Update on diagnosis and management of sepsis in cirrhosis: Current advances

Philips, Cyriac Abby; Ahamed, Rizwan; Rajesh, Sasidharan; George, Tom; Mohanan, Meera; Augustine, Philip

doi:10.4254/wjh.v12.i8.451

Cited by 16 publications

(16 citation statements)

References 87 publications

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“…The CDI induced sepsis can lead to new-onset or worsening of the pre-existing decompensation of liver cirrhosis leading to high mortality rate. 17 Liver cirrhosis can affect mortality in patients with CDI irrespective of the severity of the illness. Hence, it is worthwhile to evaluate for escalation of the antibiotics therapy for CDI in patients with liver cirrhosis.…”

Section: Discussionmentioning

confidence: 99%

Clostridioides difficile Infection and Liver Cirrhosis – A Retrospective, Cohort Study

Mantri

Patel

Badipatla

et al. 2021

CEG

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Purpose Clostridioides difficile infection (CDI) is one of the most common health care-associated infections in the United States. Studies revealed a higher mortality when CDI is associated with liver cirrhosis. We aim to present the outcomes of CDI among patients with and without liver cirrhosis and to analyze the association of Model for End-Stage Liver Disease (MELD) and Child-Pugh (CPT) scoring with the severity of CDI. Methods A retrospective observational study was conducted in hospitalized patients with CDI diagnosed via a 2-step method – glutamate dehydrogenase (GDH) and toxin polymerase chain reaction (PCR). Patients with liver cirrhosis were identified based on ICD codes and chart review. MELD and CPT scores were calculated using laboratory parameters at the time of hospitalization. We compared CDI-related mortality in patients with and without cirrhosis and reviewed the CDI severity distribution in cirrhosis patients. Results A total of 526 patients were included in the study, of which 478 (90.87%) were non-cirrhotic and 48 (9.13%) were cirrhotic patients. Mortality rate was higher in cirrhosis group compared to the non-cirrhosis group (39.6% vs. 14.6%,P = 0.001). Among cirrhosis patients, those who survived had lower MELD score compared to the expired group (14.9 vs. 18.58, P = 0.106). There was no correlation of mortality based on CPT score in the cirrhosis group (P = 0.062). In post hoc analysis comparing the severity of CDI to liver cirrhosis, cirrhosis patients are more likely to present with severe-complicated disease. Multivariate logistic regression identified liver cirrhosis, severe-complicated CDI and serum albumin level as independent predictors of mortality. Conclusion Our study noted a more severe disease presentation and higher mortality in patients with cirrhosis admitted with CDI. Further studies are required for better understanding of the clinical course of CDI in cirrhosis and to evaluate the need for early intervention in this patient group.

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Section: Discussionmentioning

confidence: 99%

Clostridioides difficile Infection and Liver Cirrhosis – A Retrospective, Cohort Study

Mantri

Patel

Badipatla

et al. 2021

CEG

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“…Irrespective of liver disease aetiology, multiple factors predispose cirrhotic patients to bacteraemia; including increased translocation of gut-resident bacteria, 5 cirrhosis-associated immune dysfunction 6 and the requirement for invasive procedures or indwelling devices during hospitalisation. Bacterial infections may lead to sepsis (defined as suspected or confirmed infection in the presence of an organ failure) 7 and may precipitate or worsen hepatic decompensation.…”

Section: Introductionmentioning

confidence: 99%

Bacteraemia, sepsis and antibiotic resistance in Australian patients with cirrhosis: a population-based study

Johnson

Ratnasekera

Irvine

et al. 2021

BMJ Open Gastroenterol

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ObjectiveMultiple factors predispose patients with cirrhosis to sepsis and/or bacteraemia and this has a high mortality rate. Within different geographical regions there are marked differences in the prevalence of infection with multidrug-resistant organisms (MDR). This study examined risk factors for and outcomes of sepsis/bacteraemia in public hospital admissions with cirrhosis in the state of Queensland, Australia, over the last decade, along with the bacterial pathogens responsible and their antibiotic susceptibility profiles.DesignA population-based retrospective cohort study of public hospital admissions was conducted from 1 January 2008 to 31 December 2017. Hospital admissions for patients with a diagnosis of cirrhosis were categorised by the presence or absence of sepsis/bacteraemia. Clinical and sociodemographic information including cirrhosis aetiology, complications and comorbidities, and in-hospital mortality were examined using bivariate and multivariate analyses. In patients with bacteraemia, the type and prevalence of bacteria and antibiotic resistance was assessed.ResultsSepsis/bacteraemia was present in 3951 of 103 165 hospital admissions with a diagnosis of cirrhosis. Factors associated with sepsis/bacteraemia included disease aetiology, particularly primary sclerosing cholangitis (adj-OR 15.09, 95% CI 12.24 to 18.60), alcohol (adj-OR 2.90, 95% CI 2.71 to 3.09), Charlson Comorbidity Index ≥3 (adj-OR 3.54, 95% CI 3.19 to 3.93) and diabetes (adj-OR 1.87, 95% CI 1.74 to 2.01). Overall case-fatality rate among admissions with sepsis/bacteraemia was 27.7% (95% CI 26.3% to 29.1%) vs 3.7% (95% CI 3.6% to 3.8%) without sepsis/bacteraemia. In-hospital death was significantly associated with sepsis/bacteraemia (adj-OR 6.50, 95% CI 5.95 to 7.11). The most common organisms identified were Escherichia coli and Staphylococcus aureus, present in 22.9% and 18.1%, respectively, of the 2265 admissions with a positive blood culture. The prevalence of MDR bacteria was low (5.6%)ConclusionMorbidity and mortality related to sepsis/bacteraemia in patients with cirrhosis remains a critical clinical problem.

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“…All critically ill patients with COVID-19 and cirrhosis can be considered to have ACLF and must be managed as per the general rules and recommendations for ACLF inclusive of specific considerations for COVID-19 treatment. 107,108 Generally, as per current evidence, the following measures are advisable for critically ill patients with cirrhosis and COVID-19: [109][110][111][112] The lowest possible fraction of inspired oxygen should ideally target a peripheral oxygen saturation level of 90-96%, even in those with hepatopulmonary syndrome.…”

Section: Covid-19 Treatment In Advanced Cirrhosis Including Liver Transplant-listed Patientsmentioning

confidence: 99%

Section: Treatment and Managementmentioning

confidence: 99%

Critical Update on the Diagnosis and Management of COVID-19 in Advanced Cirrhosis and Liver Transplant Recipients

Philips¹,

Rela²,

Soin³

et al. 2021

Journal of Clinical and Translational Hepatology

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The novel coronavirus disease 2019 (COVID-19) pandemic has impacted health care worldwide, with specific patient populations, such as those with diabetes, cardiovascular disease, and chronic lung disease, at higher risk of infection and others at higher risk of disease progression. Patients with decompensated cirrhosis fall into the latter category and are a unique group that require specific treatment and management decisions because they can develop acute-on-chronic liver failure. In liver transplant recipients, the atypical immunity profile due to immunosuppression protects against downstream inflammatory responses triggered by COVID-19. This exhaustive review discusses the outcomes associated with COVID-19 in patients with advanced cirrhosis and in liver transplant recipients. We focus on the immunopathogenesis of COVID-19, its correlation with the pathogenesis of advanced liver disease, and the effect of immunosuppression in liver transplant recipients to provide insight into the outcomes of this unique patient population.

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Update on diagnosis and management of sepsis in cirrhosis: Current advances

Cited by 16 publications

References 87 publications

Clostridioides difficile Infection and Liver Cirrhosis – A Retrospective, Cohort Study

Clostridioides difficile Infection and Liver Cirrhosis – A Retrospective, Cohort Study

Bacteraemia, sepsis and antibiotic resistance in Australian patients with cirrhosis: a population-based study

Critical Update on the Diagnosis and Management of COVID-19 in Advanced Cirrhosis and Liver Transplant Recipients

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