Infections in cirrhosis

Compared with other methods, cyanoacrylate and lauromacrogol in treating esophagogastric varices did not increase the risk of postoperative infection

BACKGROUND

Patients with cirrhosis commonly undergo endoscopic cyanoacrylate injection for gastric and esophageal variceal bleeding. However, postoperative infections can increase the risk of rebleeding and mortality.

AIM

This study aimed to determine the risk of postoperative infections and its associated factors following cyanoacrylate injection treatment in these patients.

METHODS

A retrospective analysis was conducted on 57 patients treated with ligation (ligation group), 66 patients treated with cyanoacrylate injection (injection group), and 91 patients treated with conservative treatment (control group) at the Nanchong Central Hospital.

RESULTS

The rate of postoperative infection was similar among the cyanoacrylate, ligation, and conservative treatment groups, with no significant statistical difference observed ( P  = 0.97). Multivariate analysis identified postoperative Child-Pugh score and renal insufficiency as two independent risk factors for postoperative infection. The rebleeding rate in the injection group was significantly lower than in the other groups ( P  = 0.01). Mortality was significantly higher in the control group compared with the ligation and injection groups ( P  = 0.01).

CONCLUSION

Cyanoacrylate combined with lauromacrogol injection did not significantly increase the risk of infection compared with ligation and conservative treatments, and it was more effective in reducing the risk of rebleeding. This method is safe, effective, and holds clinical value for broader application.

Pyogenic spinal infections in patients with chronic liver disease: illustrative case and systematic review

BACKGROUND

Pyogenic spinal infections (PSIs) are a group of uncommon but serious infectious diseases that are characterized by inflammation of the endplate–disc unit. PSIs are considered more prevalent and aggressive among patients with chronic immunocompromised states. Association between PSIs and liver disease has not been systematically analyzed. The authors performed a systematic review to study baseline characteristics, clinical presentation, and mortality of patients with PSI in the setting of chronic liver disease.

OBSERVATIONS

The authors presented the case of a 72-year-old female patient with chronic liver disease who presented with severe low back pain and bilateral lower weakness. Imaging studies showed T10–11 spondylodiscitis. The patient received decompression and fusion surgery with partial neurological improvement. The authors performed a systematic literature search of spondylodiscitis and liver disease, and eight published articles met the studies inclusion and exclusion criteria. These studies featured a total of 144 patients, of whom 129 met inclusion criteria (mean age, 60.5 years, range 40 to 83 years; 62% males). Lumbar infection was the most common report (67%), with Staphylococcus aureus (48%) as the main causative microorganism. Neurological compromise was present in 69% of patients. Surgical intervention occurred in 70.5% of patients, and the average duration of antibiotic treatment was 69.4 days. Postoperative complication rate was 28.5%, with a 30- and 90-day mortality of 17.2% and 24.8%, respectively.

LESSONS

Pyogenic spondylodiscitis in patients with liver disease was associated with a high rate of neurological compromise, postoperative complications, and mortality.

Haematogenous Spondylodiscitis in Patients With Liver Cirrhosis: Case Series of 36 Patients

STUDY DESIGN

A retrospective study of 36 liver cirrhosis patients presenting with spondylodiscitis.

OBJECTIVES

The aim of this study was to analyze the characteristics of spondylodiscitis in the presence of liver cirrhosis and furthermore, to evaluate the outcome of surgery in this specific group of patients.

SUMMARY OF BACKGROUND DATA

The incidence of haematogenous spondylodiscitis is increasing. The coexistence of liver cirrhosis makes the course of the disease more aggressive.

METHODS

A total of 36 liver cirrhosis patients presented with haematogenous spondylodiscitis. The onset of infection, clinical course and outcomes of management were reviewed retrospectively.

RESULTS

The associated comorbidities were cardiac in 17 patients, diabetes in 19, renal insufficiency in 16, and another focus for infection in nine cases. Neurological deficits were found in 24 patients (67%) and fever in 15 cases. Nine patients had septic manifestations. The lumbar spine was affected in 25 patients (69%). Noncontiguous spinal infection was found in nine patients (25%) and epidural abscess in 24 individuals. The preoperative C-reactive protein was elevated in all cases. The causative organism was most commonly Staphylococcus aureus (17 patients). A combined anteroposterior approach was necessary in 28 patients and a minimallly invasive surgery was performed in 30 cases. In-hospital mortality was 14% (5 patients). The neurological improvement rate was 82%. The postoperative antibiotic therapy was taken for more than 8 weeks in 22 patients. In 15 patients, a combination of antibiotics was necessary.

CONCLUSION

Spinal infection in the presence of liver cirrhosis is challenging. The rate epidural abscess formation is relatively high. Early diagnosis remains the main cornerstone in the management and the indication for surgery should be carefully considered. Minimally invasive techniques should be used when possible to minimize complication rate, and higher amounts of intraoperative blood loss should be expected.

LEVEL OF EVIDENCE

4.

Follow-up Creatinine Level Is an Important Predictive Factor of In-hospital Mortality in Cirrhotic Patients with Spontaneous Bacterial Peritonitis

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is one of the severe complications of liver cirrhosis. Early detection of high-risk patients is essential for prognostic improvement. The aim of this study is to investigate the predictive factors related to in-hospital mortality in patients with SBP.

METHODS

This was a retrospective study of 233 SBP patients (181 males, 52 females) who were admitted to four tertiary referral hospitals between August 2002 and February 2013. The patients' laboratory and radiologic data were obtained from medical records. The Child-Turcotte-Pugh (CTP) score and model for end-stage liver disease sodium model (MELD-Na) scores were calculated using the laboratory data recorded at the time of the SBP episode.

RESULTS

The causes of liver cirrhosis were hepatitis B (44.6%), alcohol (43.8%), hepatitis C (6.0%), and cryptogenic cirrhosis (5.6%). The mean MELD-Na and CTP scores were 27.1 and 10.7, respectively. Thirty-one of the patients (13.3%) died from SBP in hospital. Multivariate analysis revealed that maximum creatinine level during treatment was a statistically significant factor for in-hospital mortality (P = 0.005). The prognostic accuracy of the maximum creatinine level during treatment was 78.0% (P < 0.001). The optimal cutoff point for the maximum serum creatinine was 2 mg/dL (P < 0.001).

CONCLUSION

The follow-up creatinine level during treatment is an important predictive factor of in-hospital mortality in cirrhotic patients with SBP. Patients with SBP and a serum creatinine level during treatment of ≥ 2.0 mg/dL might have a high risk of in-hospital mortality.

Overview of Infections in the Immunocompromised Host

Understanding the components of the immune system that contribute to host defense against infection is key to recognizing infections that are more likely to occur in an immunocompromised patient. In this review, we discuss the integrated system of physical barriers and of innate and adaptive immunity that contributes to host defense. Specific defects in the components of this system that predispose to particular infections are presented. This is followed by a review of primary immunodeficiency diseases and secondary immunodeficiencies, the latter of which develop because of a specific illness or condition or are treatment-related. The effects of treatment for neoplasia, autoimmune diseases, solid organ and stem cell transplants on host defenses are reviewed and associated with susceptibility to particular infections. In conclusion, an approach to laboratory screening for a suspected immunodeficiency is presented. Knowledge of which host defects predispose to specific infections allows clinicians to prevent, diagnose, and manage infections in their immunocompromised patients most effectively.

PREVALENCE OF BACTERIAL RESISTANCE IN HOSPITALIZED CIRRHOTIC PATIENTS IN SOUTHERN BRAZIL: A NEW CHALLENGE

BACKGROUND & AIMS

An increased frequency of infections by multiresistant bacteria has been described in hospitalized patients. The aim of this study was to evaluate the bacterial resistance profile in cirrhotic patients.

METHODS

This is a retrospective observational study. We assessed the antimicrobial susceptibility of 5,839 bacterial isolates from patients with and without cirrhosis. Regarding the multidrug resistance, we evaluated 4,505 bacterial isolates from 2,180 patients.

RESULTS

Two hundred and fifty-one patients had cirrhosis (mean age 57.6 ± 11 years; 61.8% were male, 47.8% of cases associated with hepatitis C virus). Of the isolates of patients with and without cirrhosis, 174/464 (37.5%) and 1,783/4,041 (44.1%) were multiresistant, respectively (p = 0.007). E. coli was the most common multiresistant bacteria in both groups. Approximately 20% of E. coli and Klebsiella sp. isolates were ESBL-producers and 44% of S. aureus isolates were methicillin-resistant in cirrhotic patients. In cirrhotic patients admitted to the emergency department, hospital ward, and intensive care unit, 28.3%, 50% and 40% had multiresistant isolates, respectively. In patients with and without cirrhosis, 36.2% and 33.5% of isolates were resistant to third-generation cephalosporins, respectively.

CONCLUSIONS

The empirical treatment of infections in hospitalized patients using broad-spectrum antibiotics should consider the observed pattern of bacterial resistance.

Appropriate and timely antimicrobial therapy in cirrhotic patients with spontaneous bacterial peritonitis-associated septic shock: a retrospective cohort study

BACKGROUND

Spontaneous bacterial peritonitis (SBP)-associated septic shock carries significant mortality in cirrhosis.

AIM

To determine whether practice-related aspects of antimicrobial therapy contribute to high mortality.

METHODS

Retrospective cohort study of all (n = 126) cirrhotics with spontaneous bacterial peritonitis (neutrophil count >250 or positive ascitic culture)-associated septic shock (1996-2011) from an international, multicenter database. Appropriate antimicrobial therapy implied either in vitro activity against a subsequently isolated pathogen (culture positive) or empiric management consistent with broadly accepted norms (culture negative).

RESULTS

Overall hospital mortality was 81.8%. Comparing survivors (n = 23) with non-survivors (n = 103), survivors had lower Acute Physiology and Chronic Health Evaluation (APACHEII) (mean ± s.d.; 22 ± 7 vs. 32 ± 8) and model for end-stage liver disease (MELD) (24 ± 9 vs. 34 ± 11) scores and serum lactate on admission (4.9 ± 3.1 vs. 8.9  ± 5.3), P < 0.001 for all. Survivors were less likely to receive inappropriate initial antimicrobial therapy (0% vs. 25%, P = 0.013) and received appropriate antimicrobial therapy earlier [median 1.8 (1.1-5.2) vs. 9.5 (3.9-14.3) h, P < 0.001]. After adjusting for covariates, APACHEII [OR, odds ratio 1.45 (1.04-2.02) per 1 unit increment, P = 0.03], lactate [OR 2.34 (1.04-5.29) per unit increment, P = 0.04] and time delay to appropriate antimicrobials [OR 1.86 (1.10-3.14) per hour increment, P = 0.02] were significantly associated with increased mortality.

CONCLUSIONS

Cirrhotic patients with septic shock secondary to spontaneous bacterial peritonitis have high mortality (>80%). Each hour of delay in appropriate antimicrobial therapy was associated with a 1.86 times increased hospital mortality. Admission APACHEII and serum lactate also significantly impacted hospital mortality. Earlier initiation of appropriate antimicrobial therapy could substantially improve outcome.

Pathfast presepsin assay for early diagnosis of bacterial infections in surgical patients: preliminary study

BACKGROUND

Various biomarkers have been studied for diagnosing bacterial infections, seeking to stop the sepsis cascade. Presepsin, which is ∼13 kDa in size, has been identified to increase specifically in the blood of sepsis patients. Additionally, measurement of presepsin is useful to evaluate the severity of infection and monitor clinical responses. We evaluated the analytical and clinical performance of the Pathfast presepsin (PFP) assay system for early diagnosis of infection.

MATERIALS AND METHODS

From November 2011 to June 2012 we studied 70 adult patients, including 35 cadaveric organ transplant recipients and 35 abdominal surgery patients. The 32 female and 38 male subjects had a mean age of 56.1 years (range, 19-70). Heparinized whole blood for PFP assay was tested at 48 hours after surgery together with blood cultures.

RESULTS

The mean presepsin level (PL) in the 50 positive patients was 3,957.45 pg/mL (range 255-20,000). For transplant patients, PL was 3,034.43 ± 2,880.791 pg/mL, with 30 positive results. Microbiologic findings confirmed the presence of bacterial infections within 69 ± 2.5 hours from enrollment despite that when the test was performed, 70% showed no sign or symptom of infection. In 15 abdominal surgery patients, the PFP test was negative with negative blood cultures. The positive PFP test in 20 other abdominal surgery patients showed PL of 2,363 ± 7,988.47 pg/mL in the absence of signs or symptoms of infection in 25% of them. The 20 positive patients showed positive blood cultures within 67 ± 1.8 hours from enrollment.

CONCLUSIONS

The PFP test had a (100%) sensitivity to show the presence of infection in a short time (15 min), confirmed by positive blood cultures.

The end-organ impairment in liver cirrhosis: appointments for critical care

Liver cirrhosis (LC) can lead to a clinical state of liver failure, which can exacerbate through the course of the disease. New therapies aimed to control the diverse etiologies are now more effective, although the disease may result in advanced stages of liver failure, where liver transplantation (LT) remains the most effective treatment. The extended lifespan of these patients and the extended possibilities of liver support devices make their admission to an intensive care unit (ICU) more probable. In this paper the LC is approached from the point of view of the pathophysiological alterations present in LC patients previous to ICU admission, particularly cardiovascular, but also renal, coagulopathic, and encephalopathic. Infections and available liver detoxifications devices also deserve mentioning. We intend to contribute towards ICU physician readiness to the care for this particular type of patients, possibly in dedicated ICUs.

Bloodstream infection after elective liver transplantation is associated with increased mortality in patients with cirrhosis

PURPOSE

This study aims to investigate what factors predict the development of postoperative bloodstream infection (BSI) in patients transplanted electively for chronic liver disease and compare outcomes in infected transplant recipients (BCLD) with noninfected patients (CLD).

METHODS

A retrospective cohort study of 218 patients who had elective liver transplantation (LT) between January 2003 and July 2005 and admitted to a specialist intensive care unit (ICU) was done.

RESULTS

Fifteen patients had BSI post-LT (BCLD, 29 isolates) while in the ICU, and 203 patients did not (CLD). Thirty-eight percent of isolates were gram negatives; 55%, gram positives; and 7%, fungemia. Median time to first BSI post-LT was 11 days (range, 3-16 days). On admission post-LT to the ICU, patients with BCLD had higher Acute Physiology and Chronic Health Evaluation II scores (23 vs 10, P < .001). While in the ICU, patients with BCLD had greater requirements for renal replacement therapy (73% vs 8%) and days on mechanical ventilation (17 vs 2 days) and longer median ICU stay (21 vs 3 days, P < .001 for all). One-year survival was worse in the BCLD group (40% vs 94%, P < .001). On multivariate analysis, Acute Physiology and Chronic Health Evaluation II score (odds ratio, 1.36) post-LT was independently associated with subsequent BSI. Bloodstream infection (hazards ratio, 8.7) was independently associated with mortality.

CONCLUSION

Bloodstream infection post-LT was associated with increased severity of illness on admission, greater requirements for organ support, and increased mortality.

Clinical features and outcome of community-acquired bacterial meningitis in adult patients with liver cirrhosis

INTRODUCTION

This study aimed to analyze the clinical features, causative pathogens and therapeutic outcomes of bacterial meningitis in patients with liver cirrhosis.

METHODS

Adult cirrhotic patients with community-acquired bacterial meningitis were evaluated. Clinical data were collected over a 22-year period. For comparison, the clinical features and therapeutic outcomes between patients with and without liver cirrhosis were analyzed.

RESULTS

Liver cirrhosis accounted for 11% (25/217) of the predisposing factors. Significant statistical analysis between the 2 groups (patients with and without liver cirrhosis) included median Glasgow Coma Scale score at presentation, presence of seizure, bacteremia and septic shock. The mean duration between arrival at the emergency room and confirmed diagnosis of bacterial meningitis was 39 hours (range, 2-240 hours). Ten (10/25, 40%) were initially diagnosed with bacterial meningitis, and 6 (6/25, 24%) were initially suggested as having infection of unknown origin. In this study, Klebsiella pneumoniae was the most frequent causative pathogen in patients with liver cirrhosis. The overall case fatality rates for patients with and without liver cirrhosis were 38.5% (74/192) and 64% (16/25), respectively.

CONCLUSIONS

Patients with liver cirrhosis have a more fulminant course with a higher prevalence of disturbed consciousness, bacteremia, seizure and shock. Diagnosis and effective treatment ARE often delayed, resulting in high overall mortality. When patients with liver cirrhosis develop disturbed consciousness, seizures and septicemia, immediate neuroimaging and cerebrospinal fluid studies should be undertaken to determine bacterial meningitis. Early diagnosis and treatment are essential for survival.

Bacteremia, acute physiology and chronic health evaluation II and modified end stage liver disease are independent predictors of mortality in critically ill nontransplanted patients with acute on chronic liver failure

OBJECTIVES

To determine what physiological and biochemical factors predict development of bacteremia in nontransplanted patients with acute on chronic liver failure and, on diagnosis of bacteremia, what is the natural history of bacteremic patients versus control subjects (acute on chronic liver failure).

INTERVENTIONS

None.

DESIGN

Retrospective analysis of data collected prospectively and entered into a dedicated physiology database.

SETTING

Specialist liver intensive therapy unit.

PATIENTS

Critically ill non-transplanted patients with acute on chronic liver failure admitted between January 2003 and July 2005.

MEASUREMENTS AND MAIN RESULTS

One hundred eighty-four patients were defined with acute on chronic liver failure; 67 (36%) had bacteremia. One hundred seventeen (64%) patients did not (acute on chronic liver failure). Fifty-eight percent of isolates were Gram-negative organisms, 36% were Gram-positives, and 6% fungemia. Median time to first bacteremia was 8 days (range, 3-12 days). On admission (univariate), bacteremic patients had significantly higher Modified End Stage Liver Disease scores (27 vs. 24, p = .037), Acute Physiology and Chronic Health Evaluation II scores (23 vs. 21, p = .049), and greater degrees of encephalopathy (Glasgow Coma Scale score 10 vs. 12, p = .001). During their liver intensive therapy unit course, bacteremic patients had significantly greater requirements for renal replacement therapy (64% vs. 49%, p = .043), mechanical ventilation (88% vs. 68%, p = .002), and a longer median liver intensive therapy unit stay (16 vs. 5 days, p < .001). Survival to hospital discharge was worse in the bacteremic group (25% vs. 56%, p < .001). Multivariate analysis (logistic regression) was performed separately modeling with Acute Physiology and Chronic Health Evaluation II and Modified End Stage Liver Disease. In the first model, Acute Physiology and Chronic Health Evaluation II (odds ratio 1.24) and bacteremia (2.24) were independent predictors of mortality. In the later model, Modified End Stage Liver Disease (odds ratio, 1.06), requirement for renal replacement therapy (3.08), Glasgow Coma Scale (0.72), and bacteremia (2.30) were significant. Both models performed similarly (Modified End Stage Liver Disease area under the receiver operating characteristic curve, 0.864; Acute Physiology and Chronic Health Evaluation II, 0.862).

CONCLUSIONS

In nontransplanted patients with acute on chronic liver failure, bacteremia was associated with increased severity of illness on admission, greater requirements for organ support, and independently adversely impacted on survival. Higher Acute Physiology and Chronic Health Evaluation II and Modified End Stage Liver Disease scores were also independently predictive of mortality.

Sorafenib attenuates the portal hypertensive syndrome in partial portal vein ligated rats

BACKGROUND/AIMS

Angiogenesis plays a key role in development of portal hypertension (PHT) and represents a potential therapeutic target. We aimed to evaluate the molecular effects of sorafenib, a multiple tyrosine kinase inhibitor, on splanchnic hemodynamics in rats with partial portal vein ligation (PPVL).

METHODS

The following four groups of rats were treated orally with sorafenib (10mg/kg per day; SORA group) or placebo (PLAC group) for 7 days, beginning at the day of PPVL or sham operation (SO): (1) PPVL-SORA, (2) PPVL-PLAC, (3) SO-SORA and (4) SO-PLAC. Measurements of mean arterial pressure (MAP), portal pressure (PP), and superior mesenterial artery blood flow (SMABF) were performed. Portosystemic collateral blood flow (PSCBF) was determined by radioactive microspheres. Splanchnic protein expression of CD31, alpha-smooth muscle actin (alphaSMA), phospho-extracellular signal-regulated kinase (pERK), vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), tumor necrosis factor alpha (TNFalpha), and endothelial nitric oxide synthetase (eNOS) was assessed by Western blot. Gene expression was studied by angiogenesis-focused real-time reverse transcription polymerase chain reaction microarray.

RESULTS

PP, SMABF, and PSCBF were significantly higher in PPVL rats than in SO rats. MAP and heart rate were similar in all groups. Treatment with sorafenib resulted in a significant decrease of PP (p<0.001) and SMABF (p<0.05) in PPVL-SORA rats compared to PPVL-PLAC rats. PPVL-SORA rats had markedly less PSCBF than PPVL-PLAC rats (p<0.001). Superior mesenteric artery resistance (SMAR) was significantly lower in both PPVL groups compared to both SO groups, but PPVL-SORA rats showed significantly higher SMAR than PPVL-PLAC rats (p<0.05). The increased protein expression of CD31, alphaSMA, pERK, VEGF, PDGF, TNFalpha, and eNOS in rats with PHT was markedly decreased by sorafenib treatment. Sorafenib decreased mRNA levels of TNFalpha, VEGF receptor 2, VEGF receptor 1, transforming growth factor beta, cyclooxygenase 1, and expression of various genes that are involved in pathways of cellular proliferation, fibrogenesis, tissue remodeling, inflammation, and angiogenesis.

CONCLUSIONS

Treatment with sorafenib reduced PP, SMABF, and PSCBF in noncirrhotic rats with prehepatic PHT, without affecting systemic hemodynamics. Additional antiproliferative, anti-inflammatory, and antiangiogenic effects of sorafenib were identified.

Chronic liver failure and concomitant distant infections are associated with high rates of neurological involvement in pyogenic spinal infections

STUDY DESIGN

A retrospective study of a consecutive series of all patients with pyogenic spinal infections treated at a single institution over a 10-year period.

OBJECTIVE

To investigate risk factors for neurologic impairment with pyogenic spinal infections.

SUMMARY OF BACKGROUND DATA

Pyogenic spinal infections are frequently associated with neurologic deficit at the time of initial diagnosis. Current evidence suggests that advanced age, diabetes mellitus, rheumatoid arthritis, systemic corticosteroid therapy, impaired immune status, infection with Staphylococcus aureus, and more proximal infections are risk factors for neurologic involvement. To the authors' knowledge, however, the influence of chronic liver failure or concomitant nonspinal infection has not been previously investigated.

METHODS

A review of all patients discharged with a diagnosis of pyogenic spinal infection was performed. Data were collected, including age, sex, site of infection, degree of neurologic impairment, bacterial organism isolated, and various medical comorbidities such as diabetes mellitus, rheumatoid arthritis, chronic corticosteroid therapy, chronic liver failure, chronic renal failure, smoking, human immunodeficiency virus infection, intravenous drug abuse, cancer, cardiac disease, and the presence of a distant, nonspinal site of infection.

RESULTS

Fifty-five consecutive patients with pyogenic spinal infections were identified. Statistical analysis demonstrated that the presence of an epidural abscess, chronic liver failure, or a distant nonspinal infection were the only significant risk factors for neurologic involvement.

CONCLUSION

The current data suggest that chronic liver failure and the presence of a distant nonspinal infection are possible risk factors for neurologic involvement in patients with pyogenic spinal infections. These risk factors have not been previously described. This knowledge warrants closer surveillance for neurologic deficit in patients with these conditions.

Outcome of patients with liver cirrhosis admitted to a specialty liver intensive care unit in India

PURPOSE

The study aimed to describe the clinical outcome of patients with liver cirrhosis admitted to intensive care unit (ICU) and to compare the performance of Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) in predicting mortality.

METHODS

In this prospective study of patients with cirrhosis admitted to the ICU, demographic data, APACHE II score, SOFA score, presence of acute renal failure (ARF), need for organ support, and mortality were collected.

RESULTS

The observed mortality in ICU and at 30 days among 104 patients was 42.3% (95% confidence interval [CI], 32.7%-52.0%) and 56.7% (95% CI, 47.0%-66.4%), respectively. Area under the receiver operating characteristic curve for first-day APACHE II in predicting 30-day mortality was 0.90 (95% CI, 0.83-0.96) and 0.93 (95% CI, 0.88-0.98) for SOFA score (P = .24). On multivariate analysis, ARF (adjusted odds ratio, 7.7; 95% CI, 1.09-54.64) and mechanical ventilation (adjusted odds ratio, 277.6; 95% CI, 12.83-6004.94) were significantly associated with mortality.

CONCLUSIONS

Presence of ARF and need for mechanical ventilation are associated with high mortality in patients with liver cirrhosis admitted to the ICU. Acute Physiology and Chronic Health Evaluation II and SOFA are good prognostic models in predicting 30-day mortality and do not differ in performance.

Community-acquired bacterial meningitis in cirrhotic patients

The Hospital Universitari de Bellvitge (Barcelona, Spain) records all cases of bacterial meningitis in a 120-variable database. The characteristics of bacterial meningitis in cirrhotic patients are not well-known, and all cases of community-acquired bacterial meningitis occurring in cirrhotic patients were therefore identified. During 1977-2002, there were 602 episodes of community-acquired bacterial meningitis in adults, of which 29 (4.8%) occurred in cirrhotic patients. Compared to non-cirrhotic patients, there were significant differences in: duration of disease for >4 days at the time of diagnosis; absence of nuchal rigidity; certain aetiologies, e.g., Escherichia coli and Listeria monocytogenes; renal and liver function impairment; relapse of fever; and incidence of relapse and mortality. Overall, bacterial meningitis in cirrhotic patients was associated with a high mortality rate and a large number of complications. A high index of suspicion is necessary because of the frequent absence of meningeal signs. In addition to the classic meningeal pathogens, other aetiologies, including E. coli and L. monocytogenes, should be considered when prescribing empirical therapy.

Clinical impact of influenza immunization in patients with liver cirrhosis

BACKGROUND

Influenza vaccine is considered to reduce influenza-related morbidity and mortality in patients with underlying chronic medical conditions. Yet in liver cirrhosis, influenza vaccines have received little attention in determining the potential benefits.

OBJECTIVES

We intended to evaluate the clinical benefits of influenza vaccination and clinical outcomes of influenza in patients with liver cirrhosis.

METHODS

We performed a controlled, prospective clinical trial of 311 cirrhotic patients, who were enrolled in October 2004. Among them, 198 patients were vaccinated with a trivalent influenza vaccine and the rest were not vaccinated. Both groups were followed with respect to the occurrence of influenza-like illness (ILI) until May 2005.

RESULTS

Overall incidences of ILI (p=0.064) and culture positivity of influenza (p=0.009) were remarkably higher in unvaccinated group compared to the vaccinated group. Most of the cirrhotic patients with influenza had fever (91.6%) and complained of myalgia (83.3%) without respiratory symptoms, which were not typical clinical presentations of influenza. Influenza vaccination also decreased influenza-related complication rates in patients with liver cirrhosis.

CONCLUSION

Influenza vaccination should be recommended to all cirrhotic patients. High suspicion is required for early diagnosis and antiviral treatment, allowing for the frequent hepatic decompensation among cirrhotic patients.

Changes in the Profiles of Causative Agents and Antibiotic Resistance Rate for Spontaneous Bacterial Peritonitis: an Analysis of Cultured Microorganisms in Recent 12 Years

BACKGROUNDS/AIMS

The causative agents for spontaneous bacterial peritonitis (SBP) and antibiotic resistance rate vary according to the regions and time. This study evaluated the recent changes in the profiles of microorganisms and antibiotic resistance rate for the choice of effective antibiotics in treating SBP.

METHODS

The clinical records of 1,018 episodes of SBP from November, 1994 to December, 2005, were analyzed retrospectively. The profiles of the causative agents for SBP and the rate of antibiotic resistance were compared in every 4-year-term.

RESULTS

The microorganisms were isolated in 394 out of 1018 episodes (38.7%). Gram negative and positive organisms constituted 71.6% and 21.3%, respectively. The five most commonly isolated organisms were E. coli (35.8%), K. pneumoniae (15.5%), viridans Streptococci (10.4%), S. pneumoniae (4.8%) and Aeromonas group (4.6%). The rate of E. coli resistant to cefotaxime (0%, 5.4%, 7.4%) and ciprofloxacin (4.3%, 21.6%, 28.4%) were increased in recent years. In the gram positive organisms, all isolates of viridans Streptococci and Pneumococci were sensitive to cefotaxime and ciprofloxacin. Recently, methicillin-resistant Staphylococcus aureus (MRSA) (28%) and vancomycin-resistant Enterococci (VRE) (31%) have been isolated. In each period, the overall antibiotic resistance rates to cefotaxime were 12.5%, 14.0%, 14.8%, to ciprofloxacin were 3.1%, 16.7%, 18.0%, and to imipenem were 4.7%, 7.0%, 4.2%.

CONCLUSIONS

Cefotaxime may still be the choice of primary empirical antibiotics for the treatment of SBP in Korea because the rate of resistance is acceptable. However, it is important to be aware of the recent increase in ciprofloxacin-resistant E. coli, extended spectrum beta-lactamase (ESBL)-producing gram negative bacilli, MRSA and VRE.

Distinct toll-like receptor expression in monocytes and T cells in chronic HCV infection

AIM: Hepatitis C virus often establishes chronic infections. Recent studies suggest that viral and bacterial infections are more common in HCV-infected patients compared to controls. Pathogens are recognized by Toll-like receptors (TLRs) to shape adaptive and innate immune responses.

METHODS: In this study, to assess the ability of HCV-infected host to recognize invading pathogens, we investigated Toll-like receptor expression in innate (monocytes) and adaptive (T cells) immune cells by real-time PCR.

RESULTS: We determined that RNA levels for TLRs 2, 6. 7, 8, 9 and 10 mRNA levels were upregulated in both monocytes and T cells in HCV-infected patients compared to controls. TLR4 was only upregulated in T lymphocytes, while TLR5 was selectively increased in monocytes of HCV-infected patients. MD-2, a TLR4 co-receptor, was increased in patients’ monocytes and T cells while CD14 and MyD88 were increased only in monocytes.

CONCLUSION: Our data reveal novel details on TLR expression that likely relates to innate recognition of pathogens and immune defense in HCV-infected individuals.

Humoral and cellular immune responses to influenza vaccine in patients with advanced cirrhosis

Influenza vaccine has been shown to successfully reduce influenza- and pneumonia-associated hospitalizations and deaths. Yet in liver cirrhosis, influenza vaccines have received little attention in determining the potential benefits. Thus, we undertook this study to evaluate the humoral and cellular immune responses to vaccination against influenza in patients with advanced cirrhosis. We measured interferon (IFN)-gamma secretion response and hemagglutinin inhibition (HI) of antibody titer from pre- and post-vaccination blood samples in 80 cirrhotic patients (Child-Pugh class B or C) and 80 healthy, age-matched subjects. Although the patients with advanced cirrhosis showed similar humoral immune response against influenza vaccination compared to the healthy controls, cell-mediated immunity showed different results according to the remnant liver function.

Risk factors for nosocomial infective endocarditis in patients with methicillin-resistant Staphylococcus aureus bacteremia

BACKGROUND AND OBJECTIVE

Nosocomial infections caused by methicillin-resistant Staphylococcus aureus (MRSA) are increasing. Only a few studies of MRSA infective endocarditis have been conducted, and none have reported its risk factors. We sought to determine the host-related risk factors for infective endocarditis in patients with nosocomial MRSA bacteremia.

SETTING

A 2,000-bed, university-affiliated, tertiary-care hospital.

PATIENTS

Thirty-one patients with nosocomial MRSA infective endocarditis between October 1996 and May 2003.

DESIGN

A retrospective chart review was conducted. Data were compared with those from a control group of patients with nosocomial MRSA bacteremia. Logistic regression was used to identify independent risk factors for nosocomial infective endocarditis.

RESULTS

Compared with patients who had nosocomial MRSA bacteremia and no infective endocarditis, patients who had infective endocarditis had a higher incidence of chronic liver disease and a lower incidence of immunodeficiency. The risk of developing infective endocarditis was approximately 10% for patients with nosocomial MRSA bacteremia.

CONCLUSION

Patients with MRSA bacteremia and underlying chronic liver disease were prone to infective endocarditis.

Risk factors for bacteraemia and endovascular infection due to non-typhoid salmonella: a reappraisal

BACKGROUND

Endovascular infections are rare complications of non-typhoid salmonellosis. The diagnosis is frequently not established until the infection is advanced. It is important to identify high-risk patients and treat them as early as possible.

AIM

To identify risk factors for bacteraemia and endovascular infection in patients with non-typhoid salmonellosis.

DESIGN

Retrospective study.

SETTING

A single tertiary-care hospital in Taiwan.

METHODS

Data were collected by retrospective chart review. Log-logistic regression modelling was used to identify independent risk factors for bacteraemia and endovascular infection. We analysed the characteristics of patients with gastroenteritis vs. those with bacteraemia, and of bacteraemic patients with vs. without endovascular infection.

RESULTS

Between 1984 and 2004, there were 373 adult cases of non-typhoid salmonellosis. There were 76 intestinal Salmonella infections, 290 bloodstream infections (including 47 endovascular infections), and 7 extra-intestinal non-bacteraemic infections. The independent positive predictors of bacteraemia were systemic lupus erythematosus, liver cirrhosis, HIV infection, and solid organ cancers. The only independent positive predictor of endovascular infection was atherosclerosis. The independent negative predictors of endovascular infection were solid organ cancers and immunodeficiency.

DISCUSSION

Risk factors for atherosclerosis predisposed our patients with bacteraemia to endovascular infection. Although immunodeficiency predisposed patients to bacteraemia, it was associated with a low incidence of endovascular infection.

Nontyphoid Salmonella Bacteremia in Patients with Liver Cirrhosis

BACKGROUND

Bacteremia is reported to occur in 4% to 9% of hospitalized patients with liver cirrhosis. Escherichia coli and Klebsiella pneumoniae are the most commonly isolated organisms. Only sporadic cases of nontyphoid Salmonella bacteremia are reported in the literature. In this study, we sought to determine the clinical features and prognosis of patients with liver cirrhosis and bacteremia due to nontyphoid Salmonella.

METHOD

Data were collected by retrospective chart review.

RESULTS

From December 1996 to May 2003, we identified 23 patients (18 males, 5 females) with a median age of 58 years. The Child classification for liver cirrhosis was A in 4, B in 9, and C in 10 patients. Solid organ cancers were present in 14 patients: hepatocellular carcinoma in 13 patients and gastric carcinoma in 1 patient. Hospital death occurred in 11 patients (48%): 7 died of sepsis and 4 of hepatic failure. Using a logistic regression model, the independent risk factors for death in patients with nontyphoid Salmonella bacteremia were young age and an advanced stage of liver cirrhosis.

CONCLUSION

Most nontyphoid Salmonella bacteremia in patients with liver cirrhosis was community-acquired. An advanced stage of liver cirrhosis and hepatocellular carcinoma were common. The prognosis for young patients was unfavorable; this was seemingly due to hepatocellular carcinoma producing more unfavorable results in younger cirrhotic patients.

Brevundimonas bacteremia: two case reports and literature review

Brevundimonas spp. are infrequently isolated from clinical samples, including blood. The vast majority of reported cases have underlying diseases. Whether these microorganisms represent true pathogens of human disease in all populations remains to be explored. We present 2 cases of bloodstream infection caused by Brevundimonas sp., with one of these individuals immunocompetent, and discuss the possible role of these organisms in different patient populations.

Cirrhosis as a risk factor for sepsis and death: analysis of the National Hospital Discharge Survey

STUDY OBJECTIVES

The unfavorable influence of cirrhosis on survival in the critically ill has been supported by several single-center reports. Variations in case mix, the technological capabilities of individual facilities, and differences in organizational staffing and structure could limit the extrapolation and generalization of these data to other institutions. To assess the impact of a diagnosis of cirrhosis on outcomes of sepsis, sepsis-related mortality, and respiratory failure in hospitalized patients, we analyzed data from the National Hospital Discharge Survey (NHDS) from 1995 to 1999 to determine its national consequence.

DESIGN

Secondary analysis of an existing national database.

PATIENTS OR PARTICIPANTS

Based on NHDS estimates, 175 million hospital discharges occurred during the 5-year period of study. One percent (1.7 million) of these hospitalizations involved a diagnosis of cirrhosis.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

After adjustments for age, race, and gender, cirrhotic individuals are significantly more likely to die while hospitalized (adjusted risk ratio [RR], 2.7; 95% confidence interval [CI], 2.3 to 3.1), to have hospitalizations associated with sepsis (adjusted RR, 2.6; 95% CI, 1.9 to 3.3), and to die from sepsis (adjusted RR, 2.0; 95% CI, 1.3 to 2.6). Additionally, cirrhosis is associated with an increased RR for acute respiratory failure (adjusted RR, 1.4; 95% CI, 1.1 to 1.8) and death from acute respiratory failure (adjusted RR, 2.6; 95% CI, 1.5 to 3.6).

CONCLUSIONS

In this national database of hospital discharge information, a diagnosis of cirrhosis is strongly associated with an increased risk of sepsis, acute respiratory failure, sepsis-related mortality, and acute respiratory failure-related mortality.