Early invasive fungal infections and colonization in patients with cirrhosis admitted to the intensive care unit

Abstract

Bacterial infections in cirrhosis are common and associated with increased mortality, but little is known about fungal infections. The aim of this study, a sub-analysis of the Fungal Infection Risk Evaluation study, was to assess the incidence and implications of early invasive fungal disease (IFD) in patients with cirrhosis admitted to intensive care units (ICU). Clinical and laboratory parameters collected in the first 3 days of ICU stay for 782 patients with cirrhosis and/or portal hypertension were analysed and compared with those of 273 patients with very severe cardiovascular disease (CVD). The CVD patients had more co-morbidities and higher APACHE II scores. The overall incidence of IFD was similar in the two groups, but the incidence of IFD in ICU was higher in liver patients (1% versus 0.4%; p 0.025) as was fungal colonization (23.8% versus 13.9%; p 0.001). The ICU and in-hospital mortality, and length of stay were similar in the two groups. A higher proportion of liver patients received antifungal therapy (19.2% versus 7%; p <0.0005). There was no difference in mortality between colonized patients who received antifungal therapy and colonized patients who did not. The incidence of IFD in patients with cirrhosis in ICU is higher compared with another high-risk group, although it is still very low. This risk might be higher in patients with advanced liver disease admitted with acute-on-chronic liver failure, and this should be investigated further. Our data do not support prophylactic use of antifungal therapy in cirrhosis. Clinical Microbiology and Infection

Bacterial and fungal infections in acute-on-chronic liver failure: prevalence, characteristics and impact on prognosis

“…This figure is in line with recent studies showing a low incidence of invasive fungal infections in patients with cirrhosis admitted to ICU (1%) 50. However, fungal infections could have been underestimated in our study since specific cultures were not performed.…”

Bacterial and fungal infections in acute-on-chronic liver failure: prevalence, characteristics and impact on prognosis

“…This figure is in line with recent studies showing a low incidence of invasive fungal infections in patients with cirrhosis admitted to ICU (1%). 50…”

New clinical phenotypes of fungal infections in special hosts

“…Cirrhosis associated impaired immunity is related to impaired monocyte activation, reticuloendothelial dysfunction, decreased neutrophil mobilization, impaired leucocyte function, low complement levels and low cytokine production [49]. A large multicentre study of patients with cirrhosis found an overall incidence of IFD of 1% [50]. In another study, spontaneous peritonitis was one of the most common infections reported in patients with liver cirrhosis, accounting for 3.5% of all infectious peritonitis [51].…”

“…Fungal peritonitis appeared in patients with more advanced liver disease than bacterial spontaneous peritonitis [51]. The important risk of fungal colonization in intensive care units for patients with cirrhosis could be partly explained by the common use of antimicrobial therapy in these patients [50]. Interestingly, a study of 128 patients with liver cirrhosis caused by chronic hepatitis B virus infection reported an association between the hepatitis B viral load and the risk of developing an IFD [52].…”