Louvet Alexandre, Wartel Faustine, Castel Hélène, Dharancy Sébastien, Hollebecque Antoine, Canva-Delcambre Valérie, Deltenre Pierre, Mathurin Philippe
Service des Maladies de l'Appareil digestif, Hôpital Huriez, Lille, France.
Gastroenterology. 2009 Aug;137(2):541-8. doi: 10.1053/j.gastro.2009.04.062. Epub 2009 May 13.
BACKGROUND & AIMS: In severe (Maddrey score >or=32) alcoholic hepatitis (AH), infection is classically viewed as a contraindication for corticosteroids, although specific data are lacking. This study's aims were (1) to evaluate the incidence of infection in patients with severe AH before and after corticosteroid treatment; (2) to determine whether infection contraindicates corticosteroids; and (3) to focus on predictive factors of development of infection.
At admission, systematic screening of infection consisted of chest x-ray and blood, ascites, and urinary cultures. All patients were treated with prednisolone. Response to steroids was defined using the Lille model.
Two hundred forty-six patients with severe AH were prospectively included. Infections at admission were as follows: 63 infections (25.6%) were diagnosed: 28 (44.4%) spontaneous bacterial peritonitis or bacteremia, 8 (12.7%) pulmonary infections, 20 (31.7%) urinary tract infections, and 7 (11.2%) other infections. Patients infected before using corticosteroids had 2-month survival similar to that of others: 70.9% +/- 6.1% vs 71.6% +/- 3.4%, respectively, P = .99. Development of infection after steroids: 57 patients (23.7%) developed infection: 16 (28.1%) spontaneous bacterial peritonitis or bacteremia, 23 (40.3%) pulmonary, 10 (17.5%) urinary tract, and 8 (14.1%) other infections. Infection occurred more frequently in nonresponders than in responders: 42.5% vs 11.1%, respectively, P < .000001. In multivariate analysis, only the Lille model (P = .0002) independently predicted infection upon steroids use. The Lille model (P = .000001) and Model for End-Stage Liver Disease score (P = .006) were independently associated with survival, whereas infection was not (P = .52).
Severe AH is associated with high risk of infection. Infection screening is warranted but should not contraindicate steroids. In terms of mechanisms, nonresponse to steroids is the key factor in development of infection and prediction of survival.
在严重（Maddrey评分≥32）酒精性肝炎（AH）中，尽管缺乏具体数据，但感染传统上被视为使用皮质类固醇的禁忌证。本研究的目的是：（1）评估严重AH患者在接受皮质类固醇治疗前后的感染发生率；（2）确定感染是否为皮质类固醇使用的禁忌证；（3）关注感染发生的预测因素。
入院时，系统性感染筛查包括胸部X线检查以及血液、腹水和尿液培养。所有患者均接受泼尼松龙治疗。使用Lille模型定义对类固醇的反应。
前瞻性纳入了246例严重AH患者。入院时的感染情况如下：共诊断出63例感染（25.6%）：28例（44.4%）自发性细菌性腹膜炎或菌血症，8例（12.7%）肺部感染，20例（31.7%）尿路感染，7例（11.2%）其他感染。在使用皮质类固醇之前感染的患者2个月生存率与其他患者相似：分别为70.9%±6.1%和71.6%±3.4%，P = 0.99。使用类固醇后发生感染的情况：57例患者（23.7%）发生感染：16例（28.1%）自发性细菌性腹膜炎或菌血症，23例（40.3%）肺部感染，10例（17.5%）尿路感染，8例（14.1%）其他感染。无反应者比有反应者感染更频繁：分别为42.5%和11.1%，P < 0.000001。在多变量分析中，只有Lille模型（P = 0.0002）能独立预测使用类固醇时的感染情况。Lille模型（P = 0.000001）和终末期肝病模型评分（P = 0.006）与生存率独立相关，而感染与生存率无关（P = 0.52）。
严重AH与高感染风险相关。有必要进行感染筛查，但不应将其作为类固醇使用的禁忌证。就机制而言，对类固醇无反应是感染发生和生存预测的关键因素。
