‘Call to action’: Variation in cirrhosis infections support streamlined antibiotic use
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Key takeaways:
- According to analysis, 31.9% of patients with cirrhosis had confirmed infection at hospital admission.
- Admission infections were associated with a higher rate of in-hospital death or hospice transfer.
Significant variations in global rates of infection, culture-positivity and drug resistance serve as a “call to action” to streamline antibiotic use and improve outcomes among inpatients with cirrhosis, according to researchers.
“Infections are a major cause of mortality worldwide, with the highest burden in low-income countries (LICs) and lower-middle-income countries (LMICs; together L-LMICs),” Zhujun Cao, MD, of the department of infectious diseases at Shanghai Jiao Tong University School of Medicine, and colleagues wrote in The Lancet Gastroenterology & Hepatology. “Regional variations in infection prevention and control policies, access to treatments and the prevalence of antimicrobial resistance (AMR) can influence infection-related outcomes.”
They added, “Understanding the burden of infection at both global and regional levels is crucial to develop robust policies.”
In a prospective cohort study initiated by The Chronic Liver Disease Evolution and Registry for Events and Decompensation Consortium, Cao and colleagues investigated regional variations in infections and clinical outcomes among 4,238 patients with cirrhosis (mean age, 56.1 years; 64% men) admitted to 98 hospitals across 26 countries.
The researchers collected data on demographics, country income, comorbidities, characteristics related to cirrhosis and infections, antibiotic use and disease course at admission, during hospitalization and for 30 days following discharge. Most patients were from upper-middle-income countries (UMICs; 45.4%), followed by high-income countries (HICs; 36.7%) and L-LMICs (18%).
The primary outcome was in-hospital death or hospice referral among those with vs. without infection at admission, while the main secondary outcome was death at 30 days after discharge.
According to analysis, 31.9% of patients had confirmed infection at hospital admission, with a higher proportion of those patients experiencing infection or hospitalization in the preceding 6 months or being listed for liver transplantation. A greater proportion of those in L-LMICs had infections (41.7% vs. 58.3%) compared with UMICs (30.6% vs. 69.4%) and HICs (28.6% vs. 71.4%). The most common infection types were spontaneous bacterial peritonitis (28.9%), pneumonia (17.2%) and urinary tract infections (14.3%).
Health care centers in HICs had higher rates of culture positivity compared with UMICs and L-LMICs (52.1% vs. 32% vs. 40.6%, respectively), with 63% of isolated organisms identified as Gram-negative, 29% Gram-positive and 9% fungi or mixed. Escherichia coli, Klebsiella pneumoniae and Enterococcus species were the top three isolated pathogens.
Results also demonstrated an overall drug resistance rate of 40%, which was highest in UMICs. Third-generation cephalosporins were among the most used empirical antimicrobials (37%), as well as broad-spectrum beta-lactams and beta-lactamase inhibitors (23%).
In addition, admission infections were associated with greater in-hospital death or hospice transfer (22.1% vs. 8%), which corresponded with an adjusted RR of 1.75 (95% CI, 1.42-2.06) on multivariable analysis. Additional factors linked to this outcome included older age, female sex, residence outside of an HIC, lactulose use and higher MELD-Na score.
Further, analysis demonstrated an association between admission infections and 30-day mortality (adjusted RR = 1.55; 95% CI, 1.36-1.77).
“Admission infections were associated with a higher risk of inpatient (plus hospice referral) and 30-day mortality, despite controlling for key factors,” Cao and colleagues wrote. “There are substantial variations in types of infection, culture-positivity rates and antibiotic use across regions.”
They continued: “These results serve as a call to action to ensure awareness, improve logistics and streamline antibiotic use in cirrhosis care to curb antibiotic resistance and ensure appropriate and timely therapy in patients with cirrhosis and infections worldwide.”
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