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Stroffolini T, Stroffolini G. Vaccination in Patients with Liver Cirrhosis: A Neglected Topic. Vaccines (Basel) 2024; 12:715. [PMID: 39066353 PMCID: PMC11281357 DOI: 10.3390/vaccines12070715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 06/20/2024] [Accepted: 06/26/2024] [Indexed: 07/28/2024] Open
Abstract
Patients with liver cirrhosis, due to their weakened innate and adaptive immunity, are more prone to frequent and severe vaccine-preventable infections. Moreover, impaired adaptive immunity results in a limited antibody response to vaccines. Despite this suboptimal antibody response, vaccines have proven to be very effective in reducing severe outcomes and deaths in these patients. In the Western world, regulatory authorities and scientific liver societies (e.g., AASLD and EASL) have recommended vaccinations for cirrhotic patients. However, despite these strong recommendations, vaccine coverage remains suboptimal. Improving vaccine effectiveness and safety information, providing comprehensive counseling to patients, fact-checking to combat fake news and disinformation and removing barriers to vaccination for disadvantaged individuals may help overcome the low coverage rate. In view of this, vaccines should be administered early in the course of chronic liver diseases, as their efficacy declines with the increasing severity of the disease.
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Affiliation(s)
- Tommaso Stroffolini
- Department of Tropical and Infectious Diseases, Policlinico Umberto I, 00161 Rome, Italy;
| | - Giacomo Stroffolini
- Department of Infectious-Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Via Don A. Sempreboni, 5, 37024 Verona, Italy
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2
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Bajaj JS, Kamath PS, Reddy KR, Asrani SK, Keaveny AP, Tandon P, Duarte-Rojo A, Kappus M, Verna E, Biggins SW, Vargas HE, Albhaisi S, Shaw J, Dahiya M, Filipek N, Fallahzadeh MA, Wegermann K, Cabello R, Bera C, Thuluvath P, Bush B, Thacker LR, Wong F. Predictors of Respiratory Failure Development in a Multicenter Cohort of Inpatients With Cirrhosis. Am J Gastroenterol 2024; 119:712-718. [PMID: 37938163 DOI: 10.14309/ajg.0000000000002574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 10/18/2023] [Indexed: 11/09/2023]
Abstract
INTRODUCTION Hospitalized patients with cirrhosis can develop respiratory failure (RF), which is associated with a poor prognosis, but predisposing factors are unclear. METHODS We prospectively enrolled a multicenter North American cirrhosis inpatient cohort and collected admission and in-hospital data (grading per European Association for the Study of Liver-Chronic Liver Failure scoring system, acute kidney injury [AKI], infections [admission/nosocomial], and albumin use) in an era when terlipressin was not available in North America. Multivariable regression to predict RF was performed using only admission day and in-hospital events occurring before RF. RESULTS A total of 511 patients from 14 sites (median age 57 years, admission model for end-stage liver disease [MELD]-Na 23) were enrolled: RF developed in 15%; AKI occurred in 24%; and 11% developed nosocomial infections (NI). At admission, patients who developed RF had higher MELD-Na, gastrointestinal (GI) bleeding/AKI-related admission, and prior infections/ascites. During hospitalization, RF developers had higher NI (especially respiratory), albumin use, and other organ failures. RF was higher in patients receiving albumin (83% vs 59%, P < 0.0001) with increasing doses (269.5 ± 210.5 vs 208.6 ± 186.1 g, P = 0.01) regardless of indication. Admission for AKI, GI bleeding, and high MELD-Na predicted RF. Using all variables, NI (odds ratio [OR] = 4.02, P = 0.0004), GI bleeding (OR = 3.1, P = 0.002), albumin use (OR = 2.93, P = 0.01), AKI (OR = 3.26, P = 0.008), and circulatory failure (OR = 3.73, P = 0.002) were associated with RF risk. DISCUSSION In a multicenter inpatient cirrhosis study of patients not exposed to terlipressin, 15% of patients developed RF. RF risk was highest in those admitted with AKI, those who had GI bleeding on admission, and those who developed NI and other organ failures or received albumin during their hospital course. Careful volume monitoring and preventing nosocomial respiratory infections and renal or circulatory failures could reduce this risk.
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Affiliation(s)
- Jasmohan S Bajaj
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
| | - Patrick S Kamath
- Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | | | | | - Andrew P Keaveny
- Mayo Clinic College of Medicine and Science, Jacksonville, Florida, USA
| | | | - Andres Duarte-Rojo
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- Northwestern University, Chicago, Illinois, USA
| | | | | | | | - Hugo E Vargas
- Mayo Clinic College of Medicine and Science, Phoenix, Arizona, USA
| | - Somaya Albhaisi
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
| | - Jawaid Shaw
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
| | | | | | | | | | | | | | - Paul Thuluvath
- Mercy Medical Center & University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Brian Bush
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
| | - Leroy R Thacker
- Virginia Commonwealth University and Central Virginia Veterans Healthcare System, Richmond, Virginia, USA
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3
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Sophonsri A, Lou M, Ny P, Minejima E, Nieberg P, Wong-Beringer A. Machine learning to identify risk factors associated with the development of ventilated hospital-acquired pneumonia and mortality: implications for antibiotic therapy selection. Front Med (Lausanne) 2023; 10:1268488. [PMID: 38170135 PMCID: PMC10759933 DOI: 10.3389/fmed.2023.1268488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 11/28/2023] [Indexed: 01/05/2024] Open
Abstract
Background Among patients with nosocomial bacterial pneumonia, those who decompensated to requiring mechanical ventilation (vHABP) faced the highest mortality followed by ventilator-associated pneumonia (VABP) and non-ventilated hospital-acquired pneumonia (nvHABP). The objectives of this study were to identify risk factors associated with the development and mortality of vHABP and to evaluate antibiotic management. Methods A multicenter retrospective cohort study of adult inpatients with nosocomial pneumonia during 2014-2019 was performed. Groups were stratified by vHABP, nvHABP, and VABP and compared on demographics, clinical characteristics, treatment, and outcomes. Multivariable models were generated via machine learning to identify risk factors for progression to vHABP as well as pneumonia-associated mortality for each cohort. Results 457 patients (32% nvHABP, 37% vHABP, and 31% VABP) were evaluated. The vHABP and nvHABP groups were similar in age (median age 66.4 years) with 77% having multiple comorbidities but more vHABP patients had liver disease (18.2% vs. 7.7% p = 0.005), alcohol use disorder (27% vs. 7.1%, p < 0.0001), and were hospitalized within the past 30 days (30.4% vs. 19.5%, p = 0.02). An immediate need for ventilatory support occurred in 70% of vHABP patients on the day of diagnosis. Mortality was the highest in vHABP followed by VABP and nvHABP groups (44.6% vs. 36% vs. 14.3%, p < 0.0001). Nearly all (96%) vHABP patients had positive cultures, with Gram-negative pathogens accounting for 58.8% whereby 33.0% were resistant to extended-spectrum β-lactams (ESBLs), ceftriaxone (17.5%), fluoroquinolones (20.6%), and carbapenems (12.4%). Up to half of the vHABP patients with ESBL-Enterobacterales or P. aeruginosa did not receive an effective empiric regimen; over 50% increase in mortality rate was observed among patients whom effective therapy was initiated past the day of pneumonia diagnosis. Risk factors associated with vHABP development were alcohol use disorder, APACHE II score, vasopressor therapy prior to infection, and culture positive for ESBL-Enterobacterales whereas history of hospitalization in the past 30 days, active malignancy, isolation of ceftriaxone-resistant pathogens or Pseudomonas aeruginosa, and vasopressor therapy were risk factors for vHABP-associated mortality. Conclusion Patients with vHABP experienced an acute and severe decompensation upon diagnosis. The risk factors identified in this study could provide actionable data for clinicians to identify those at risk for vHABP at the onset of pneumonia and to target antimicrobial stewardship efforts to improve treatment success.
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Affiliation(s)
- Anthony Sophonsri
- Department of Clinical Pharmacy, University of Southern California, Mann School of Pharmacy and Pharmaceutical Sciences, Los Angeles, CA, United States
| | - Mimi Lou
- Department of Clinical Pharmacy, University of Southern California, Mann School of Pharmacy and Pharmaceutical Sciences, Los Angeles, CA, United States
| | - Pamela Ny
- Department of Pharmacy, Huntington Hospital, Pasadena, CA, United States
| | - Emi Minejima
- Department of Clinical Pharmacy, University of Southern California, Mann School of Pharmacy and Pharmaceutical Sciences, Los Angeles, CA, United States
- Department of Pharmacy, Los Angeles General Medical Center, Los Angeles, CA, United States
| | - Paul Nieberg
- Department of Medicine – Infectious Diseases, Huntington Hospital, Pasadena, CA, United States
| | - Annie Wong-Beringer
- Department of Clinical Pharmacy, University of Southern California, Mann School of Pharmacy and Pharmaceutical Sciences, Los Angeles, CA, United States
- Department of Pharmacy, Huntington Hospital, Pasadena, CA, United States
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4
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Perricone G, Artzner T, De Martin E, Jalan R, Wendon J, Carbone M. Intensive care management of acute-on-chronic liver failure. Intensive Care Med 2023; 49:903-921. [PMID: 37552333 DOI: 10.1007/s00134-023-07149-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/21/2023] [Indexed: 08/09/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is a clinical syndrome defined by an acute deterioration of the liver function associated with extrahepatic organ failures requiring intensive care support and associated with a high short-term mortality. ACLF has emerged as a major cause of mortality in patients with cirrhosis and chronic liver disease. ACLF has a unique pathophysiology in which systemic inflammation plays a key role; this provides the basis of novel therapies, several of which are now in clinical trials. Intensive care unit (ICU) therapy parallels that applied in the general ICU population in some organ failures but has peculiar differential characteristics in others. Critical care management strategies and the option of liver transplantation (LT) should be balanced with futility considerations in those with a poor prognosis. Nowadays, LT is the only life-saving treatment that can radically improve the long-term prognosis of patients with ACLF. This narrative review will provide insights on the current understanding of ACLF with emphasis on intensive care management.
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Affiliation(s)
- Giovanni Perricone
- Hepatology and Gastroenterology Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
| | - Thierry Artzner
- Hôpitaux Universitaires de Strasbourg, 67000, Strasbourg, France
| | - Eleonora De Martin
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris-Saclay, Villejuif, France
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Julia Wendon
- Liver Intensive Therapy Unit, Division of Inflammation Biology, King's College London, London, UK
| | - Marco Carbone
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- European Reference Network On Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
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5
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Stroffolini T, Ciancio A, Federico A, Benigno RG, Colloredo G, Lombardi A, Cotugno R, Verucchi G, Ferrigno L, Gioli F, Marignani M, Troshina Y, Romeo M, Di Costanzo F, Niro GA, Badia L. Pneumococcal vaccination status among cirrhotic patients in Italy: a neglected topic. Eur J Clin Microbiol Infect Dis 2023:10.1007/s10096-023-04614-9. [PMID: 37169944 DOI: 10.1007/s10096-023-04614-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 04/26/2023] [Indexed: 05/13/2023]
Abstract
To date, few reports have evaluated the pneumococcal vaccination status in cirrhotic patients. No data are available for European countries. We have explored this topic and the potential independent predictors motivating lack of vaccination in Italy. Between January 1st and June 30th 2022, 1419 cirrhotic patients of any etiology were consecutively enrolled in an observational, prospective study at 8 referral centers in Italy. Adjusted odds ratios (ORs) for the association with lack of vaccination were evaluated by multiple logistic regression analysis. Overall vaccine coverage was 17.9% (8.9% in patients < 65 years of age and 27.1% in those aged ≥ 65 years; p < 0.001). Among the 1165 unvaccinated patients, 1068 (91.7%) reported lack of information regarding vaccination as the reason for not having undergone vaccination. Independent predictors associated with lack of vaccination were age < 65 years (OR 3.39, CI 95% 2.41-4.76) and a higher number of schooling years (OR 2.14, CI 95% 1.58-2.91); alcoholic etiology resulted only marginally associated (OR 1.91, CI 95% 1.03-3.52). These findings establish evidence on how pneumococcal vaccination status in Italy is largely suboptimal among cirrhotic patients. These results raise concern, considering the severe outcomes of pneumococcal infection in patients with chronic liver diseases.
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Affiliation(s)
- Tommaso Stroffolini
- Department of Tropical and Infectious Diseases, Policlinico Umberto I, Rome, Italy
| | - Alessia Ciancio
- Department of Gastroenterology, Ospedale Molinette, Torino, Italy
| | - Alessandro Federico
- Hepato-Gastroenterology Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Rosa G Benigno
- Liver Unit, Department of Internal Medicine, ARNAS Garibaldi, Catania, Italy
| | - Guido Colloredo
- Internal Medicine Unit, Policlinico S. Pietro, Bergamo, Italy
| | | | - Rosa Cotugno
- Gastroenterology Unit, Fondazione Casa Sollievo della Sofferenza IRCCS, San Giovanni Rotondo, Italy
| | | | - Luigina Ferrigno
- National Health Institute, National Center for Global Health, Rome, Italy
| | - Federico Gioli
- Department of Digestive and Liver Disease, S. Andrea University Hospital, Rome, Italy
| | - Massimo Marignani
- Department of Digestive and Liver Disease, S. Andrea University Hospital, Rome, Italy.
| | - Yulia Troshina
- Department of Gastroenterology, Ospedale Molinette, Torino, Italy
| | - Mario Romeo
- Hepato-Gastroenterology Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | | | - Grazia Anna Niro
- Gastroenterology Unit, Fondazione Casa Sollievo della Sofferenza IRCCS, San Giovanni Rotondo, Italy
| | - Lorenzo Badia
- Department of Infectious Diseases, S. Orsola Hospital, Bologna, Italy
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6
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Brozat JF, Hanses F, Haelberger M, Stecher M, Dreher M, Tometten L, Ruethrich MM, Vehreschild JJ, Trautwein C, Borgmann S, Vehreschild MJGT, Jakob CEM, Stallmach A, Wille K, Hellwig K, Isberner N, Reuken PA, Geisler F, Nattermann J, Bruns T. COVID-19 mortality in cirrhosis is determined by cirrhosis-associated comorbidities and extrahepatic organ failure: Results from the multinational LEOSS registry. United European Gastroenterol J 2022; 10:409-424. [PMID: 35482663 PMCID: PMC9103364 DOI: 10.1002/ueg2.12232] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 04/11/2022] [Indexed: 02/06/2023] Open
Abstract
Background and Objective International registries have reported high mortality rates in patients with liver disease and COVID‐19. However, the extent to which comorbidities contribute to excess COVID‐19 mortality in cirrhosis is controversial. Methods We used the multinational Lean European Open Survey on SARS‐CoV‐2‐infected patients (LEOSS) to identify patients with cirrhosis documented between March 2020 and March 2021, when the wild‐type and alpha variant were predominant. We compared symptoms, disease progression and mortality after propensity score matching (PSM) for age, sex, obesity, smoking status, and concomitant diseases. Mortality was also compared with that of patients with spontaneous bacterial peritonitis (SBP) without SARS‐CoV‐2 infection, a common bacterial infection and well‐described precipitator of acute‐on‐chronic liver failure. Results Among 7096 patients with SARS‐CoV‐2 infection eligible for analysis, 70 (0.99%) had cirrhosis, and all were hospitalized. Risk factors for severe COVID‐19, such as diabetes, renal disease, and cardiovascular disease were more frequent in patients with cirrhosis. Case fatality rate in patients with cirrhosis was 31.4% with the highest odds of death in patients older than 65 years (43.6% mortality; odds ratio [OR] 4.02; p = 0.018), Child‐Pugh class C (57.1%; OR 4.00; p = 0.026), and failure of two or more organs (81.8%; OR 19.93; p = 0.001). After PSM for demographics and comorbidity, the COVID‐19 case fatality of patients with cirrhosis did not significantly differ from that of matched patients without cirrhosis (28.8% vs. 26.1%; p = 0.644) and was similar to the 28‐day mortality in a comparison group of patients with cirrhosis and SBP (33.3% vs. 31.5%; p = 1.000). Conclusions In immunologically naïve patients with cirrhosis, mortality from wild‐type SARS‐CoV‐2 and the alpha variant is high and is largely determined by cirrhosis‐associated comorbidities and extrahepatic organ failure.
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Affiliation(s)
- Jonathan F Brozat
- Department of Internal Medicine III, University Hospital RWTH Aachen, RWTH Aachen University, Aachen, Germany
| | - Frank Hanses
- Emergency Department, University Hospital Regensburg, Regensburg, Germany.,Department for Infectious Diseases and Infection Control, University Hospital, Regensburg, Germany
| | | | - Melanie Stecher
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Michael Dreher
- Department of Pneumology and Intensive Care Medicine, Internal Medicine V, University Hospital RWTH Aachen, RWTH Aachen University, Aachen, Germany
| | - Lukas Tometten
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,Clinic for Intensive Care and Emergency Medicine, Hospital Ernst von Bergmann, Potsdam, Germany
| | - Maria M Ruethrich
- Department of Internal Medicine II, Hematology and Medical Oncology, University Hospital Jena, Jena, Germany
| | - Janne J Vehreschild
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany.,Department II of Internal Medicine, Hematology/Oncology, Goethe University, Frankfurt, Frankfurt Am Main, Germany
| | - Christian Trautwein
- Department of Internal Medicine III, University Hospital RWTH Aachen, RWTH Aachen University, Aachen, Germany
| | - Stefan Borgmann
- Department of Infectious Diseases and Infection Control, Ingolstadt Hospital, Ingolstadt, Germany
| | - Maria J G T Vehreschild
- Department of Internal Medicine, Infectious Diseases, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Carolin E M Jakob
- Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany.,German Centre for Infection Research (DZIF), Partner Site Bonn-Cologne, Cologne, Germany
| | - Andreas Stallmach
- Department of Internal Medicine IV, Jena University Hospital, Jena, Germany
| | - Kai Wille
- Johannes Wesling Klinikum Minden, Oncology, Haemostaseology and Palliative Care, Johannes Wesling Klinikum, University of Bochum, Minden, Germany
| | - Kerstin Hellwig
- Department of Neurology, St. Josef-Hospital Bochum, Ruhr University Bochum, Bochum, Germany
| | - Nora Isberner
- Department of Internal Medicine II, Infectious Diseases, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Philipp A Reuken
- Department of Internal Medicine IV, Jena University Hospital, Jena, Germany
| | - Fabian Geisler
- Department of Internal Medicine II, School of Medicine, Technical University of Munich, University Hospital Rechts der Isar, Munich, Germany
| | - Jacob Nattermann
- Department of Internal Medicine I, UKB University Hospital Bonn, Bonn, Germany
| | - Tony Bruns
- Department of Internal Medicine III, University Hospital RWTH Aachen, RWTH Aachen University, Aachen, Germany
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Onorato L, Monari C, Capuano S, Grimaldi P, Coppola N. Prevalence and Therapeutic Management of Infections by Multi-Drug-Resistant Organisms (MDROs) in Patients with Liver Cirrhosis: A Narrative Review. Antibiotics (Basel) 2022; 11:232. [PMID: 35203834 PMCID: PMC8868525 DOI: 10.3390/antibiotics11020232] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/06/2022] [Accepted: 02/08/2022] [Indexed: 12/11/2022] Open
Abstract
Bacterial infections are common events that significantly impact the clinical course of patients with cirrhosis. As in the general population, infections caused by multi-drug-resistant organisms (MDROs) are progressively increasing in cirrhotic patients, accounting for up to 30-35% of all infections. Nosocomial acquisition and prior exposure to antimicrobial treatment or invasive procedures are well-known risk factors for MDRO infections. Several studies have demonstrated that infections due to MDROs have a poorer prognosis and higher rates of treatment failure, septic shock, and hospital mortality. Due to the increasing rate of antimicrobial resistance, the approach to empirical treatment in cirrhotic patients with life-threatening infections has become significantly more challenging. In order to ensure a prompt administration of effective antibiotic therapy while avoiding unnecessary antibiotic exposure at the same time, it is of utmost importance to choose the correct antimicrobial therapy and administration schedule based on individual clinical characteristics and risk factors and rapidly adopt de-escalation strategies as soon as microbiological data are available. In the present paper, we aimed to provide an overview of the most frequent infections diagnosed in cirrhotic patients, the prevalence and impact of antimicrobial resistance, and potential therapeutic options in this population.
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Affiliation(s)
| | | | | | | | - Nicola Coppola
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, University of Campania Luigi Vanvitelli, 80138 Naples, Italy; (L.O.); (C.M.); (S.C.); (P.G.)
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8
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Atteberry P, Biederman B, Jesudian A, Lucero C, Brown RS, Verna E, Sundaram V, Fortune B, Rosenblatt R. Mortality, sepsis, and organ failure in hospitalized patients with cirrhosis vary by type of infection. J Gastroenterol Hepatol 2021; 36:3363-3370. [PMID: 34293211 DOI: 10.1111/jgh.15633] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 07/11/2021] [Accepted: 07/16/2021] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Preston Atteberry
- New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA
| | - Benjamin Biederman
- New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA
| | - Arun Jesudian
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA
| | - Catherine Lucero
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA
| | - Robert S Brown
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA
| | - Elizabeth Verna
- Center for Liver Disease and Transplantation, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Vinay Sundaram
- Division of Digestive and Liver Diseases, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Brett Fortune
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA
| | - Russell Rosenblatt
- Weill Cornell Medicine, Division of Gastroenterology and Hepatology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, New York, USA
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9
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Demirtas CO, Keklikkiran C, Ergenc I, Erturk Sengel B, Eskidemir G, Cinel I, Odabasi Z, Korten V, Yilmaz Y. Liver stiffness is associated with disease severity and worse clinical scenarios in coronavirus disease 2019: A prospective transient elastography study. Int J Clin Pract 2021; 75:e14363. [PMID: 33993597 PMCID: PMC8237050 DOI: 10.1111/ijcp.14363] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 05/11/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Pre-existing chronic liver disease is currently considered a poor prognostic factor for coronavirus disease 2019 (COVID-19). The present study aimed to investigate the association of liver stiffness measurement (LSM) with disease severity and clinical course of COVID-19. METHODS We prospectively recruited consecutive hospitalised adult patients with COVID-19 in a 3-month period. Demographic, laboratory, clinical and vibration-controlled transient elastography (VCTE) features were recorded at entry, and all patients were prospectively followed-up. Severe liver fibrosis was defined as an LSM value higher than 9.6 kPA. Multivariate logistic regression analysis was performed to reveal factors associated with disease severity and outcomes. RESULTS Out of 98 eligible patients with COVID-19, 12 (12.2%) had severe liver fibrosis. Patients with severe liver fibrosis had higher baseline disease severity (P = .022), more commonly required oxygen treatment at entry (P = .010), and had intensive-care unit (ICU) requirements during the 6 (1-39)-day median follow-up time (P = .017). The presence of severe liver fibrosis was independently associated with disease severity (odds ratio (OR): 7.685, 95% confidence interval (CI): 1.435-41.162, P = .017) and ICU requirement (OR: 46.656, 95% CI: 2.144-1015.090, P = .014). LSM was correlated with alanine aminotransferase levels (P = .005, r: 0.283), but not with other markers of acute hepatic injury or inflammation. CONCLUSION Initial VCTE application might help physicians identify patients who are more likely to have severe illness or worse clinical outcomes, in addition to other well-established clinical and laboratory factors. Further multicentre prospective studies are warranted to validate our results.
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Affiliation(s)
- Coskun Ozer Demirtas
- Department of GastroenterologySchool of MedicineMarmara UniversityIstanbulTurkey
| | - Caglayan Keklikkiran
- Department of GastroenterologySchool of MedicineMarmara UniversityIstanbulTurkey
| | - Ilkay Ergenc
- Department of GastroenterologySchool of MedicineMarmara UniversityIstanbulTurkey
| | - Buket Erturk Sengel
- Department of Infectious DiseasesSchool of MedicineMarmara UniversityIstanbulTurkey
| | - Gunes Eskidemir
- Department of Critical Care MedicineSchool of MedicineMarmara UniversityIstanbulTurkey
| | - Ismail Cinel
- Department of Critical Care MedicineSchool of MedicineMarmara UniversityIstanbulTurkey
| | - Zekaver Odabasi
- Department of Infectious DiseasesSchool of MedicineMarmara UniversityIstanbulTurkey
| | - Volkan Korten
- Department of Infectious DiseasesSchool of MedicineMarmara UniversityIstanbulTurkey
| | - Yusuf Yilmaz
- Department of GastroenterologySchool of MedicineMarmara UniversityIstanbulTurkey
- Institute of GastroenterologyMarmara UniversityIstanbulTurkey
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10
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Tapadia A, Jain M, Reddy MS, Mahadevan B, Varghese J, Venkataraman J. Serum C-reactive protein and neutrophil-to-lymphocyte ratio as predictors of survival in cirrhotic patients with systemic inflammatory response syndrome and bacterial infection. Indian J Gastroenterol 2021; 40:265-271. [PMID: 33974227 DOI: 10.1007/s12664-020-01134-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Accepted: 11/29/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Cirrhotic patients are prone to infections due to underlying immune dysfunction in them. We aimed to study the role of inflammatory markers, serum C-reactive protein (CRP) and neutrophil-to-lymphocyte ratio (NLR), in predicting infection, blood culture positivity, and short-term (1 month) mortality in hospitalized cirrhotic patients. METHODS This prospective study was done over a period of 14 months (October 2017 to November 2018). Patient data included age, gender, etiology of cirrhosis, reason for admission, and comorbidity. Laboratory tests included blood chemistry and blood cell counts, and blood and urine culture. The specific tests included were CRP and NLR. Survival of patients in the following 1 month was noted. Area under receiver operating characteristic curve (AUROC), sensitivity, specificity, predictive values, diagnostic accuracy were calculated and logistic regression analysis performed. A p-value < 0.05 was considered significant. RESULTS Two hundred and eight patients formed the study cohort. The median age was 51.5 years and male predominance was noted. Alcohol-related liver disease (49%) was the commonest etiology. The infection rate was 62%, culture positivity was 58.5%, and mortality was 30.8%. NLR and CRP were significantly higher in those with documented infection (culture positive or negative) and among nonsurvivors. Optimal cutoffs for NLR and CRP to predict infection were 5.86 and 33.7, respectively. The risk of having an infection was 7.5 times and about 15 times if NLR and CRP were above the cutoffs. The risk of 1-month mortality was 2-3 times higher if patients had NLR and CRP above the cutoffs. The combination of NLR and CRP (≥ 5.86 and ≥ 33.7, respectively) increased specificity and diagnostic accuracy for infection. CONCLUSION NLR and CRP were independently good predictors of infection and 1-month survival among the patients with cirrhosis of liver included in this study.
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Affiliation(s)
- Ashishkumar Tapadia
- Department of Gastroenterology and Hepatology, Gleneagles Global Health City, Chennai 600, 100, India
| | - Mayank Jain
- Department of Gastroenterology and Hepatology, Gleneagles Global Health City, Chennai 600, 100, India.
- Department of Gastroenterology, Arihant Hospital and Research Centre, Indore, 452 009, India.
| | - Mettu Srinivas Reddy
- Institute of Liver Disease and Transplantation, Dr. Rela's Institute of Medical Sciences, Chennai 600 044, India
| | - B Mahadevan
- Department of Gastroenterology and Hepatology, Gleneagles Global Health City, Chennai 600, 100, India
| | - Joy Varghese
- Department of Gastroenterology and Hepatology, Gleneagles Global Health City, Chennai 600, 100, India
| | - Jayanthi Venkataraman
- Department of Gastroenterology and Hepatology, Gleneagles Global Health City, Chennai 600, 100, India
- Department of Hepatology, Sri Ramachandra Medical College, Porur, Chennai 600 116, India
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11
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Lippi G, de Oliveira MHS, Henry BM. Chronic liver disease is not associated with severity or mortality in Coronavirus disease 2019 (COVID-19): a pooled analysis. Eur J Gastroenterol Hepatol 2021; 33:114-115. [PMID: 32282549 PMCID: PMC7690326 DOI: 10.1097/meg.0000000000001742] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 03/24/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Giuseppe Lippi
- Section of Clinical Biochemistry, Department of Neuroscience, Biomedicine and Movement, University of Verona, Verona, Italy
| | | | - Brandon Michael Henry
- Cardiac Intensive Care Unit, The Heart Institute, Cincinnati Children’s Hospital Medical Center, Ohio, USA
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12
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Ahmmad EM, Roberts LR. Quality of Care in Patients With Cirrhosis: Trends in Recommended Adult Vaccination Coverage. Mayo Clin Proc Innov Qual Outcomes 2020; 4:667-682. [PMID: 33367212 PMCID: PMC7749261 DOI: 10.1016/j.mayocpiqo.2020.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective To assess the proportion of patients with cirrhosis up to date with vaccinations and associations of vaccination with age, sex, race, ethnicity, marital status, and type of provider follow-up. Patients and Methods Patients with cirrhosis diagnosed at Mayo Clinic in Rochester and Mayo Clinic Health System in Minnesota from January 1, 2007, to December 31, 2009, were followed up from diagnosis until May 31, 2015. Data were abstracted from Mayo Clinic and Minnesota State records. Factors determining vaccination coverage were assessed. Results At the end of the study period (8 years follow-up), 26.4% (95 of 360), 24.7% (82 of 332), 63.2% (180 of 285), and 25.5% (54 of 212) of patients with cirrhosis were up to date with hepatitis A virus (HAV), hepatitis B virus, pneumococcal pneumonia (PN), and herpes zoster vaccinations, respectively. Influenza (FLU) vaccine coverage increased from 36.1% (57 of 158) in 2007 to 2008 to 65.8% (106 of 161) in 2014 to 2015. Of those unvaccinated for HAV and hepatitis B virus before cirrhosis diagnosis, 18.6% (59 of 318) and 23.4% (71 of 304) completed vaccination. For HAV, more whites than nonwhites (28.3% [91 of 322] vs 10.5% [4 of 38]; odds ratio [OR], 3.35; 95% CI, 1.29 to 11.45; P=.02) and more non-Hispanics than Hispanics (27.4% [95 of 347] vs 0% [0 of 13]; OR, 0.00; 95% CI, 0.00 to 0.43; P=.03) were vaccinated. For PN, more younger than elderly people (66.8% [135 of 202] vs 54.2% [45 of 83]; OR, 1.70; 95% CI, 1.01 to 2.87; P=.04) and married vs single people (56.8% [100 of 176] vs 73.4% [80 of 109]; OR, 2.10; 95% CI, 1.26 to 3.56; P=.005) were vaccinated. For FLU, in 2013 to 2014, more elderly (72.0% [54 of 75] vs 58.0% [69 of 119]; OR, 0.54; 95% CI, 0.28 to 0.99; P=.05); in 2008 to 2009, more Hispanics (100% [4 of 4] vs 41.6% [116 of 279]; OR, ∞; 95% CI, 2.25 to ∞; P=.02); and in 2011 to 2012, more married people (62.4% [101 of 162] vs 50.5% [56 of 111]; OR, 1.63; 95% CI, 0.1.0 to 2.66; P=.05) were vaccinated. For FLU in 2008 to 2009, coverage was higher in the primary care than the specialist setting (55.8% [48 of 86] vs 36.6% [72 of 197]; P=.003). Conclusion Except for PN and FLU, vaccination coverage in patients with cirrhosis falls short of Healthy People 2020 target. Specific interventions are needed to improve vaccination coverage in patients with cirrhosis.
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Key Words
- ACIP, Advisory Committee on Immunization Practices
- CLD, chronic liver disease
- EMR, electronic medical record
- FLU, influenza
- GIH, gastroenterologist and/or hepatologist
- HAV, hepatitis A virus
- HBV, hepatitis B virus
- HR, high-risk people
- HZ, herpes zoster
- LT, liver transplant specialist
- OR, odds ratio
- PCP, primary care provider
- PN, pneumococcal pneumonia
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Affiliation(s)
- Eimad M Ahmmad
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Lewis R Roberts
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN
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13
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Zhai XR, Tong JJ, Wang HM, Xu X, Mu XY, Chen J, Liu ZF, Wang Y, Su HB, Hu JH. Infection deteriorating hepatitis B virus related acute-on-chronic liver failure: a retrospective cohort study. BMC Gastroenterol 2020; 20:320. [PMID: 32993547 PMCID: PMC7526233 DOI: 10.1186/s12876-020-01473-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 09/25/2020] [Indexed: 02/07/2023] Open
Abstract
Background Infection is common in acute-on-chronic liver failure (ACLF), which may worsen the clinical condition and prognosis. However, the characteristics of infection and its influence on prognosis in hepatitis B virus related ACLF (HBV-ACLF) as defined by the European Association for the Study of the Liver (EASL) have not been clarified. We aimed to investigate the characteristics of infection and its influence on mortality in patients with HBV-ACLF defined by EASL in China. Methods We performed a retrospective cohort study in patients with HBV-ACLF defined by EASL in a single center from January 2015 to December 2017. These patients were divided into two groups with and without infection. The incidence, sites of infection, isolated strains, and risk factors associated with mortality were evaluated. Results A total of 289 patients were included, among them 185 (64.0%) were diagnosed with an infection. The most common type of infection was pneumonia (55.7%), followed by spontaneous bacterial peritonitis (47.6%) and others. The gram-negative bacteria were the most frequent (58.3%). Patients with one, two, and three or more infection sites had a gradually increasing incidence of sepsis (P < 0.01), septic shock (P < 0.001), and ACLF-3 (P < 0.05). Also, patients with infection isolated one, two, and three or more strains showed a growing incidence of sepsis (P < 0.01) and septic shock (P < 0.001). Patients with infection showed a significantly higher 28-day mortality than those without (P < 0.01), especially in patients with ACLF-3. Infection was identified as an independent risk factor for 28-day mortality in all HBV-ACLF patients. Pneumonia and sepsis were identified as independent predictors of 28-day mortality for patients with infection. Conclusions Infection is associated with severe clinical course and high mortality in HBV-ACLF defined by EASL. The increased number of infection sites or isolated strains was associated with the occurrence of sepsis and septic shock. Pneumonia and sepsis were independent predictors for mortality in HBV-ACLF patients with infection.
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Affiliation(s)
- Xing-Ran Zhai
- Peking University 302 Clinical Medical School, Beijing, China
| | - Jing-Jing Tong
- Liver Failure Treatment and Research Center, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China.,Medical School of Chinese PLA, Beijing, China
| | - Hong-Min Wang
- Peking University 302 Clinical Medical School, Beijing, China
| | - Xiang Xu
- Liver Failure Treatment and Research Center, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Xiu-Ying Mu
- Peking University 302 Clinical Medical School, Beijing, China
| | - Jing Chen
- Liver Failure Treatment and Research Center, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China.,Medical School of Chinese PLA, Beijing, China
| | - Zi-Feng Liu
- Medical School of Chinese PLA, Beijing, China
| | - Yu Wang
- Medical School of Chinese PLA, Beijing, China
| | - Hai-Bin Su
- Liver Failure Treatment and Research Center, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China.
| | - Jin-Hua Hu
- Peking University 302 Clinical Medical School, Beijing, China. .,Liver Failure Treatment and Research Center, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China. .,Medical School of Chinese PLA, Beijing, China.
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14
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Bajpai V, Gupta E, Mitra LG, Kumar H, Maiwall R, Soni KD, Gupta A. Spectrum of respiratory viral infections in liver disease patients with cirrhosis admitted in critical care unit. J Lab Physicians 2020; 11:356-360. [PMID: 31929704 PMCID: PMC6943874 DOI: 10.4103/jlp.jlp_6_19] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND: Clinical significance of respiratory viruses (RVs) as an etiology of pneumonia in liver disease patients with cirrhosis is usually underestimated. Therefore, the aim of this study was to evaluate the spectrum of RVs in cirrhotic patients with pneumonia admitted in critical care units (CCUs) and its impact on the clinical outcome of cirrhotic patients. MATERIAL AND METHOD: A prospective study was conducted in a tertiary care CCU, and consecutive cirrhotic patients with pneumonia were included. Bronchoalveolar lavage or throat swab/nasal swab was collected in viral transport medium for analysis of RVs by multiplex real-time polymerase chain reaction. A total of 135 cirrhotic patients were included, viral and bacterial etiology of pneumonia was identified, and analysis was done with the clinical outcome. RESULTS: Overall, RVs were detected in 30 (22.2%) cirrhotic patients and viral–bacterial coinfection in 16 (11.8%) cirrhotic patients. The most common virus detected was rhinovirus in 9 (30%) patients. Mortality in cirrhotic patients with RV infection was significantly higher in comparison to cirrhotic patients with no RV infection (25 [83.3%] and 11 [12.3%], respectively, P < 0.001). CONCLUSION: Respiratory viruses in cirrhotic patients with pneumonia are associated with poor clinical outcome.
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Affiliation(s)
- Vijeta Bajpai
- Departments of Clinical Virology, JPNATC, All India Institute of Medical Sciences, New Delhi, India
| | - Ekta Gupta
- Departments of Clinical Virology, JPNATC, All India Institute of Medical Sciences, New Delhi, India
| | - Lalita Gauri Mitra
- Critical Care and Anaesthesia, JPNATC, All India Institute of Medical Sciences, New Delhi, India
| | - Hemant Kumar
- Pulmonary Medicine, JPNATC, All India Institute of Medical Sciences, New Delhi, India
| | - Rakhi Maiwall
- Hepatology, Institute of Liver and Biliary Sciences, JPNATC, All India Institute of Medical Sciences, New Delhi, India
| | - Kapil Dev Soni
- Department of Trauma and Critical Intensive Care Unit, JPNATC, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Gupta
- Department of Surgery, JPNATC, All India Institute of Medical Sciences, New Delhi, India
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15
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Hung TH, Tsai CC, Lee HF. Effects of poor hepatic reserve in cirrhotic patients with bacterial infections: A population-based study. Tzu Chi Med J 2020; 32:47-52. [PMID: 32110520 PMCID: PMC7015002 DOI: 10.4103/tcmj.tcmj_142_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 09/18/2018] [Accepted: 10/03/2018] [Indexed: 11/04/2022] Open
Abstract
Objective: Ascites, hepatic encephalopathy, hepatorenal syndrome, spontaneous bacterial peritonitis, and esophageal variceal bleeding are major complications associated with cirrhosis. The presence of these complications indicates poor hepatic reserve. This study aimed to identify the effects of poor hepatic reserve on mortality in cirrhotic patients with bacterial infections. Patients and Methods: The Taiwan National Health Insurance Database was used to identify 43,042 cirrhotic patients with bacterial infections hospitalized between January 1, 2010, and December 31, 2013, after propensity score matching analysis. Of these, 21,521 cirrhotic patients had major cirrhotic-related complications and were considered to have poor hepatic reserve. Results: Mortality rates at 30 and 90 days were 24.2% and 39.5% in the poor hepatic reserve group and 12.8% and 21.7% in the good hepatic reserve group, respectively (P < 0.001 for each group). The cirrhotic patients with poor hepatic reserve (hazard ratio [HR], 2.10; 95% confidence interval [CI] = 2.03–2.18; P < 0.001) had significantly increased mortality at 90 days. The mortality HRs in patients with one, two, and three or more complications compared to patients without complications were 1.92 (95% CI = 1.85–1.99, P < 0.001), 2.61 (95% CI = 2.47–2.77, P < 0.001), and 3.81 (95% CI = 3.18–4.57, P < 0.001), respectively. Conclusion: In cirrhotic patients with bacterial infections, poor hepatic reserve is associated with a poor prognosis. The presence of three or more cirrhotic-related complications increases mortality almost four folds.
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Affiliation(s)
- Tsung-Hsing Hung
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chih-Chun Tsai
- Department of Mathematics, Tamkang University, New Taipei, Taiwan
| | - Hsing-Feng Lee
- Division of Gastroenterology, Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
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16
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Lameirão Gomes C, Violante Silva R, Carrola P, Presa J. Bacterial Infections in Patients with Liver Cirrhosis in an Internal Medicine Department. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2019; 26:324-332. [PMID: 31559323 PMCID: PMC6751436 DOI: 10.1159/000494568] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 10/12/2018] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND AIMS Liver cirrhosis (LC) is the end stage of multiple processes that lead to hepatic failure and is the 10th most common cause of death in the Western world. Bacterial infections are one of the most important clinical problems in patients with LC, as their underlying immune status is compromised. Approximately 60% of bacterial infections in cirrhotic patients are community acquired (CA) and 40% are nosocomial. The most common infections in cirrhotic patients are spontaneous bacterial peritonitis (SBP) (25%), urinary tract infection (UTI) (20%), pneumonia (15%), bacteremia (12%), and cellulitis (2-11%). The aim of this study was to evaluate the most frequent infections in patients with LC and describe the evolution of the microbiology in these patients. MATERIAL AND METHODS This is a retrospective analysis of 4 interspersed years (2008, 2010, 2012, and 2014) that included 372 patients. Demographic characteristics were evaluated, including gender, age, type of infection, bacteria resistance profile, antibiotic use, Child-Pugh-Turcotte and Model for End-Stage Liver Disease scores, and mortality rate. RESULTS The mean age of all patients enrolled in this study was 64.5 ± 12.2 years. Male patients were significantly more prevalent than female ones (72 vs. 28%). In the 4 analyzed years, the following numbers of infections occurred: 71 infections (49% CA and 51% nosocomial) in 2008; 86 infections (60.5% CA and 39.5% nosocomial) in 2010; 99 infections (56.6% CA and 43.4% nosocomial) in 2012; and 116 infections (70.7% CA and 29.3% nosocomial) in 2014. The most frequent infections were UTI (32.5%), respiratory tract infection (29.3%), SBP (26.1%), and cellulitis (6.2%). A microbiological agent was identified in 32.4, 59.3, 53.5, and 61.2% of infections in 2008, 2010, 2012, and 2014, respectively, with a predominance of gram-negative bacilli. In all series, a third-generation cephalosporin was the most frequent antibiotic used empirically. The majority of patients was in stage B (42.7%) of the Child-Pugh-Turcotte score, followed by stage C (39.3%) and stage A (18%). Mortality increased significantly over the years, from 7% in 2008 to 25% in 2014 (p = 0.016). CONCLUSIONS The present study showed a high prevalence of bacterial infections in patients with LC. A high rate of suspicion is needed for an infectious process in these patients, and an appropriate antibiotic treatment can decrease the morbidity and mortality in cirrhotic patients.
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Affiliation(s)
- Cristina Lameirão Gomes
- Liver Unit, Internal Medicine Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
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17
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Effect of proton pump inhibitors on mortality of cirrhotic patients with pneumonia. PLoS One 2019; 14:e0216041. [PMID: 31022265 PMCID: PMC6483244 DOI: 10.1371/journal.pone.0216041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 04/12/2019] [Indexed: 12/12/2022] Open
Abstract
Objective Pneumonia is life-threatening in patients with liver cirrhosis. Proton pump inhibitors (PPIs) may increase the risk of these patients developing pneumonia. However, whether PPIs increase mortality in patients with cirrhosis and pneumonia remain unknown. Methods We used the Taiwan National Health Insurance Database to enroll 1,201 cirrhotic patients with pneumonia without active gastrointestinal bleeding who were receiving PPIs and were hospitalized between January 1, 2010 and December 31, 2013. A one-to-three propensity score match was performed to select a comparison group based on age, gender, and comorbid disorders. Results The overall 30-day and 90-day all-cause mortality rates were 13.7% and 26.9% in the PPI group, and 14.3% and 25.1% in the non-PPI group, respectively. After Cox regression model adjusting for age, gender, and comorbid disorders, the hazard ratios of the effect of PPIs on 30-day and 30 to 90-day mortality were 0.94 (95% Confidence Interval [CI], 0.79–1.12, P = 0.468) and 1.26 (95% CI, 1.05–1.52; P = 0.013), respectively. Conclusions PPIs were not associated with 30-day mortality among cirrhotic patients with pneumonia but not active gastrointestinal bleeding. However, prolonged PPI therapy may be associated with higher mortality.
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Abstract
Purpose of review Patients with cirrhosis are at high risk of developing serious infections. Bacterial infections remain the most common cause of morbidity and mortality in these patients. This review is focused on the prevalence of infections in those with cirrhosis, including multidrug-resistant (MDR) pathogens, pathogenesis of infection-related acute-on-chronic liver failure (ACLF), current treatment recommendations, and prophylactic strategies in patients with cirrhosis. Recent findings Recent epidemiological studies have noted an emerging prevalence of MDR bacterial infections and associated with poor prognosis, and a high rate of treatment failure and mortality. Therefore, new recommendations on empirical antibiotic use based on epidemiological data have been developed in order to improve outcomes. Summary Spontaneous bacterial peritonitis (SBP) and urinary tract infection (UTI) are the most frequent infections followed by pneumonia, cellulitis, and bacteremia, while pneumonia carries the highest risk of mortality. The incidence of MDR bacterial infections has been increasing, especially in healthcare-associated settings. Second infections that develop during hospitalization, multiple organ failures, and high MELD score are associated with poor survival. Preventive measures, early diagnosis, and adequate treatment of infections are essential key concepts in minimizing morbidity and mortality in patients with cirrhosis.
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19
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Boivin Z, Perez MF, Atuegwu NC, Anzueto A, Mortensen EM. Impact of Cirrhosis on Pneumonia-Related Outcomes in Hospitalized Older Veterans. Am J Med Sci 2019; 357:296-301. [PMID: 30904044 DOI: 10.1016/j.amjms.2019.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 12/09/2018] [Accepted: 01/08/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Prior research has demonstrated high mortality rates in patients with cirrhosis who contract bacterial infections. The purpose of our study was to explore clinical outcomes such as 90-day mortality, rehospitalization, and intensive care unit (ICU) admission in older veterans with pneumonia and cirrhosis. METHODS We conducted a retrospective cohort study of hospitalized patients with community-acquired pneumonia at any Departments of Veterans Affairs (VA) hospital over a 10-year period. We included patients 65 years or older who consistently received VA care and who were diagnosed with community-acquired pneumonia. There were 103,997 patients who met the inclusion criteria, and 1,246 patients with cirrhosis. We used multilevel regression models to examine the association between cirrhosis and the outcomes of interest after controlling for potential confounders. RESULTS Cirrhosis was associated with significantly increased odds of 90-day mortality (odds ratio 1.79, 95% confidence interval, 1.57-2.04). There were also significantly increased odds of rehospitalization within 90-days (1.30, 1.16-1.47). No significant association was found with ICU admission (1.00, 0.83-1.19). CONCLUSIONS We found an association between cirrhosis and 90-day mortality and rehospitalization in older patients with pneumonia. We suggest that physicians should carefully monitor patients with cirrhosis who develop pneumonia.
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Affiliation(s)
- Zachary Boivin
- UConn Health, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Mario F Perez
- UConn Health, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Nkiruka C Atuegwu
- UConn Health, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Antonio Anzueto
- University of Texas Health Science Center at San Antonio, San Antonio, Texas; South Texas Veterans Health Care System, San Antonio, Texas
| | - Eric M Mortensen
- UConn Health, University of Connecticut School of Medicine, Farmington, Connecticut; VA North Texas Health Care System, Dallas, Texas.
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20
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Xu L, Ying S, Hu J, Wang Y, Yang M, Ge T, Huang C, Xu Q, Zhu H, Chen Z, Ma W. Pneumonia in patients with cirrhosis: risk factors associated with mortality and predictive value of prognostic models. Respir Res 2018; 19:242. [PMID: 30514312 PMCID: PMC6280505 DOI: 10.1186/s12931-018-0934-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 11/12/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Cirrhosis always goes with profound immunity compromise, and makes those patients easily be the target of pneumonia. Cirrhotic patients with pneumonia have a dramatically increased mortality. To recognize the risk factors of mortality and to optimize stratification are critical for improving survival rate. METHODS Two hundred and three cirrhotic patients with pneumonia at a tertiary care hospital were included in this retrospective study. Demographical, clinical and laboratory parameters, severity models and prognosis were recorded. Multivariate Cox regression analysis was used to identify independent predictors of 30-day and 90-day mortality. Area under receiver operating characteristics curves (AUROC) was used to compare the predictive value of different prognostic scoring systems. RESULTS Patients with nosocomial acquired or community acquired pneumonia indicated similar prognosis after 30- and 90-day follow-up. However, patients triggered acute-on-chronic liver failure (ACLF) highly increased mortality (46.4% vs 4.5% for 30-day, 69.6% vs 11.2% for 90-day). Age, inappropriate empirical antibiotic therapy (HR: 2.326 p = 0.018 for 30-day and HR: 3.126 p < 0.001 for 90-day), bacteremia (HR: 3.037 p = 0.002 for 30-day and HR: 2.651 p = 0.001 for 90-day), white blood cell count (WBC) (HR: 1.452 p < 0.001 for 30-day and HR: 1.551 p < 0.001 for 90-day) and total bilirubin (HR: 1.059 p = 0.002 for 90-day) were independent factors for mortality in current study. Chronic liver failure-sequential organ failure assessment (CLIF-SOFA) displayed highest AUROC (0.89 and 0.90, 95% CI: 0.83-0.95 and 0.85-0.95 for 30-day and 90-day respectively) in current study. CONCLUSIONS This study found age, bacteremia, WBC, total bilirubin and inappropriate empirical antibiotic therapy were independently associated with increased mortality. Pneumonia triggered ACLF remarkably increased mortality. CLIF-SOFA was more accurate in predicting mortality than other five prognostic models (model for end-stage liver disease (MELD), MELD-Na, quick sequential organ failure assessment (qSOFA), pneumonia severity index (PSI), Child-Turcotte-Pugh (CTP) score).
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Affiliation(s)
- Lichen Xu
- State Key Laboratory for Diagnosis and Treatment of Infectious, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Shuangwei Ying
- Department of Hematology, Taizhou Hospital of Zhejiang Province, Linhai, Taizhou, China
| | - Jianhua Hu
- State Key Laboratory for Diagnosis and Treatment of Infectious, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Yunyun Wang
- State Key Laboratory for Diagnosis and Treatment of Infectious, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Meifang Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Tiantian Ge
- State Key Laboratory for Diagnosis and Treatment of Infectious, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Chunhong Huang
- State Key Laboratory for Diagnosis and Treatment of Infectious, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Qiaomai Xu
- State Key Laboratory for Diagnosis and Treatment of Infectious, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Haihong Zhu
- State Key Laboratory for Diagnosis and Treatment of Infectious, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, Zhejiang, 310003, People's Republic of China
| | - Zhi Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, Zhejiang, 310003, People's Republic of China.
| | - Weihang Ma
- State Key Laboratory for Diagnosis and Treatment of Infectious, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, 79 Qingchun Road, Hangzhou, Zhejiang, 310003, People's Republic of China.
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Cardoso FS, Karvellas CJ. Respiratory Complications Before and After Liver Transplant. J Intensive Care Med 2018; 34:355-363. [PMID: 29886790 DOI: 10.1177/0885066618781526] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Respiratory complications before and after liver transplant are common, diverse, and potentially have a negative impact on patient outcomes. In this review, we discuss the most frequent respiratory conditions that patients may develop in the perioperative period. Their prevention and/or treatment may help to maximize the benefit these patients may derive from liver transplant. This review examines diagnostic and therapeutic approaches to these complications for hepatologists, surgeons, and critical care physicians.
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Affiliation(s)
- Filipe S Cardoso
- 1 Gastroenterology and Intensive Care Divisions, Hospital Curry Cabral, Central Lisbon Hospital Center, Nova Medical School, Nova University, Lisbon, Portugal
| | - Constantine J Karvellas
- 2 Division of Gastroenterology (Liver Unit) and Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
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Hung TH, Tsai CC, Hsieh YH, Tsai CC, Tseng CW, Tseng KC. The Effect of the First Spontaneous Bacterial Peritonitis Event on the Mortality of Cirrhotic Patients with Ascites: A Nationwide Population-Based Study in Taiwan. Gut Liver 2017; 10:803-7. [PMID: 27563023 PMCID: PMC5003205 DOI: 10.5009/gnl13468] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Revised: 03/06/2014] [Accepted: 03/10/2014] [Indexed: 12/15/2022] Open
Abstract
Background/Aims Spontaneous bacterial peritonitis (SBP) contributes to poorer short-term mortality in cirrhotic patients with ascites. However, it is unknown how long the effect of the first SBP event persists in these patients. Methods The National Health Insurance Database, derived from the Taiwan National Health Insurance Program, was used to identify and enroll 7,892 cirrhotic patients with ascites who were hospitalized between January 1 and December 31, 2007. All patients were free from episodes of SBP from 1996 to 2006. Results The study included 1,176 patients with SBP. The overall 30-day, 90-day, 1-year, and 3-year mortality rates in this group were 21.8%, 38.9%, 57.5%, and 73.4%, respectively. The overall 30-day, 90-day, 1-year, and 3-year mortality rates in the non-SBP group were 15.7%, 32.5%, 53.3%, and 72.5%, respectively. After adjusting for gender, age, and other medical comorbidities, the adjusted hazard ratios of SBP for 30-day, 30- to 90-day, 90-day to 1-year, and 1- to 3-year mortality were 1.49 (95% confidence interval [CI], 1.30 to 1.71), 1.19 (95% CI, 1.02 to 1.38), 1.04 (95% CI, 0.90 to 1.20), and 0.90 (95% CI, 0.77 to 1.05), respectively, compared with the non-SBP group. Conclusions The effect of SBP on the mortality of cirrhotic patients with ascites disappeared in those surviving more than 90 days after the first SBP event.
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Affiliation(s)
- Tsung-Hsing Hung
- Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chen-Chi Tsai
- Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Yu-Hsi Hsieh
- Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Chih-Chun Tsai
- Department of Mathematics, Tamkang University, Tamsui, Taiwan
| | - Chih-Wei Tseng
- Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Kuo-Chih Tseng
- Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan.,School of Medicine, Tzu Chi University, Hualien, Taiwan
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Prognostic values of pneumonia severity index, CURB-65 and expanded CURB-65 scores in community-acquired pneumonia in Zagazig University Hospitals. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2017. [DOI: 10.1016/j.ejcdt.2017.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Vaccinating Adult Patients with Cirrhosis: Trends over a Decade in the United States. Gastroenterol Res Pract 2016; 2016:5795712. [PMID: 27239192 PMCID: PMC4867062 DOI: 10.1155/2016/5795712] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 03/23/2016] [Accepted: 04/17/2016] [Indexed: 02/07/2023] Open
Abstract
Introduction. The progression of chronic liver disease to cirrhosis involves both innate and adaptive immune system dysfunction resulting in increased risk of infectious complications. Vaccinations against pneumococcus, hepatitis A virus (HAV), and hepatitis B virus (HBV) are well tolerated and effective in disease prevention and reduction in morbidity and mortality. Prior studies assessing vaccination rates in patients with cirrhosis have specific limitations and to date no study has provided a comprehensive evaluation of vaccination rates in patients with cirrhosis in the United States. Aim. This study assessed vaccination rates for pneumococcus, HAV, and HBV in patients with cirrhosis. Results. Overall 59.7% of patients with cirrhosis received at least 1 vaccination during the study period. Vaccination rates within the same or following year of cirrhosis diagnosis were 19.9%, 7.7%, and 11.0% against pneumococcus, HAV, and HBV, respectively. Trend analysis revealed significant increases in vaccination rates for pneumococcus in all patients with cirrhosis and within subgroups based on age, gender, and presence of concomitant diabetes. Conclusion. The study demonstrated that vaccination rates in patients with cirrhosis remain suboptimal. Ultimately, the use of electronic medical record (EMR) reminders improved communication between healthcare professionals and public health programs to increase awareness are fundamental to reducing morbidity, mortality, and health-care related costs of vaccine preventable diseases in patients with cirrhosis.
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Could Adherence to Quality of Care Indicators for Hospitalized Patients With Cirrhosis-Related Ascites Improve Clinical Outcomes? Am J Gastroenterol 2016; 111:87-92. [PMID: 26729545 DOI: 10.1038/ajg.2015.402] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 09/02/2015] [Accepted: 11/02/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The diagnosis of cirrhotic ascites is associated with significant morbidity, mortality, and reduced health-related quality of life. Adherence by health professionals to quality indicators (QIs) of care for ascites is low. We evaluated the effect of adherence to ascites QIs on clinical outcomes for patients hospitalized with new onset cirrhotic ascites. METHODS The medical records of 302 patients admitted with new onset cirrhotic ascites were interrogated for demographic and clinical data and adherence to eight Delphi panel-derived QIs for ascites management. Associations between adherence to each QI and 30-day emergent readmission and 90-day mortality were analyzed. RESULTS The majority of patients were males (68.9%) over 50 years of age (mean 57±12.83 years) with alcohol-related cirrhosis (59%). Twenty-nine percent were readmitted within 30 days. Patients who received an abdominal paracentesis within 30 days of ascites diagnosis (QI 1, relative risk (RR) 0.41, P=0.004) or during index hospitalization (QI 2, RR 0.57, P=0.006) were significantly less likely to experience a 30-day emergent readmission. Baseline serum bilirubin >2.5 mg/dl was associated with increased 30-day cirrhosis-related readmission (RR 1.51, P=0.03). A total of 18.5% of patients died within 90 days of index admission; median interval to death was 139 days (37-562 days). Pneumonia was the most frequent cause of death. Independent predictors of 90-day mortality included older age (odds ratio (OR) 1.03, P=0.03), increased Model for End-stage Liver Disease (MELD)-Na score (OR 1.06, P=0.05), primary SBP prophylaxis (QI 7, OR 2.30, P=0.04), and readmission within 30 days (OR 30.26, P<0.001). Discharge prescription of diuretics (QI 8, OR 0.28, P=0.01) was associated with reduced 90-day mortality. CONCLUSIONS Early paracentesis in patients with new onset cirrhotic ascites lowers 30-day readmission rates, and early initiation of diuretic therapy lowers 90-day mortality.
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Gacouin A, Tadié JM, Le Tulzo Y. Infections bronchopulmonaires chez le patient cirrhotique. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/s13546-015-1046-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Hung TH, Tseng CW, Tseng KC, Hsieh YH, Tsai CC, Tsai CC. Effect of renal function impairment on the mortality of cirrhotic patients with hepatic encephalopathy: a population-based 3-year follow-up study. Medicine (Baltimore) 2014; 93:e79. [PMID: 25255022 PMCID: PMC4616283 DOI: 10.1097/md.0000000000000079] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Kidney is an important organ to clear neurotoxic substance in circulation. However, it is still unknown about the effect of renal function impairment (RFI) on the mortality of cirrhotic patients with hepatic encephalopathy (HE). We used the Taiwan National Health Insurance Database to identify 4932 cirrhotic patients with HE, hospitalized between January 1, 2007 and December 31, 2007. The enrolled patients were followed up individually for 3 years to identify their 3-year mortalities. There were 411 (8.3%) patients with RFI and 4521 (91.7%) patients without RFI. The adjusted hazard ratio (HR) of RFI for 3-year mortality was 2.03 (95% CI, 1.82-2.27). In RFI group, there were 157 (38.2%) patients with acute renal failure (ARF), 61 (14.8%) with hepatorenal syndrome (HRS), 93 (22.6%) with chronic kidney disease (CKD), and 100 (24.3%) with end-stage renal disease (ESRD). Compared with the non-RFI group, the adjusted HR of ARF for 3-year mortality was 2.57 (95% CI, 2.17-3.06), CKD 1.93 (95% CI, 1.55-2.40), ESRD 1.26 (95% CI, 1.01-1.57), and HRS 3.58 (95% CI, 2.78-4.63). Among ESRD patients, there were 99 patients receiving hemodialysis regularly. Compared with the CKD group, the adjusted HR of ESRD with hemodialysis for 3-year mortality was 0.664 (95% CI, 0.466-0.945). RFI increased the 3-year mortality of cirrhotic patients with HE, especially ARF and HRS. HE patients with ESRD receiving hemodialysis had better 3-year survival rate than those with CKD.
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Affiliation(s)
- Tsung-Hsing Hung
- Division of Gastroenterology (T-HH, C-WT, K-CT, Y-HH), Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi; School of Medicine (T-HH, C-WT, K-CT, Y-HH, C-Chi Tsai), Tzu Chi University, Hualien; Department of Mathematics (C-Chun Tsai), Tamkang University, Tamsui; Division of Infectious Disease (C-Chi Tsai), Department of Medicine, Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, Chiayi, Taiwan
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Bruns T, Zimmermann HW, Stallmach A. Risk factors and outcome of bacterial infections in cirrhosis. World J Gastroenterol 2014; 20:2542-2554. [PMID: 24627590 PMCID: PMC3949263 DOI: 10.3748/wjg.v20.i10.2542] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 01/05/2014] [Accepted: 01/20/2014] [Indexed: 02/06/2023] Open
Abstract
Viable and non-viable pathological bacterial translocation promote a self-perpetuating circle of dysfunctional immune activation and systemic inflammation facilitating infections and organ failure in advanced cirrhosis. Bacterial infections and sepsis are now recognized as a distinct stage in the natural progression of chronic liver disease as they accelerate organ failure and contribute to the high mortality observed in decompensated cirrhosis. The increasing knowledge of structural, immunological and hemodynamic pathophysiology in advanced cirrhosis has not yet translated into significantly improved outcomes of bacterial infections over the last decades. Therefore, early identification of patients at the highest risk for developing infections and infection-related complications is required to tailor the currently available measures of surveillance, prophylaxis and therapy to the patients in need in order to improve the detrimental outcome of bacterial infections in cirrhosis.
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