Highlights
- •Among patients with cirrhosis and bacterial infections, 48% have bacterial infection related-ACLF.
- •ACLF following bacterial infection occurs most commonly in the Indian subcontinent and less so in Southern Europe.
- •ACLF occurs more frequently following spontaneous bacterial peritonitis, pneumonia, and nosocomial infections.
- •Patients with ACLF have lower infection resolution rate and higher mortality rate.
Background & Aims
Bacterial infections can trigger the development of organ failure(s) and acute-on-chronic
liver failure (ACLF). Geographic variations in bacteriology and clinical practice
could lead to worldwide differences in ACLF epidemiology, phenotypes and associated
outcomes. Herein, we aimed to evaluate regional differences in bacterial infection-related
ACLF in patients with cirrhosis admitted to hospital.
Methods
This post hoc analysis included 1,175 patients with decompensated cirrhosis (with bacterial infection
on admission or nosocomial infection) from 6 geographic regions worldwide. Clinical,
laboratory and microbiological data were collected from the diagnosis of infection.
Patients were followed-up for organ failure(s) and ACLF development according to the
EASL-CLIF criteria from enrolment to discharge/death.
Results
A total of 333 patients (28%) had ACLF at diagnosis of infection, while 230 patients
developed ACLF after diagnosis of infection, resulting in an overall rate of bacterial
infection related-ACLF of 48%, with rates differing amongst different geographic regions
(38% in Southern Europe vs. 75% in the Indian subcontinent). Bacterial infection related-ACLF more frequently
developed in younger patients (55 ± 13 vs. 58 ± 14 years), males (73% vs. 62%), patients with alcohol-related cirrhosis (59% vs. 45%) and those with a higher baseline MELD score (25 ± 11 vs. 16 ± 5) (all p <0.001). Spontaneous bacterial peritonitis, pneumonia or infections caused by extensively
drug resistant (XDR) bacteria were more frequently associated with ACLF development.
More patients with ACLF had a positive quick sequential organ failure assessment score
and septic shock, resulting in a lower infection resolution rate (all p <0.001).
Conclusions
Bacterial infections, especially with XDR organisms, are associated with the highest
risk of ACLF development, accounting for almost half of cases globally. Geographic
differences result in variable epidemiology and clinical outcomes.
Lay summary
Bacterial infections can trigger a sudden deterioration in an otherwise stable cirrhotic
patient, a condition known as acute-on-chronic liver failure or ACLF. This study has
found that the development of ACLF following bacterial infection occurs most commonly
in the Indian subcontinent and less so in Southern Europe. The common infections that
can trigger ACLF include infection of the abdominal fluid, known as spontaneous bacterial
peritonitis, pneumonia and by bacteria that are resistant to multiple antibiotics.
Patients who develop ACLF following a bacterial infection have high death rates and
are frequently unable to clear the infection.
Graphical abstract
Graphical Abstract
Keywords
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References
- Bacterial infections in cirrhosis: a position statement based on the EASL Special Conference 2013.J Hepatol. 2014; 60: 1310-1324
- Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis.Gastroenterology. 2010; 139: 1246-1256.e5
- Infections complicating cirrhosis.Liver Int. 2018; 38: 126-133
- Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis.Gastroenterology. 2013; 144: 1426-1437.e9
- Survival in infection-related acute-on-chronic liver failure is defined by extrahepatic organ failures.Hepatology. 2014; 60: 250-256
- Epidemiology and effects of bacterial infections in patients with cirrhosis worldwide.Gastroenterology. 2019; 156: 1368-1380.e10
- Hepatic encephalopathy in chronic liver disease: 2014 practice guideline by the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases.J Hepatol. 2014; 61: 642-659
- Development and validation of a prognostic score to predict mortality in patients with acute-on-chronic liver failure.J Hepatol. 2014; 61: 1038-1047
- NACSELD acute-on-chronic liver failure (NACSELD-ACLF) score predicts 30-day survival in hospitalized patients with cirrhosis.Hepatology. 2018; 67: 2367-2374
- Health care and equity in India.Lancet. 2011; 377: 505-515
- Bacterial and fungal infections in acute-on-chronic liver failure: prevalence, characteristics and impact on prognosis.Gut. 2018; 67: 1870-1880
- Clinical course of acute-on-chronic liver failure syndrome and effects on prognosis.Hepatology. 2015; 62: 243-252
Article info
Publication history
Published online: August 08, 2020
Accepted:
July 29,
2020
Received in revised form:
July 20,
2020
Received:
May 7,
2020
Footnotes
Author names in bold designate shared co-first authorship
Identification
Copyright
© 2020 Published by Elsevier B.V. on behalf of European Association for the Study of the Liver.
