Opportunistic infections in end stage liver disease

Liver cirrhosis is a risk-factor for Pneumocystis jirovecii associated mortality

Background

Pneumocystis jirovecci pneumonia (PCP) is a life threating disease in immunodeficient patients. Liver cirrhosis itself can lead to immunodefiency, however little is known if Pneumocystis jirovecci infection affects the outcome of patients with liver cirrhosis.

Aim

We aimed to assess the predictors for Pneumocystis jirovecci-associated mortality in patients with Pneumocystis jirovecci infection treated at intensive care units.

Methods

A total of 151 patients hospitalized between January 2013 and November 2019 with a PCR-confirmed Pneumocystis jirovecci infection were retrospectively included in this study and analysed for clinical predictors for PCJ associated mortality.

Results

The overall mortality in our patient cohort was 60%. Out of 151 patients included in the analysis, 67 (44%) patients suffered from liver cirrhosis. Patients with an advanced liver cirrhosis (Child-Pugh class C) showed the highest mortality rate of 84.7%. The presence of a liver cirrhosis was associated with a significant increased risk of mortality (OR: 4.809) ([95%-CI: 2.32-9.97]; p < 0.001). There was a significant correlation of Meld score and mortality (r = 0.612, p < 0.001).

Discussion

To our knowledge, this study represents the largest evaluation of Pneumocystis jirovecci infection in patients with advanced liver cirrhosis. Cirrhosis associated immune dysfunction (CAID) describes the spectrum of immunological disturbances in patients with cirrhosis, which is linked to a heightened vulnerability to bacterial infections. Our data indicate a heightened susceptibility to fungal infections. Understanding the phenotypic manifestations of CAID could lead to immune-targeted therapies aimed at reducing infection susceptibility and decreasing CAID-associated mortality in cirrhosis patients.

Definition, reasons, and risk factors for mortality of patients listed for liver transplantation - a single-center study

BACKGROUND

 In Germany, following the principle "sickest first", patients awaiting liver transplantation (LTPL) are often transplanted with high MELD score and run the risk that they can no longer be transplanted, getting "too sick for transplant".

METHODS

 In a retrospective single-center study, we analyzed the mortality of adult patients on the waiting list for LTPL during the years 2014 to 2017. To stratify risk factors, we compared characteristics of deceased and transplanted patients.

RESULTS

 The main reasons for mortality were sepsis (42.9 %), malignancy (24.3 %) and bleeding (10.0 %). Risk factors for mortality (OR, univariate logistic regression, p < 0.05) were acute on chronic liver failure (ACLF), loss of E-MELD, sepsis, pneumonia, proof of pathogens, candidemia, stay at ICU, multiple organ failure and mechanical ventilation. Multivariate analysis revealed pneumonia (p < 0.001) and high MELD (p = 0.031) as risk factors. Transplantation was more likely in patients with E-MELD. We suggest a Waiting List Mortality Index for Transplantation (WMIT), by dividing deceased patients to transplanted patients to assess mortality. Average WMIT in our cohort was 0.65.

CONCLUSIONS

 Mortality on the waiting list is mainly determined by pneumonia and infections in high-MELD patients. Therefore, patients with ACLF after infections should be prioritized for LTPL. A WMIT might suitably represent waiting list mortality.

A case series of rapidly growing mycobacterial catheter-related bloodstream infections among immunocompetent patients

Rapidly growing mycobacteria (RGM) are ubiquitous in the environment and can cause a variety of human infections. Catheter-related bloodstream infections (CRBSI) caused by RGM have been reported predominantly among immunocompromised patients. Removal of central lines and antimicrobial therapy with at least 2 active agents are generally recommended for immunocompromised patients. RGM bloodstream infections (BSIs) are rare in immunocompetent patients and clinical data are very limited. Retrospective medical record review was conducted on patients with blood cultures positive for RGM from July 2012 through March 2015 at Lemuel Shattuck Hospital, a public teaching hospital in Jamaica Plain, Massachusetts, United States. RGM was suspected by presence of beaded Gram-positive bacilli on Gram staining of positive conventional blood cultures and it was confirmed as RGM by Massachusetts State Public Health Laboratory. Nineteen episodes of RGM BSI were identified in 17 patients who had no known immunocompromised conditions that predispose them to opportunistic pathogens. They were predominantly young male with history of intravenous drug use. Peripherally inserted central catheter (PICC) was present in all episodes of RGM BSI and 74% of them clinically improved with PICC removal alone without specific antibiotic therapy for RGM. They were followed up for median duration of 45 days (interquartile range 25–385). The patients remained alive and asymptomatic until the end of follow-up periods. In immunocompetent patients, removal of catheters alone without adding specific antibiotics may be sufficient for RGM CRBSI.

Presentation and outcomes of end stage liver disease patients presenting with septic shock to the emergency department

BACKGROUND

Patients with end stage liver disease (ESLD) are particularly vulnerable to sepsis. ESLD patients are often excluded from controlled sepsis trials and more data are needed to guide the management of this population.

OBJECTIVE

To describe the clinical factors and outcomes of patients with ESLD presenting to the emergency department (ED) with septic shock.

METHODS

We performed a retrospective review of patients registered in our dedicated ED adult septic shock pathway. All patients registered between January 2014 and May 2016 were included. Clinical and treatment variables for ESLD patients were compared with non-ESLD patients. A second analysis assessed ESLD survivors compared to non-survivors.

RESULTS

2,584 septic shock patients were enrolled. ESLD was present in 6.2% (n = 161) of patients. Patients with ESLD had higher mortality compared to patients without ESLD 36.6% vs 21.2% (p < 0.001). ESLD patients were more likely to be younger, female, obese, and have other comorbidities. ESLD patients exhibited lower temperature, higher lactate, and higher incidence of acute kidney injury. There was no difference in antibiotics or fluid resuscitation between groups. ESLD patients received more ED vasopressor support. Among ESLD septic shock patients, maximum lactate and presence of pneumonia were independently associated with death.

CONCLUSIONS

Patients with ESLD comprise a small but important subgroup of patients with ED septic shock that experience high mortality compared to patients without ESLD. Maximum ED lactate and pneumonia as the source of sepsis are independently associated with adverse outcome and may be used for early recognition of high-risk ESLD sepsis patients.

Hepatitis C viremia as a risk factor for opportunistic infections in kidney transplant recipients

The aim of the present study was to determine the clinical characteristics, frequency of opportunistic infections (OI) in HCV-positive kidney recipients, and to evaluate HCV replication as a risk factor for developing an OI. We conducted a retrospective study of all kidney recipients from 2003 to 2014. A total of 1203 kidney transplants were performed during the study period. Opportunistic infections were recorded in 251 patients (21%) and nucleic acid amplification testing (NAAT) positivity in 75 (6%). Patients who are HCV NAAT positive were more likely to present an OI than those who are HCV NAAT negative (45% vs 20%, P < 0.001). Multivariate analysis showed the factors that were independently associated with the development of OI to be acute rejection, graft loss, post-transplantation hemodialysis, and HCV replication. Liver cirrhosis after transplantation could not be considered a risk factor to develop OI. To conclude, a high index of suspicion of OI must be maintained in the case of kidney recipients with HCV replication. Active surveillance of cytomegalovirus infection and other prophylactic strategies against OI should be considered after 6 month post-transplantation. Prompt initiation of DAA therapies may be a useful option aiming to decrease the incidence of OI after transplantation.