Hepatology International

, Volume 5, Issue 3, pp 800–807 | Cite as

Risk factors for mortality in cirrhotic patients with sepsis

  • Lee-Guan Lim
  • Xiang-Xuan Eunice Tan
  • Shu-Jeng Woo
  • Yock-Young Dan
  • Yin-Mei Lee
  • Vincent Lai
  • Seng-Gee Lim
Original Article



Patients with cirrhosis and sepsis had increased mortality.


Determine factors associated with increased in-hospital mortality in cirrhotic patients admitted for sepsis.


All cirrhotic patients admitted from 2004 to 2007 for sepsis were identified from hospital electronic database. Patients were included if they had liver cirrhosis and sepsis, defined as identified sources of infection, and at least one of fever, altered total white cell count, or raised C-reactive protein. Baseline characteristics, investigations, infections, and outcomes were collected. Main outcome measure was in-hospital mortality.


A total of 205 admissions in 153 patients were included. In-hospital mortality rate was 24.4%. In predicting in-hospital death, area under the receiver-operating-characteristic curve for Child-Pugh score was 0.934, with optimum cut-off at 10 and above, while for model for end-stage liver disease (MELD) score was 0.751, with optimum cut-off at 17 and above. Four factors were significantly associated with in-hospital mortality on multivariate analysis: presence of >1 site of infection, pneumonia, Child’s C status, and MELD score 17 and above. In-hospital mortality rate increased with more factors: 0% with no factor, 7% with one factor, 21% with two factors, 87% with three factors, and 100% with four factors. The mortality of those with <3 risk factors was significantly lower than those with three or more risk factors (7 vs. 91%, p = 0.000).


Septic cirrhotic patients with pneumonia, >1 site of infection, Child’s C cirrhosis, and high MELD score had a high mortality risk.


Pneumonia Infection MELD Child-Pugh score 


Conflict of interest

No conflicts of interests exist.


  1. 1.
    Navasa M, Fernandez J, Rodes J. Bacterial infections in liver cirrhosis. Ital J Gastroenterol Hepatol 1999;31:616–625Google Scholar
  2. 2.
    Foreman MG, Mannino DM, Moss M. Cirrhosis as a risk factor for sepsis and death: analysis of the National Hospital Discharge Survey. Chest 2003;124:1016–1020Google Scholar
  3. 3.
    Fernandez J, Navasa M, Gomez J, et al. Bacterial infections in cirrhosis: epidemiological changes with invasive procedures and norfloxacin prophylaxis. Hepatology 2002;35(1):140–148Google Scholar
  4. 4.
    Gines P, Rimola A, Planas R, et al. Norfloxacin prevents spontaneous bacterial peritonitis recurrence in cirrhosis: Results of a double-blind, placebo-controlled trial. Hepatology 1990;12(4 Pt 1):716–724Google Scholar
  5. 5.
    Moore KP, Aithal GP. Guidelines on the management of ascites in cirrhosis. Gut 2006;55:1–12Google Scholar
  6. 6.
    Runyon BA. Management of adult patients with ascites due to cirrhosis. Hepatology 2004;39(3):841–856Google Scholar
  7. 7.
    Bone RC, Balk RA, Cerra FB, et al. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 1992;101:1644–1655Google Scholar
  8. 8.
    Wong F, Bernardi M, Balk R, et al. International Ascites Club. Sepsis in cirrhosis: report on the 7th meeting of the International Ascites Club. Gut 2005;54(5):718–725Google Scholar
  9. 9.
    Park WB, Lee KD, Lee CS, et al. Production of C-reactive protein in Escherichia coli-infected patients with liver dysfunction due to liver cirrhosis. Diagn Microbiol Infect Dis 2005;51:227–230Google Scholar
  10. 10.
    Hooton TM, Stamm WE. Diagnosis and treatment of uncomplicated urinary tract infection. Infect Dis Clin North Am 1997;11(3):551–581Google Scholar
  11. 11.
    Armitage K, Woodhead M. New guidelines for the management of adult community-acquired pneumonia. Curr Opin Infect Dis 2007;20(2):170–176Google Scholar
  12. 12.
    Aggarwal A, Ong JP, Younossi ZM, Nelson DR, Hoffman-Hogg L, Arroliga AC. Predictors of mortality and resource utilization in cirrhotic patients admitted to the medical ICU. Chest 2001;119(5):1489–1497Google Scholar
  13. 13.
    Mellencamp MA, Preheim LC. Pneumococcal pneumonia in a rat model of cirrhosis: effects of cirrhosis on pulmonary defense mechanisms against Streptococcus pneumoniae. J Infect Dis 1991;163(1):102–108Google Scholar
  14. 14.
    Wallaert B, Aerts C, Colombel JF, Voisin C. Human alveolar macrophage antibacterial activity in the alcoholic lung. Am Rev Respir Dis 1991;144:278–283Google Scholar
  15. 15.
    Gosset P, Wallaert B, Canva-Delacambre JF, Colombel JF, Tonnel AB. Impaired secretion and mRNA expression of monokines by alveolar macrophages from nonsmoking patients with alcoholic liver cirrhosis. J Infect Dis 1995;171:743–746Google Scholar
  16. 16.
    Feikin DR, Schuchat A, Kolczak M, et al. Mortality from invasive pneumococcal pneumonia in the era of antibiotic resistance, 1995–1997. Am J Public Health 2000;90(2):223–229Google Scholar
  17. 17.
    Caly WR, Strauss E. A prospective study of bacterial infections in patients with cirrhosis. J Hepatol 1993;18:353–358Google Scholar
  18. 18.
    Such J, Frances R, Munoz C, et al. Detection and identification of bacterial DNA in patients with cirrhosis and culture-negative, nonneutrocytic ascites. Hepatology 2002;36(1):135–141Google Scholar
  19. 19.
    Cirera I, Bauer TM, Navasa M, et al. Bacterial translocation of enteric organisms in patients with cirrhosis. J Hepatol 2001;34:32–37Google Scholar
  20. 20.
    Rimola A, Soto R, Bory F, et al. Reticuloendothelial system phagocytic activity in cirrhosis and its relation to bacterial infections and prognosis. Hepatology 1984;4:53–58Google Scholar
  21. 21.
    Fiuza C, Salcedo M, Clemente G, et al. In vivo neutrophil dysfunction in cirrhotic patients with advanced liver disease. J Infect Dis 2000;182:526–533Google Scholar
  22. 22.
    Byl B, Roucloux I, Crusiaux A, et al. Tumor necrosis factor alpha and interleukin 6 plasma levels in infected cirrhotic patients. Gastroenterology 1993;104:1492–1497Google Scholar
  23. 23.
    Herzig SJ, Howell MD, Ngo LH, Marcantonio ER. Acid-suppressive medication use and the risk for hospital-acquired pneumonia. JAMA 2009;301(20):2120–2128Google Scholar
  24. 24.
    Bajaj JS, Zadvornova Y, Heuman DM, et al. Association of proton pump inhibitor therapy with spontaneous bacterial peritonitis in cirrhotic patients with ascites. Am J Gastroenterol 2009;104:1130–1134Google Scholar
  25. 25.
    Wiest R, Garcia-Tsao G. Bacterial translocation (BT) in cirrhosis. Hepatology 2005,41(3):422–433Google Scholar
  26. 26.
    Wiesner R, Edwards E, Freeman R, et al. The United Network for Organ Sharing Liver Disease Severity Score Committee. Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroenterology 2003;124:91Google Scholar
  27. 27.
    Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, et al. A model to predict survival in patients with end-stage liver disease. Hepatology 2001;33:464–470Google Scholar
  28. 28.
    Cazzaniga M, Dionigi E, Gobbo G, Fioretti A, Monti V, Salerno F. The systemic inflammatory response syndrome in cirrhotic patients: relationship with their in-hospital outcome. J Hepatol 2009;51(3):475–482Google Scholar
  29. 29.
    Tsiakalos A, Karatzaferis A, Ziakas P, Hatzis G. Acute-phase proteins as indicators of bacterial infection in patients with cirrhosis. Liver Int 2009;29(10):1538–1542Google Scholar

Copyright information

© Asian Pacific Association for the Study of the Liver 2011

Authors and Affiliations

  • Lee-Guan Lim
    • 1
  • Xiang-Xuan Eunice Tan
    • 2
  • Shu-Jeng Woo
    • 1
  • Yock-Young Dan
    • 1
  • Yin-Mei Lee
    • 1
  • Vincent Lai
    • 1
  • Seng-Gee Lim
    • 1
  1. 1.Department of Gastroenterology and HepatologyNational University Health SystemSingaporeSingapore
  2. 2.National University of Singapore High SchoolSingaporeSingapore

Personalised recommendations