Skin and soft tissue infections in cirrhotics: a prospective analysis of clinical presentation and factors affecting outcome

Expert consensus on the diagnosis and treatment of end-stage liver disease complicated by infections

End-stage liver disease (ESLD) is a life-threatening clinical syndrome and when complicated with infection the mortality is markedly increased. In patients with ESLD, bacterial or fungal infection can induce or aggravate the occurrence or progression of liver decompensation. Consequently, infections are among the most common complications of disease deterioration. There is an overwhelming need for standardized protocols for early diagnosis and appropriate management for patients with ESLD complicated by infections. Asia Pacific region has the largest number of ESLD patients, due to hepatitis B and the growing population of alcohol and NAFLD. Concomitant infections not only add to organ failure and high mortality but also to financial and healthcare burdens. This consensus document assembled up-to-date knowledge and experience from colleagues across the Asia-Pacific region, providing data on the principles as well as evidence-based current working protocols and practices for the diagnosis and treatment of patients with ESLD complicated by infections.

Current challenges in acute bacterial skin infection management

PURPOSE OF REVIEW

There are aspects of skin and soft tissue infections (SSTIs) that remain unresolved, such as current numbers, classification criteria, how best to define severity and predict the outcome, what diagnostic tests to perform, what new treatment options are available, or what the duration of antibiotic treatment should be. We have reviewed the literature over the last 18 months to clarify these issues and provide our opinion.

RECENT FINDINGS

SSTIs are common and among the top 10 most frequent infections worldwide. They represent a burden on the healthcare system and have a major impact on the quality of life of patients. Regarding classification, the Infectious Diseases Society of America (IDSA) provides a practical guide that distinguishes between uncomplicated and complicated infections, acute and chronic wound infections, and necrotising and nonnecrotizing infections based on skin extension and tissue necrosis. With new microbiological and imaging diagnostic techniques, SSTIs can now be better diagnosed. New PCR techniques are available, and mass spectrometry can be applied to samples collected in liquid transport media. Moreover, new treatment methods such as photodynamic therapy, reactive oxygen, and phages are emerging. SSTI patients can be treated with shorter antibiotic courses if they receive an active drug with good tissue penetration. Antibiotic treatment in necrotizing infections can be shortened to 48 h after the last debridement.

SUMMARY

SSTIs remain a challenge regarding rapid and accurate diagnosis and clinical management.

Etiological Spectrum of Cirrhosis in India: A Systematic Review and Meta-analysis

BACKGROUND

Cirrhosis is a significant cause of morbidity and mortality globally and in India. This systematic review and meta-analysis aimed to ascertain the etiological spectrum and changing trends of cirrhosis in India.

METHODS

We searched electronic databases, including Pubmed/Medline, Scopus, and Embase. We included original studies that reported the etiology of cirrhosis in the Indian population.

RESULTS

We included 158 studies (adults: 147, children: 11). The overall pooled estimate of alcohol as a cause of cirrhosis in adults was 43.2% (95% confidence interval (CI) 39.8-46.6%; I2 = 97.8%), followed by nonalcoholic fatty liver disease (NAFLD)/cryptogenic in 14.4%, 95% CI (11.7-17.3%; I2 = 98.4%), hepatitis B virus (HBV) in 11.5%, 95% CI (9.8-13.3%; I2 = 96.6%), and hepatitis C virus (HCV) in 6.2%, 95% CI (4.8-7.8%; I2 = 97.2%) of the included patients. The most common cause of cirrhosis in all zones was alcohol-related. Comparison of etiologies over time revealed a reduction in the viral hepatitis-related and an increase in the proportion of alcohol-related and NAFLD/cryptogenic-related cirrhosis. The overall pooled estimates of various etiologies in children were: HBV in 10.7%, 95% CI (4.6-18.7%; I2 = 91.0%), NAFLD/Cryptogenic in 22.3%, 95% CI (9.0-39.2%; I2 = 96.7%), and HCV in 2.0%, 95% CI (0.0-8.5%; I2 = 94.6%).

CONCLUSIONS

Alcohol is the most common etiology of cirrhosis in adults in India. The proportions of alcohol and NAFLD-related cirrhosis are increasing, and those of viral hepatitis-related cirrhosis are reducing. The results of our meta-analysis will help formulate health policies and the allocation of resources.

Mortality, sepsis, and organ failure in hospitalized patients with cirrhosis vary by type of infection

BACKGROUND AND AIM

Infection is associated with substantial morbidity and mortality in cirrhosis, but presumably, not all infections carry the same risk of mortality. We compared outcomes of different sites of infection in a nationally representative sample of inpatients with cirrhosis.

METHODS

We queried the Nationwide Readmissions Database for patients with cirrhosis from 2011 to 2014. Cirrhosis and infection diagnoses were identified by previously used algorithms of ICD-9 codes. The following infections were compared: urinary tract infection (UTI), pneumonia, cellulitis, spontaneous bacterial peritonitis (SBP), and Clostridium difficile infection (CDI). The primary outcome was inpatient mortality. Secondary outcomes included sepsis, any organ failure, multiple organ failures, and 30-day readmission. Outcomes were analyzed using logistic regression and included a priori covariates.

RESULTS

A total of 1 798 830 weighted index admissions were identified. Infection was present in 29.2% overall-including UTI (13.7%), pneumonia (8.9%), cellulitis (5.2%), CDI (2.8%), and SBP (2.0%). Mortality was significantly higher in pneumonia (19.6%), SBP (18.6%), and CDI (17.4%) compared with cellulitis (7.6%) and UTI (11.8%). Sepsis, any, and multiple organ failures were most commonly seen in pneumonia, SBP, and CDI. Multivariable analysis demonstrated that pneumonia had the highest associated mortality (odds ratio [OR] 2.73, confidence interval [CI] 2.68-2.80) and multiple organ failures (OR 3.59, CI 3.50-3.68). Significantly increased 30-day readmission was seen only with SBP (24.9%).

CONCLUSIONS

Outcomes of inpatients with cirrhosis vary significantly depending on the type of infection. The severity and epidemiology of infection in cirrhosis appears to be shifting with pneumonia, not SBP, having the highest prevalence of multiple organ failures and inpatient mortality.

Cellulitis in liver cirrhosis - a series of 25 cases from southern India

Introduction

Cirrhosis of the liver predisposes patients to serious bacterial infections including cellulitis. The aim of the study was to determine the clinical and bacteriological profile of cellulitis in patients with liver cirrhosis.

Material and methods

In this prospective study, consecutive cirrhotic patients hospitalized between February and September 2017 were enrolled. Data retrieved included demographics, aetiology, co-morbidity, cirrhosis-related complications, site of cellulitis, baseline investigations, and wound and blood culture.

Results

Three hundred and thirty-eight patients were admitted, of whom 25 had cellulitis (mean age 52.8 ± 10.4 years, men 88.0%, median MELD [model of end-stage liver disease] 18.8 ± 10.4). Non-alcoholic steatohepatitis and alcohol were each the cause of cirrhosis in 40% of cases. Nine patients (36%) had diabetes mellitus. Cultures were positive in 13 cases (52%; 1 - blood, 11 - wound, 1 - both blood and skin). The majority of the cultures showed monomicrobial growth (9; 70%). Escherichia coli was the commonest isolate (6/13), followed by Klebsiella (4). 61% of isolates had multidrug resistant organisms. The outcome was favourable.

Conclusions

Prevalence of cellulitis was 7.4% in hospitalised cirrhotics. Culture positivity was 52%. Escherichia coli and Klebsiella were the most common isolates and three fifths of isolates were multidrug resistant.

Incidence, predictive factors and impacts of acute kidney injury in cirrhotic patients hospitalized for cellulitis

BACKGROUND & AIMS

Cellulitis is a common infection in patients with cirrhosis but its impact on progression of liver disease has been hardly addressed. This study examines the incidence of acute kidney injury (AKI), predictive factors and its impacts on mortality in cirrhotic patients hospitalized for cellulitis.

METHODS

Retrospective data from cirrhotic patients hospitalized for cellulitis over the period January 2006 to September 2015 were analysed. AKI was defined according to revised criteria of the International Club of Ascites.

RESULTS

A total of 101 episodes of cellulitis were examined (70.3% men; mean age 60.6 ± 13.6 years). Of patients, 27% met criteria for acute on chronic liver failure (ACLF) (grade 1: 63%; grade 2: 22%; grade 3: 15%). AKI was recorded in 50.5% (type 1: 67%; type 2: 19%; type 3: 14%). AKI was present on admission in 21 of the 51 patients (41%) who developed it. In the remaining 30 patients (59%), AKI appeared during hospitalization and its development was associated with a MELD score >14 (70% vs 30%, P=.024). In-hospital mortality was 10% and all patients who died had AKI. A high MELD score on admission, AKI and ACLF were associated with in-hospital mortality (P<.05). One-month transplant-free survival was 84% (70% vs 98% in patients with and without AKI, P=.001).

CONCLUSIONS

In cirrhotic patients, cellulitis is a serious infection that often leads to AKI and ACLF. AKI is a strong predictor of mortality in this setting.

Bacterial Infections

Bacterial infections are the most significant infectious source of morbidity and mortality in cirrhotic patients. Bacteria infections result is both acute decompensation in chronic liver disease and mortality in patients with decompensated cirrhosis. Spontaneous bacterial peritonitis (SBP), bacteremia, pneumonia, urinary tract infections (UTI) and skin and soft tissue infection (SSTI) are the most significant sources of infection in cirrhosis. Bacterial infections can precipitate renal failure and worsening hepatic encephalopathy, and patients with sepsis and liver disease have higher rates of acute respiratory distress syndrome (ARDS) and coagulopathy.

Escherichia coli Eyelid Abscess in a Patient with Alcoholic Cirrhosis

Escherichia coli (E. coli) is a rare cause of ocular infections and has not yet been reported as a cause of an ocular abscess. We describe the case of a 47-year-old woman with a history of alcoholic cirrhosis who presented with painful left lower eyelid swelling that did not improve with oral antibiotics. The abscess was drained and cultures were positive for E. coli. Patients with cirrhosis are at increased risk for developing E. coli bacterial infections, but to our knowledge this is the first case of an E. coli eyelid abscess reported in the literature.