Second Infections Independently Increase Mortality in Hospitalized Patients With Cirrhosis: The North American Consortium for the Study of End-Stage Liver Disease (NACSELD) Experience

• Type of Material: Article
• Authors: Jasmohan S Bajaj, Virginia Commonwealth University; Jacqueline G O'Leary, Baylor University; K. Rajender Reddy, University of Pennsylvania; Florence Wong, University of Toronto; Jody C Olson, Mayo Clinic; Ram Subramanian, Emory University; Geri Brown, University of Texas; Nicole A Noble, Virginia Commonwealth University; Leroy R Thacker, Virginia Commonwealth University; Patrick S Kamath, Virginia Commonwealth University
• Language: English
• Date: 2012-12-01
• Publisher: Wiley: 12 months
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2012 American Association for the Study of Liver Diseases.
• Final Published Version (URL): http://dx.doi.org/10.1002/hep.25947
• Title of Journal or Parent Work: Hepatology
• ISSN: 0270-9139
• Volume: 56
• Issue: 6
• Start Page: 2328
• End Page: 2335
• Grant/Funding Information: Partly supported by NIH grant NIDDK RO1DK087913 and UL1RR031990 from the National Center for Research Resources
• Keywords: Science & Technology; Life Sciences & Biomedicine; STRATEGIES; RISK; Gastroenterology & Hepatology; BACTERIAL; CARE-ASSOCIATED INFECTIONS
• Research Categories: Health Sciences, Public Health; Health Sciences, Medicine and Surgery

Abstract

Bacterial infections are an important cause of mortality in cirrhosis, but there is a paucity of multicenter studies. The aim was to define factors predisposing to infection-related mortality in hospitalized patients with cirrhosis. A prospective, cohort study of patients with cirrhosis with infections was performed at eight North American tertiary-care hepatology centers. Data were collected on admission vitals, disease severity (model for endstage liver disease [MELD] and sequential organ failure [SOFA] scores), first infection site, type (community-acquired, healthcare-associated [HCA] or nosocomial), and second infection occurrence during hospitalization. The outcome was mortality within 30 days. A multivariate logistic regression model predicting mortality was created. 207 patients (55 years, 60% men, MELD 20) were included. Most first infections were HCA (71%), then nosocomial (15%) and community-acquired (14%). Urinary tract infections (52%), spontaneous bacterial peritonitis (SBP, 23%) and spontaneous bacteremia (21%) formed the majority of the first infections. Second infections were seen in 50 (24%) patients and were largely preventable: respiratory, including aspiration (28%), urinary, including catheter-related (26%), fungal (14%), and Clostridium difficile (12%) infections. Forty-nine patients (23.6%) who died within 30 days had higher admission MELD (25 versus 18, P < 0.0001), lower serum albumin (2.4 g/dL versus 2.8 g/dL, P = 0.002), and second infections (49% versus 16%, P < 0.0001) but equivalent SOFA scores (9.2 versus 9.9, P = 0.86). The case fatality rate was highest for C. difficile (40%), respiratory (37.5%), and spontaneous bacteremia (37%), and lowest for SBP (17%) and urinary infections (15%). The model for mortality included admission MELD (odds ratio [OR]: 1.12), heart rate (OR: 1.03) albumin (OR: 0.5), and second infection (OR: 4.42) as significant variables. Conclusion: Potentially preventable second infections are predictors of mortality independent of liver disease severity in this multicenter cirrhosis cohort.