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Bacterial infections frequently occur in acute-on-chronic liver failure

In a recent study, two-thirds of patients with acute-on-chronic liver failure either presented with bacterial infections or developed them during follow-up, revealing that such infections are significantly common in this cohort.

“The results of our study indicate that bacterial infection is a major problem and a key prognostic determinant in [acute-on-chronic liver failure],” Javier Fernández, MD, PhD, from the University of Barcelona, Spain, and colleagues wrote. “Adequate empirical antibiotic strategies, infection control practices and prophylactic measures are essential in the management of patients with ACLF.”

The researchers enrolled patients with complete 4-week follow-up data after diagnosis of acute-on-chronic liver failure (n = 407; ACLF) or acute decompensation (n = 235).

At diagnosis, 152 patients with ACLF and 59 with acute decompensation presented with bacterial infections. During follow-up, 117 with ACLF and 32 with acute decompensation developed bacterial infections.

Patients with ACLF had a higher prevalence of bacterial infections vs. those with acute decompensation in both overall infections (37% vs. 25%; P < .001) and proven infections (33.5% vs. 19%; P < .001). Further, 52% of those patients had ACLF 3 (P = .016).

Progress to severe sepsis or septic shock occurred more often in those with ACLF at diagnosis than those with acute decompensation (49% vs. 2%; P < .001). Similarly, nosocomial infections (53% vs. 22%; P < .001) and infections caused by multidrug-resistant organisms (16% vs. 3%; P = .01) occurred more often in those with ACLF.

“There are many similarities between ACLF and severe sepsis,” the researchers wrote. “Both conditions develop in the setting of intense systemic inflammation and oxidative stress. In patients with sepsis, systemic inflammation is initiated by an acute release of [pathogen-associated molecular patterns] by bacteria and secondary activation of the innate immune system cells. Approximately 40% of patients with ACLF share this pathophysiological mechanism.”

Compared with patients with ACLF but no infection, those with ACLF 2 or 3 and bacterial infections had a worse clinical course (47% vs. 26%; P < .001) and lower 90-day probability of survival (49% vs. 72.5%; P < .001) at both diagnosis and during follow-up.

Bacterial infections also correlated with mortality among patients with ACLF 1 and 2. Fungal infections occurred in nine patients with ACLF, most often after diagnosis with a 71% 90-day mortality rate, whereas the researchers observed no fungal infections among those with acute decompensation.

“We observed significantly higher mortality rate and shorter probability of survival in patients with ACLF triggered or complicated by bacterial infections than in patients with ACLF without bacterial infections throughout the entire period of observation, suggesting that bacterial infections have a major impact on the prognosis of patients with ACLF,” the researchers concluded. “This is also supported by the observation that infection was an independent predictor of mortality in patients with ACLF grades 1 and 2.” – by Talitha Bennett

Disclosure: Fernández reports he received grant and research support from Grifols. Please see the full study for the other authors’ relevant financial disclosures.