Surgical site infections are independently associated with the development of postoperative acute-on-chronic liver failure in liver cirrhosis

Abstract

Acute-on-chronic liver failure (ACLF) is associated with organ failure and high short-term mortality. Bacterial infections and surgery have been reported as major precipitants for ACLF. However, detailed characterization of postoperative infections after elective surgery in patients with liver cirrhosis and their impact on the development of ACLF have not been investigated yet. A total of 235 patients with cirrhosis without ACLF and proven bacterial infections undergoing elective surgery were included. The primary end point was the development of ACLF within 28 days after surgery, and secondary end points were infection development within 28 days and 3-month ACLF-related mortality. Cox regression analysis was used for identification of risk factors associated with ACLF development, infection development, and mortality. A total of 86 patients (37%) developed ACLF within 28 days after surgery. Patients with new postoperative infections had significantly higher rates of associated ACLF episodes within 28 days (51% vs. 24%, p < 0.001) and higher 3-month mortality (p < 0.05) than patients without postoperative infections. New infections after surgery [HR: 2.43 (1.59–3.71), p < 0.001] and organ/space surgical site infections [HR: 2.46 (1.26–4.80), p = 0.01] in particular were independent risk factors associated with ACLF development 28 days after surgery. Extensive procedures were associated with the development of new postoperative infection episodes within 28 days. Infections treated with initial appropriate empirical antibiotic strategies showed significantly improved survival. This study characterizes and identifies bacterial infections in general and organ/space surgical site infection in particular as precipitating events for the development of ACLF after elective surgery in patients with cirrhosis. Postoperative ACLF combined with infections leads to higher postoperative short-term mortality than each condition separately, especially in extensive procedures. Interdisciplinary care, early identification of postoperative ACLF and infections, and adequate, broad, and early treatment strategies are needed to improve postoperative outcome.

Cutting deep: Understanding the risks associated with postoperative infections in patients with cirrhosis

“…In this issue of Liver Transplantation, Chang et al describe the role of postoperative infections in general, and specifically organ/space surgical site infections (SSIs), as precipitating events for the development of ACLF in patients with cirrhosis undergoing elective surgeries. [2] In this study of 235 patients, 34% developed postoperative infections within 28 days of elective surgery. SSIs occurred in 32% of patients who developed postoperative infections, and 50% of these were classified as organ/space SSIs (occurring in any part of the body deeper than the fascial/muscle layers manipulated during the procedure).…”

“…In this issue of Liver Transplantation , Chang et al describe the role of postoperative infections in general, and specifically organ/space surgical site infections (SSIs), as precipitating events for the development of ACLF in patients with cirrhosis undergoing elective surgeries 2 . In this study of 235 patients, 34% developed postoperative infections within 28 days of elective surgery.…”

“…[1] Recent data also suggest that surgery may precipitate ACLF, conveying survival outcomes in patients developing postoperative ACLF similar to those of patients undergoing surgery during an episode of ACLF. [2] Prior work has identified the development of postoperative infections as a risk factor for hepatic decompensation in patients with cirrhosis, though data evaluating the association between postoperative infections and the development of ACLF are limited.…”

“…Bacterial infections in patients with cirrhosis are known precipitants of acute-on-chronic liver failure (ACLF), a clinical entity characterized by systemic inflammation, organ failures, and high short-term mortality 1 . Recent data also suggest that surgery may precipitate ACLF, conveying survival outcomes in patients developing postoperative ACLF similar to those of patients undergoing surgery during an episode of ACLF 2 . Prior work has identified the development of postoperative infections as a risk factor for hepatic decompensation in patients with cirrhosis, though data evaluating the association between postoperative infections and the development of ACLF are limited.…”

Operating under pressure: Is there a place for preoperative TIPS?

“…demonstrated that surgical site infections (occurring in any part of the body deeper than the fascial/muscle layers manipulated during the procedure) precipitate ACLF and more than double its risk. 9 Yet, adequate empiric antibiotic therapy improved 6-month survival. These findings are supported by the PREDICT study, which identified bacterial infections as the main precipitants of ACLF development in hospitalized patients with cirrhosis.…”