Skip to main content

Advertisement

SpringerLink
Log in

A multicenter prospective study of infections related morbidity and mortality in cirrhosis of liver

  • Original Article
  • Published:
Indian Journal of Gastroenterology Aims and scope Submit manuscript

Abstract

Background and Aims

Infections are a common and serious complication among patients with cirrhosis. We assessed the epidemiology, risk factors, and clinical consequences of bacterial infections in cirrhotic patients.

Methods

In this multicenter prospective study, all patients with cirrhosis of liver with different infections were analyzed. Infections were classified as community-acquired (CA), healthcare-associated (HCA), or hospital-acquired (HA). Site of infection and characteristics of bacteria were recorded; effect on liver function and 30-day survival were evaluated.

Results

One hundred and six out of 420 (25 %) patients with cirrhosis of liver had infection. Infection rate among indoor patients was 37.5 % (92/245) and among outdoor patients was 8 % (14/175). Out of 106 patients, CA, HCA, and HA were seen in 19.8 %, 50 %, and 30.2 %, respectively. Spontaneous bacterial peritonitis (31.1 %), urinary tract infections (22.6 %), and pneumonia and cellulitis (11.3 % each) were common infections. Gram-negative bacteria (54 %) were more common than Gram-positive cocci (46 %). Multidrug resistant (MDR) organisms were seen in 41.7 % of patients. Most of the MDR organisms were seen in HCA and HA patients. The degree of liver impairment was significantly more severe in patients with infection. Independent predictor of infection was high Child-Turcott-Pugh (CTP) class (p = 0.006, Child B vs. A (odds ratio (OR) 3.04 95 % CI = 1.63 to 5.68) and Child C vs. A (OR 4.17 95 % CI = 2.12 to 8.19). Overall in-hospital mortality was 7.6 %. Patients with infection had increased mortality at 30-day follow up compared to those without infection (23.5 % vs. 2.2 %; p<0.001).

Conclusions

Infections are one of the important causes of morbidity and mortality in patients with cirrhosis of liver. The most frequent infections are HCA and HA. Infection predisposes to deterioration of liver function and increases mortality. Cirrhotic patients should be monitored closely for infections especially those with Child class B and C.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  1. Bajaj JS, O'Leary JG, Wong FK, Reddy KR, Kamath PS. Bacterial infections in end-stage liver disease: current challenges and future directions. Gut. 2012;61:1219–25.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  2. Wong F, Bernardi M, Balk R, et al. Sepsis in cirrhosis: report on the 7th meeting of the International Ascites Club. Gut. 2005;54:718–25.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  3. Caly WR, Strauss E. A prospective study of bacterial infections in patients with cirrhosis. J Hepatol. 1993;18:353–8.

    Article  CAS  PubMed  Google Scholar 

  4. Arvaniti V, D’Amico G, Fede G, et al. Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis. Gastroenterology. 2010;139:1246–56.

    Article  PubMed  Google Scholar 

  5. Fernandez J, Navasa M, Gomez J, et al. Bacterial infections in cirrhosis: epidemiological changes with invasive procedures and norfloxacin prophylaxis. Hepatology. 2002;35:140–8.

    Article  PubMed  Google Scholar 

  6. Merli M, Lucidi C, Giannelli V, et al. Cirrhotic patients are at risk for HCA bacterial infections. Clin Gastroenterol Hepatol. 2010;8:979–85.

    Article  PubMed  Google Scholar 

  7. Fernandez J, Acevedo J, Castro M, et al. Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study. Hepatology. 2012;55:1551–61.

    Article  PubMed  Google Scholar 

  8. Campillo B, Dupeyron C, Richardet JP, Mangeney N, Georges L. Epidemiology of severe hospital-acquired infections in patients with liver cirrhosis: effect of long-term administration of norfloxacin. Clini Infect Dis. 1998;26:1066–70.

    Article  CAS  Google Scholar 

  9. Bajaj JS, O’Leary JG, Reddy KR, et al. Second infections independently increase mortality in hospitalized patients with cirrhosis: the North American consortium for the study of end-stage liver disease (NACSELD) experience. Hepatology. 2012;56:2328–35.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  10. Jain AK, Sircar S, Jain M, Adkar S, Waghmare C, Chahwala F. Acute febrile illness in cirrhosis—thinking beyond spontaneous bacterial peritonitis. Trop Doct. 2012;42:200–2.

    PubMed  Google Scholar 

  11. Mohan P, Ramu B, Bhaskar E, Venkataraman J. Prevalence and risk factors for bacterial skin infection and mortality in cirrhosis. Ann Hepatol. 2011;10:15–20.

    PubMed  Google Scholar 

  12. Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg. 1973;60:646–9.

    Article  CAS  PubMed  Google Scholar 

  13. Kamath PS, Wiesner RH, Malinchoc M, et al. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001;33:464–70.

    Article  CAS  PubMed  Google Scholar 

  14. Guarner C, Soriano G. Spontaneous bacterial peritonitis. Sem Liver Dis. 1997;17:203–17.

    Article  CAS  Google Scholar 

  15. Runyon BA, Canawati HN, Akriviadis EA. Optimization of ascitic fluid culture technique. Gastroenterology. 1988;95:1351–5.

    CAS  PubMed  Google Scholar 

  16. Salerno F, Gerbes A, Gines P, Wong F, Arroyo V. Diagnosis, prevention and treatment of hepatorenal syndrome in cirrhosis. Gut. 2007;56:1310–18.

    CAS  PubMed Central  PubMed  Google Scholar 

  17. Conn HO, Leevy CM, Vlahcevic ZR, et al. Comparison of lactulose and neomycin in the treatment of chronic portal systemic encephalopathy. A double blind controlled trial. Gastroenterology. 1977;72:573–83.

    CAS  PubMed  Google Scholar 

  18. Sarin SK, Kumar A, Almeida JA, et al. Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific Association for the study of the liver (APASL). Hepatol Int. 2009;3:269–82.

    Article  PubMed Central  PubMed  Google Scholar 

  19. Lo GH, Lai KH, Shen MT, Chang CF. A comparison of the incidence of transient bacteremia and infectious sequelae after sclerotherapy and rubber band ligation of bleeding esophageal varices. Gastrointest Endosc. 1994;40:675–9.

    CAS  PubMed  Google Scholar 

  20. Rimola A, Navasa M. Infections in liver disease. In: Bircher J, Benhamou JP, McIntyre N, Rizzetto M, Rodes J, (eds). Oxford Textbook of Clinical Hepatology. 2nd ed. Oxford: Oxford University Press; 1999. pp.1861–74.

    Google Scholar 

  21. Llach J, Elizalde JI, Bordas JM, et al. Prospective assessment of the risk of bacteremia in cirrhotic patients undergoing lower intestinal endoscopy. Gastrointest Endosc. 1999;49:214–17.

    Article  CAS  PubMed  Google Scholar 

  22. Sobel JD, Kaye D. Urinary tract infections. In: Mandell GL, Bennett JE, Dolin R, (eds). Principles and Practice of Infectious Diseases. 4th ed. New York: Churchill Livingstone; 1995. pp. 662–90.

    Google Scholar 

  23. Friedman ND, Kaye KS, Stout JE, et al. Health care associated bloodstream infections in adults: a reason to change the accepted definition of CA infections. Ann Intern Med. 2002;137:791–7.

    Article  PubMed  Google Scholar 

  24. Valenti WM, Chiarello LA. Overview of hospital infection control and nosocomial infections. In: Resse RE, Douglas RG Jr, (eds). A Practical Approach to Infectious Diseases. Boston, MA: Lippincott; 1986. pp. 545–55.

    Google Scholar 

  25. Dellinger RP, Levy MM, Rhodes A, et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;39:165–228.

    Article  CAS  PubMed  Google Scholar 

  26. Falagas ME, Koletsi PK, Bliziotis IA. The diversity of definitions of multidrug-resistant (MDR) and pandrug-resistant (PDR) Acineto-bacter baumannii and Pseudomonas aeruginosa. J Med Microbiol. 2006;55:1619–29.

    Article  CAS  PubMed  Google Scholar 

  27. Rupp ME, Fey PD. Extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae: considerations for diagnosis, prevention and drug treatment. Drugs. 2003;63:353–65.

    Article  CAS  PubMed  Google Scholar 

  28. Fasolato S, Angeli P, Dallagnese L, et al. Renal failure and bacterial infections in patients with cirrhosis: epidemiology and clinical features. Hepatology. 2007;45:223–9.

    Article  PubMed  Google Scholar 

  29. Gustot T, Durand F, Lebrec D, Vincent JL, Moreau R. Severe sepsis in cirrhosis. Hepatology. 2009;50:2022–33.

    Article  CAS  PubMed  Google Scholar 

  30. Garcia Tsao G, Wiest R. Gut microflora in the pathogenesis of the complications of cirrhosis. Best Pract Res Clin Gastroenterol. 2004;18:353–72.

    Article  PubMed  Google Scholar 

  31. Taneja SK, Dhiman RK. Prevention and management of bacterial infections in cirrhosis. Int J Hepatol. 2011;2011:784540.

    Article  PubMed Central  PubMed  Google Scholar 

  32. Goulis J, Armonis A, Patch D, Sabin C, Greenslade L, Burroughs AK. Bacterial infection is independently associated with failure to control bleeding in cirrhotic patients with gastrointestinal hemorrhage. Hepatology. 1998;27:1207–12.

    Article  CAS  PubMed  Google Scholar 

  33. Rongey C, Lim NH, Runyon BA. Cellulitis in patients with cirrhosis and edema: an under-recognized complication currently more common that spontaneous bacterial peritonitis. Open Gastro J. 2008;2:24–7.

    Article  Google Scholar 

  34. Runyon BA. AASLD Practice Guidelines Committee. Management of adult patients with ascites due to cirrhosis: an update. Hepatology. 2012;49:2087–107.

    Article  Google Scholar 

  35. Perez PM, Munoz J, Albillos A, et al. Effect of propranolol on the factors promoting bacterial translocation in cirrhotic rats with ascites. Hepatology. 2000;31:43–8.

    Article  Google Scholar 

  36. Reiberger T, Ferlitsch A, Payer BA, et al. Nonselective beta-blocker therapy decreases intestinal permeability and serum levels of LBP and IL-6 in patients with cirrhosis. J Hepatol. 2012;58:911–21.

    Article  PubMed  Google Scholar 

  37. Bajaj JS, Ratliff SM, Heuman DM, Lapane KL. Non-selective beta-blockers are not associated with serious infections in veterans with cirrhosis. Aliment Pharmacol Ther. 2013;38:407–14.

    Article  CAS  PubMed  Google Scholar 

  38. Bajaj JS, Ratliff SM, Heuman DM, Lapane KL. Proton pump inhibitors are associated with a high rate of serious infections in veterans with decompensated cirrhosis. Aliment Pharmacol Ther. 2012;36:866–74.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  39. Tandon P, Garcia-Tsao G. Bacterial infections, sepsis, and multiorgan failure in cirrhosis. Semin Liver Dis. 2008;28:26–42.

    Article  CAS  PubMed  Google Scholar 

  40. Christou L, Pappas G, Falagas ME. Bacterial infection-related morbidity andmortality in cirrhosis. Am J Gastroenterol. 2007;102:1510–17.

    Article  PubMed  Google Scholar 

  41. Jun DW, Kim KT, Lee OY, et al. Association between small intestinal bacterial overgrowth and peripheral bacterial DNA in cirrhotic patients. Dig Dis Sci. 2010;55:1465–71.

    Article  CAS  PubMed  Google Scholar 

Download references

Conflict of interest

RB, DA, HRPK, SK, NS, SD, DG, MJ, NP, PK, SKI, MD, AS, MC, and SG declare that they have no conflict of interest.

Ethics statement

The study was performed in a manner to conform with the Helsinki Declaration of 1975, as revised in 2000 and 2008 concerning Human and Animal Rights and that the authors followed the policy concerning informed consent as shown on Springer.com.

Author information

Authors and Affiliations

  1. Department of Gastroenterology, Jagjivan Ram Hospital, Maratha Mandir Marg, Mumbai Central, Mumbai, 400 008, India

    Rajiv Baijal, Deepak Amarapurkar, H. R. Praveen Kumar, Sandeep Kulkarni, Nimish Shah, Soham Doshi & Deepak Gupta

  2. Department of Gastroenterology, Bombay Hospital and Research Centre, 12 Marine Lines, Mumbai, 400 020, India

    Deepak Amarapurkar, Mrudul Dharod, Apoorva Shah, Madhuri Chandnani & Sonali Gautam

  3. Department of Gastroenterology, Choitram Hospital and Research Center, Manik Bagh Road, Indore, 452 014, India

    Mayank Jain

  4. Jeevandeep Hospital, 64-B, Opp. Shubhlaxmi Shopping Centre, Station Road, Anand, 388 001, Gujarat, India

    Nikhil Patel

  5. Department of Gastroenterology, Wockhardt Hospital, No 2, Parasmani Bunglow, University Road, Panchayat Nagar, Rajkot, 360 005, India

    Praful Kamani

  6. Department of Gastroenterology, Jawaharlal Nehru Hospital and Research Centre, W Hospital Ave, Hospital Sector, Bhilai, Chhattisgarh, 490 009, India

    S. K. Issar

Authors
  1. Rajiv Baijal
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Deepak Amarapurkar
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. H. R. Praveen Kumar
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sandeep Kulkarni
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Nimish Shah
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Soham Doshi
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Deepak Gupta
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Mayank Jain
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Nikhil Patel
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Praful Kamani
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. S. K. Issar
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Mrudul Dharod
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Apoorva Shah
    View author publications

    You can also search for this author in PubMed Google Scholar

  14. Madhuri Chandnani
    View author publications

    You can also search for this author in PubMed Google Scholar

  15. Sonali Gautam
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sandeep Kulkarni.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Baijal, R., Amarapurkar, D., Praveen Kumar, H.R. et al. A multicenter prospective study of infections related morbidity and mortality in cirrhosis of liver. Indian J Gastroenterol 33, 336–342 (2014). https://doi.org/10.1007/s12664-014-0461-3

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12664-014-0461-3

Keywords

Search

Navigation