Multi-drug resistant infections increase mortality risk in cirrhosis

PARIS — Patients with cirrhosis who experienced a multi-drug resistant bacterial infection were less likely to respond to first-line treatment and resolve infection and had a significantly higher risk for in-hospital mortality, according to a presentation at the International Liver Congress.

“Bacterial infection is a very common complication in this special population,” Paolo Angeli, MD, PhD, from the University of Padova in Italy, said in a press conference. “The rate of bacterial infection in cirrhotic patients is fourfold higher than the general population. The rate of mortality due to bacterial infection in cirrhotic patients is around 30% at 1 month and 63% at 1 year.”

Angeli and colleagues – on behalf of the International Club of Ascites – designed a multicenter intercontinental study to investigate the epidemiology and outcomes of bacterial and fungal infections in hospitalized patients with cirrhosis.

From October 2015 to September 2016, the researchers enrolled 1,302 patients with cirrhosis and bacterial and/or fungal infections from North or South America (25%), Asia (32%) and Europe (43%). Infections were community-acquired (48%), health care-associated (26%) or nosocomial (26%).

Among those enrolled, 34% had multi-drug resistant infections — defined as resistant to at least one antibiotic in more than two classes — and 8% had extensively drug-resistant bacteria infections, including carbapenem resistant enterobacteriaceae, acinetobacter baumannii, pseudomonas and vancomycin-resistant enterococci.

Independent risk factors for multi-drug resistant infections included infection in Asia (OR = 2.79; P = .017), particularly in India (OR = 7.94; P < .001), or in South America (OR = 2.23; P = .053); the use of antibiotics within 3 months of hospitalization (OR = 1.92; P = .001); nosocomial (OR = 2.65; P < .001) or health care-associated infection (OR = 1.62; P = .032); and the type of infection: pneumonia (OR = 3.2; P < .001), urinary tract infection (OR = 2.48; P < .001) or skin and soft tissue infection (OR = 2.92; P = .004).

Multi-drug resistant infections correlated with a lower response to empirical antibiotic treatment (40% vs. 68%; P < .001), a higher incidence of septic shock (27% vs. 15%; P < .001) and new organ failures (42% vs. 31%; P = .001), a lower rate of resolution of infection (82% vs. 72%; P = .003), and higher in-hospital mortality (31% vs. 21%; P = .004) compared with other non-resistant bacterial infections.

“This is quite important, because when infection is sustained by a multi-drug resistant bacteria, the probability to obtain acute-on-chronic liver failure is higher, the probability to experience septic shock is higher, the probability to be transferred to ICU is higher, but overall what is highest is in-hospital mortality,” Angeli said.

Independent predictors of in-hospital mortality included age (OR = 1.02; 95% CI, 1.01-1.04), MELD score (OR = 1.08; 95% CI, 1.05-1.11), presence of ACLF (OR = 1.59; 95% CI, 1.02-2.47), C-reactive protein (OR = 1.27; 95% CI, 1.08-1.48) and ineffective first-line treatment (OR = 7.15; 95% CI, 4.88-10.47).

“Nosocomial infections, pneumonia, and both extensive drug-resistant and multi-drug resistant bacteria infections are more difficult to treat in this population,” Angeli concluded. “The efficacy of first-line treatment is crucial to improve the survival of cirrhotic patients with bacterial infections.” – by Talitha Bennett

For more information:

Piano S, et al. Abstract GS-001. Presented at: International Liver Congress; Apr. 11-15, 2018; Paris, France.

Disclosure: The authors report no relevant financial disclosures.