardship principles such as the restriction of antibiotic prophylaxis to subpopulations at a very high risk for infection, the avoidance of antibiotic overuse, and early deescalation policies are key to achieve this balance; nonantibiotic prophylactic measures such as probiotics, prokinetics, bile acids, statins, and hematopoietic growth factors could also contribute to ameliorate the development and spread of multidrug-resistant bacteria in cirrhosis. (Hepatology 2016;63:2019-2031).
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Affiliation(s)
- Javier Fernández
- Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Barcelona, Spain
| | - Puneeta Tandon
- Cirrhosis Care Clinic, Cirrhosis Care, Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Canada
| | - Jose Mensa
- Infectious Disease Department, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT.,Section of Digestive Diseases, VA-CT Healthcare System, West Haven, CT
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5
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Kimer N, Naver AV, Thiele M, Krag A, Gluud LL. Beta-blockers alone or in combination with isosorbide mononitrate for secondary prevention of bleeding from gastro-esophageal varices in adults with cirrhosis and gastro-oesophageal varices. Hippokratia 2016. [DOI: 10.1002/14651858.cd012127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Nina Kimer
- Medical Division, Copenhagen University Hospital Hvidovre; Gastrounit; Kettegaards Alle 30 Hvidovre Denmark
| | - Astrid Vinsand Naver
- Copenhagen University Hospital Hvidovre; Gastrounit, Medical Division; Hvidovre Denmark
| | - Maja Thiele
- Odense University Hospital; Department of Gastroenterology and Hepatology; Sdr. Boulevard 29, indgang 126 Odense Denmark 5000
| | - Aleksander Krag
- Odense University Hospital; Department of Gastroenterology S; Sdr. Boulevard 29, indgang 126 Odense C Denmark 5000
| | - Lise Lotte Gluud
- Copenhagen University Hospital Hvidovre; Gastrounit, Medical Division; Hvidovre Denmark
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6
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Mookerjee RP, Pavesi M, Thomsen KL, Mehta G, Macnaughtan J, Bendtsen F, Coenraad M, Sperl J, Gines P, Moreau R, Arroyo V, Jalan R. Treatment with non-selective beta blockers is associated with reduced severity of systemic inflammation and improved survival of patients with acute-on-chronic liver failure. J Hepatol 2016; 64:574-82. [PMID: 26519600 DOI: 10.1016/j.jhep.2015.10.018] [Citation(s) in RCA: 157] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 10/14/2015] [Accepted: 10/19/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Non-selective beta blockers (NSBBs) have been shown to have deleterious outcomes in patients with refractory ascites, alcoholic hepatitis and spontaneous bacterial peritonitis leading many physicians to stop the drug in these cases. Acute-on-chronic liver failure (ACLF) is characterized by systemic inflammation and high mortality. As NSBBs may have beneficial effects on gut motility and permeability and, systemic inflammation, the aims of this prospective, observational study were to determine whether ongoing use of NSBBs reduced 28-day mortality in ACLF patients. METHODS The study was performed in 349 patients with ACLF included in the CANONIC study, which is a prospective observational investigation in hospitalized cirrhotic patients with acute deterioration. The data about the use of NSBBs, its type and dosage was specifically recorded. Patient characteristics at enrollment significantly associated with treatment and mortality were taken into account as potential confounders to adjust for treatment effect. A logistic regression model was fitted. RESULTS 164 (47%) ACLF patients received NSBBs whereas 185 patients did not. Although the CLIF-C ACLF scores were similar at presentation, more patients in the NSBB treated group had lower grades of ACLF (p=0.047) at presentation and significantly more patients improved. Forty patients (24.4%) died in NSBB treated group compared with 63 patients (34.1%) (p=0.048) [estimated risk-reduction 0.596 (95%CI: 0.361-0.985; p=0.0436)]. This improvement in survival was associated with a significantly lower white cell count (NSBB: 8.5 (5.8); no NSBB: 10.8 (6.6); p=0.002). No long-term improvement in survival was observed. CONCLUSIONS This study shows for the first time that ongoing treatment with NSBBs in cirrhosis is safe and reduces the mortality if they develop ACLF. Careful thought should be given before stopping NSBBs in cirrhotic patients.
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Affiliation(s)
- Rajeshwar P Mookerjee
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, United Kingdom
| | - Marco Pavesi
- European Foundation for the Study of Chronic Liver Failure (EF-CLIF) and EASL-CLIF Consortium
| | - Karen Louise Thomsen
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, United Kingdom
| | - Gautam Mehta
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, United Kingdom
| | - Jane Macnaughtan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, United Kingdom
| | - Flemming Bendtsen
- Department of Gastroenterology, Hvidovre Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Minneke Coenraad
- Department of Gastroenterology-Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jan Sperl
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Pere Gines
- Liver Unit, Hospital Clínic de Barcelona, University de Barcelona, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), Barcelona, Spain; Centro d'Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
| | - Richard Moreau
- Inserm, U1149, Centre de Recherche sur l'Inflammation (CRI), Clichy and Paris, France; UMRS1149, Université Paris Diderot-Paris 7, Paris, France; Département Hospitalo-Universitaire (DHU) UNITY, Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France; Laboratoire d'Excellence Inflamex, PRES Sorbonne Paris Cité, Paris, France
| | - Vicente Arroyo
- European Foundation for the Study of Chronic Liver Failure (EF-CLIF) and EASL-CLIF Consortium
| | - Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, United Kingdom.
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7
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Bernsmeier C, Singanayagam A, Patel VC, Wendon J, Antoniades CG. Immunotherapy in the treatment and prevention of infection in acute-on-chronic liver failure. Immunotherapy 2015; 7:641-54. [PMID: 26065379 DOI: 10.2217/imt.15.27] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Chronic liver disease, depicted by gradual destruction and fibrosis of the liver, is a condition with high and probably increasing prevalence worldwide. Its deterioration, acute-on-chronic liver failure (ACLF), is characterized by an in-hospital mortality of up to 65%. Infectious complications are the main precipitants eliciting ACLF and concurrently the main cause of death from ACLF. Patients have a marked susceptibility to bacterial infections, which is thought to arise a consequence of an inadequate immune response to microbial challenge, termed immuneparesis. The pathophysiologic mechanisms remain poorly understood. Treatments aimed at restoring the patients' immune function may prevent onset of ACLF and death from secondary infections. A number of drugs approved for patients with liver disease bear immunomodulatory potential such as albumin, glucocorticoids, N-acetylcysteine. Specific targets have been defined that may lead to development of new immunotherapeutic agents. Here, we summarize the pathophysiology of immuneparesis in ACLF and drug candidates to restore immune function and improve survival in the future.
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Affiliation(s)
- Christine Bernsmeier
- Institute of Liver Studies, King's College Hospital, King's College London, London SE5 9RS, UK
| | - Arjuna Singanayagam
- Institute of Liver Studies, King's College Hospital, King's College London, London SE5 9RS, UK
| | - Vishal C Patel
- Institute of Liver Studies, King's College Hospital, King's College London, London SE5 9RS, UK
| | - Julia Wendon
- Institute of Liver Studies, King's College Hospital, King's College London, London SE5 9RS, UK
| | - Charalambos G Antoniades
- Institute of Liver Studies, King's College Hospital, King's College London, London SE5 9RS, UK.,Section of Hepatology, St Mary's Hospital, Imperial College London, London W2 1NY, UK
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8
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Kimer N, Naver AV, Thiele M, Krag A, Gluud LL. Beta-blockers alone or with isosorbide mononitrate for primary prevention in adults with cirrhosis and gastro-oesophageal varices. Hippokratia 2015. [DOI: 10.1002/14651858.cd011691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Nina Kimer
- Medical Division, Copenhagen University Hospital Hvidovre; Gastrounit; Kettegaards Alle 30 Hvidovre Denmark
| | - Astrid Vinsand Naver
- Copenhagen University Hospital Hvidovre; Gastrounit, Medical Division; Hvidovre Denmark
| | - Maja Thiele
- Odense University Hospital; Department of Gastroenterology and Hepatology; Sdr. Boulevard 29, indgang 126 Odense Denmark 5000
| | - Aleksander Krag
- Odense University Hospital; Department of Gastroenterology S; Sdr. Boulevard 29, indgang 126 Odense C Denmark 5000
| | - Lise Lotte Gluud
- Copenhagen University Hospital Hvidovre; Gastrounit, Medical Division; Hvidovre Denmark
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9
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O'Leary JG, Reddy KR, Wong F, Kamath PS, Patton HM, Biggins SW, Fallon MB, Garcia-Tsao G, Subramanian RM, Malik R, Thacker LR, Bajaj JS. Long-term use of antibiotics and proton pump inhibitors predict development of infections in patients with cirrhosis. Clin Gastroenterol Hepatol 2015; 13:753-9.e1-2. [PMID: 25130937 PMCID: PMC4326601 DOI: 10.1016/j.cgh.2014.07.060] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 07/22/2014] [Accepted: 07/30/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Bacterial infections, particularly repeated infections, are significant causes of morbidity and mortality among patients with cirrhosis. We investigated and characterized risk factors for repeat infections in these patients. METHODS In a prospective study, we collected data from 188 patients hospitalized with cirrhosis and infections and enrolled in the North American Consortium for the Study of End-Stage Liver Disease (12 centers). Patients were followed up for 6 months after hospital discharge and data were analyzed on type of infections and factors associated with subsequent infections. RESULTS Six months after hospital discharge, 14% of subjects had received liver transplants, 27% died, and 59% were alive without liver transplantation. After discharge, 45% had subsequent infections, but only 26% of the subsequent infections occurred at the same site. Compared with patients not re-infected, patients with repeat infections were older and a higher proportion used proton pump inhibitors (PPIs) (P = .006), rifaximin (P < .001), or prophylactic therapy for spontaneous bacterial peritonitis (SBP) (P < .001). Logistic regression showed that SBP prophylaxis (odds ratio [OR], 3.44; 95% confidence interval [CI], 1.56-7.63), PPI use (OR, 2.94; 95% CI, 1.39-6.20), SBP at hospital admission (OR, 0.37; 95% CI, 0.15-0.91), and age (OR, 1.06; 95% CI, 1.02-1.11) were independent predictors of subsequent infections. CONCLUSIONS Patients hospitalized with cirrhosis and infections are at high risk for subsequent infections, mostly at different sites, within 6 months of index infection resolution. Those at highest risk include previously infected older patients receiving PPIs and/or SBP prophylaxis, although these associations do not prove that these factors cause the infections. New strategies are needed to prevent infections in patients with cirrhosis.
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Affiliation(s)
| | | | - Florence Wong
- Medicine, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | | | | | - Raza Malik
- Medicine, Beth Israel Deaconess, Boston, MA
| | - Leroy R. Thacker
- Biostatistics, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
| | - Jasmohan S. Bajaj
- Medicine, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA
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10
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Merli M, Lucidi C, Di Gregorio V, Giannelli V, Giusto M, Ceccarelli G, Riggio O, Venditti M. The chronic use of beta-blockers and proton pump inhibitors may affect the rate of bacterial infections in cirrhosis. Liver Int 2015; 35:362-9. [PMID: 24836902 DOI: 10.1111/liv.12593] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 05/11/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Bacterial infections are among the most common and life-threatening complications in cirrhosis. Qualitative and quantitative modifications of the gut microbiota, dysfunction of the intestinal barrier and multiple immune defects are factors that contribute to a pathological 'bacterial translocation' (BT), leading to a higher susceptibility to infections in cirrhotic patients. Long-term therapies, commonly adopted in cirrhotic patients, may influence BT and modify the risk of infection in these patients. To investigate the influence of chronic therapies on the prevalence and microbiological characteristics of infections in cirrhosis. METHODS Consecutive cirrhotic patients hospitalised from 2008 to 2013 were enrolled. All previous treatments were carefully recorded. Infections were actively sought out, patients were actively monitored for infection, and possible risk factors were evaluated. RESULTS Four hundred cirrhotic patients were included. The most frequent therapies were proton pump inhibitors (PPIs) (67%), non-absorbable-disaccharides (44%), beta-blockers (BBs) (39%) and non-absorbable-antibiotics (10%). Child-Pugh C (P < 0.001; OR 5; 95%CI: 2.6-9.9) and PPI therapy (P = 0.008; OR 2; 95% CI: 1.2-3.2) were found to be independent predictors of infection, and the use of BBs was a protective factor (P = 0.001; OR 0.46; 95%CI: 0.3-0.7). Cirrhotic patients with bacterial infection showed lower morbidity and mortality when taking BBs. CONCLUSIONS Proton pump inhibitors increase the risk of infection in cirrhosis and should not be prescribed in these patients without specific indications. In contrast, the use of BBs is associated with a lower rate of infection and attenuates the consequences of infections in cirrhotic patients.
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Affiliation(s)
- Manuela Merli
- Gastroenterology, Department of Clinical Medicine, 'Sapienza' University of Rome, Rome, Italy
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11
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Baijal R, Amarapurkar D, Praveen Kumar HR, Kulkarni S, Shah N, Doshi S, Gupta D, Jain M, Patel N, Kamani P, Issar SK, Dharod M, Shah A, Chandnani M, Gautam S. A multicenter prospective study of infections related morbidity and mortality in cirrhosis of liver. Indian J Gastroenterol 2014; 33:336-42. [PMID: 24879611 DOI: 10.1007/s12664-014-0461-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Accepted: 03/30/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Infections are a common and serious complication among patients with cirrhosis. We assessed the epidemiology, risk factors, and clinical consequences of bacterial infections in cirrhotic patients. METHODS In this multicenter prospective study, all patients with cirrhosis of liver with different infections were analyzed. Infections were classified as community-acquired (CA), healthcare-associated (HCA), or hospital-acquired (HA). Site of infection and characteristics of bacteria were recorded; effect on liver function and 30-day survival were evaluated. RESULTS One hundred and six out of 420 (25 %) patients with cirrhosis of liver had infection. Infection rate among indoor patients was 37.5 % (92/245) and among outdoor patients was 8 % (14/175). Out of 106 patients, CA, HCA, and HA were seen in 19.8 %, 50 %, and 30.2 %, respectively. Spontaneous bacterial peritonitis (31.1 %), urinary tract infections (22.6 %), and pneumonia and cellulitis (11.3 % each) were common infections. Gram-negative bacteria (54 %) were more common than Gram-positive cocci (46 %). Multidrug resistant (MDR) organisms were seen in 41.7 % of patients. Most of the MDR organisms were seen in HCA and HA patients. The degree of liver impairment was significantly more severe in patients with infection. Independent predictor of infection was high Child-Turcott-Pugh (CTP) class (p = 0.006, Child B vs. A (odds ratio (OR) 3.04 95 % CI = 1.63 to 5.68) and Child C vs. A (OR 4.17 95 % CI = 2.12 to 8.19). Overall in-hospital mortality was 7.6 %. Patients with infection had increased mortality at 30-day follow up compared to those without infection (23.5 % vs. 2.2 %; p<0.001). CONCLUSIONS Infections are one of the important causes of morbidity and mortality in patients with cirrhosis of liver. The most frequent infections are HCA and HA. Infection predisposes to deterioration of liver function and increases mortality. Cirrhotic patients should be monitored closely for infections especially those with Child class B and C.
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Affiliation(s)
- Rajiv Baijal
- Department of Gastroenterology, Jagjivan Ram Hospital, Maratha Mandir Marg, Mumbai Central, Mumbai, 400 008, India
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Singal AK, Salameh H, Kamath PS. Prevalence and in-hospital mortality trends of infections among patients with cirrhosis: a nationwide study of hospitalised patients in the United States. Aliment Pharmacol Ther 2014; 40:105-12. [PMID: 24832591 DOI: 10.1111/apt.12797] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 03/18/2014] [Accepted: 04/25/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Data on bacterial infections in hospitalised patients in the US with cirrhosis are derived largely from single centre data. Countrywide data in this population are lacking. AIM To assess prevalence of infections among hospitalised patients in the US and examine their impact on in-hospital mortality and health care resources utilisation. METHODS Nationwide Inpatient Sample (1998-2007) was queried for hospitalisations with cirrhosis and examined for infections including spontaneous bacterial peritonitis (SBP), urinary tract infection (UTI), skin and soft tissue infections, pneumonia and Clostridium difficile infections (CDI). In-hospital mortality, length of stay (LOS) and total charges were analysed. RESULTS Of 742,391 admissions with cirrhosis, 168,654 (23%) had discharge diagnosis of any infection. Between 1998 and 2007, there was a trend towards increasing prevalence of infections (21-25%). Higher rates of infection were associated with ascites (22-25%) and renal insufficiency (RI) (38-43%). Infection with RI increased from 13% in 1998 to 27% in 2007. UTI was the most common infection (9-12%) followed by subcutaneous tissue infections (5-6%) and SBP (2-3%, around 12% in patients with ascites). Infection rate was similar among teaching and nonteaching hospitals with CDI and SBP being more common in teaching hospitals. In-hospital mortality was about 5%, over fivefold higher in infected cirrhotics, and associated with higher LOS and charges. Sepsis (38-42%), pneumonia (23-30%), SBP (16-23%) and CDI (11-16%) contributed most to in-hospital mortality. CONCLUSIONS The prevalence of infections among hospitalised patients with cirrhosis in the US is increasing and is associated with in-hospital mortality, renal insufficiency and costs.
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Affiliation(s)
- A K Singal
- Division of Gastroenterology and Hepatology, University of Alabama, Birmingham, AL, USA; Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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Sharma S, Feld JJ. Commentary: non-haemodynamic effects of beta-blockers in cirrhosis--more than meets the eye? Aliment Pharmacol Ther 2013; 38:652. [PMID: 23964732 DOI: 10.1111/apt.12433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Accepted: 07/08/2013] [Indexed: 12/12/2022]
Affiliation(s)
- S Sharma
- Toronto Centre for Liver Disease, University of Toronto, Toronto, Canada
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Motzkus-Feagans C, Pakyz AL, Ratliff SM, Bajaj JS, Lapane KL. Statin use and infections in Veterans with cirrhosis. Aliment Pharmacol Ther 2013; 38:611-8. [PMID: 23889738 DOI: 10.1111/apt.12430] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Revised: 12/04/2012] [Accepted: 07/05/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Evidence about the beneficial effects of statins on reducing infections is accumulating. Identifying ways to reduce infection risk in patients with cirrhosis is important because of increased mortality risk and costs associated with infections. AIM To estimate the extent to which statin use prolongs time to infection among patients with cirrhosis. METHODS We identified Veterans with cirrhosis, but without decompensation (n = 19 379) using US Veterans Health Administration data from 2001 to 2009. New users of statins were identified and propensity matched to non-users and users of other cholesterol-lowering medications (1:1 matching). The cohort was followed up for hospitalisations with infections. Cox regression models with time-varying exposures provided estimates of adjusted hazard ratios (HR) and 95% confidence intervals (CI). RESULTS New statin use was present among 13% of VA patients with cirrhosis without decompensation. Overall, 12.4% of patients developed a serious infection, and 0.1% of patients died. In the propensity-matched sample, statin users experienced hospitalisations with infections at a rate 0.67 less than non-users (95% Confidence Interval: 0.47-0.95). CONCLUSIONS Infections are a major concern among cirrhotic patients and have the potential to seriously impact both life expectancy and quality of life. Statin use may potentially reduce the risk of infections among patients with cirrhosis.
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Affiliation(s)
- C Motzkus-Feagans
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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Bajaj JS, Ratliff S, Lapane K. Commentary: non-haemodynamic effects of beta-blockers in cirrhosis - more than meets the eye? Authors' reply. Aliment Pharmacol Ther 2013; 38:653. [PMID: 23964733 DOI: 10.1111/apt.12434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 07/09/2013] [Indexed: 12/08/2022]
Affiliation(s)
- J S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA, USA.
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