Department of Medicine, Unit of Internal Medicine and Hepatology (UIMH), University of Padova, Padova, Italy.
Department of Medical and Surgical Sciences, Infectious Diseases Unit, Alma Mater Studiorum University of Bologna, Bologna, Italy.
Gut. 2018 Oct;67(10):1892-1899. doi: 10.1136/gutjnl-2017-314324. Epub 2017 Aug 31.
Patients with cirrhosis have a high risk of sepsis, which confers a poor prognosis. The systemic inflammatory response syndrome (SIRS) criteria have several limitations in cirrhosis. Recently, new criteria for sepsis (Sepsis-3) have been suggested in the general population (increase of Sequential Organ Failure Assessment (SOFA) ≥2 points from baseline). Outside the intensive care unit (ICU), the quick SOFA (qSOFA (at least two among alteration in mental status, systolic blood pressure ≤100 mm Hg or respiratory rate ≥22/min)) was suggested to screen for sepsis. These criteria have never been evaluated in patients with cirrhosis. The aim of the study was to assess the ability of Sepsis-3 criteria in predicting in-hospital mortality in patients with cirrhosis and bacterial/fungal infections.
259 consecutive patients with cirrhosis and bacterial/fungal infections were prospectively included. Demographic, laboratory and microbiological data were collected at diagnosis of infection. Baseline SOFA was assessed using preadmission data. Patients were followed up until death, liver transplantation or discharge. Findings were externally validated (197 patients).
Sepsis-3 and qSOFA had significantly greater discrimination for in-hospital mortality (area under the receiver operating characteristic (AUROC)=0.784 and 0.732, respectively) than SIRS (AUROC=0.606) (p<0.01 for both). Similar results were observed in the validation cohort. Sepsis-3 (subdistribution HR (sHR)=5.47; p=0.006), qSOFA (sHR=1.99; p=0.020), Chronic Liver Failure Consortium Acute Decompensation score (sHR=1.05; p=0.001) and C reactive protein (sHR=1.01;p=0.034) were found to be independent predictors of in-hospital mortality. Patients with Sepsis-3 had higher incidence of acute-on-chronic liver failure, septic shock and transfer to ICU than those without Sepsis-3.
Sepsis-3 criteria are more accurate than SIRS criteria in predicting the severity of infections in patients with cirrhosis. qSOFA is a useful bedside tool to assess risk for worse outcomes in these patients. Patients with Sepsis-3 and positive qSOFA deserve more intensive management and strict surveillance.
肝硬化患者发生脓毒症的风险很高，预后不良。全身炎症反应综合征（SIRS）标准在肝硬化中有多种局限性。最近，一般人群中提出了新的脓毒症（Sepsis-3）标准（从基线开始，序贯器官衰竭评估（SOFA）增加≥2 分）。在重症监护病房（ICU）外，建议使用快速 SOFA（qSOFA（至少有两项改变精神状态、收缩压≤100mmHg 或呼吸频率≥22/min））来筛查脓毒症。这些标准从未在肝硬化患者中进行过评估。本研究的目的是评估 Sepsis-3 标准预测肝硬化合并细菌/真菌感染患者住院死亡率的能力。
前瞻性纳入 259 例肝硬化合并细菌/真菌感染患者。在感染诊断时收集人口统计学、实验室和微生物学数据。使用入院前数据评估基线 SOFA。对患者进行随访，直至死亡、肝移植或出院。结果在外部队列中进行了验证（197 例患者）。
Sepsis-3 和 qSOFA 对住院死亡率的预测具有显著更高的区分度（受试者工作特征曲线下面积（AUROC）分别为 0.784 和 0.732），而 SIRS（AUROC=0.606）（两者均 p<0.01）。在验证队列中也观察到了类似的结果。Sepsis-3（亚分布风险比（sHR）=5.47；p=0.006）、qSOFA（sHR=1.99；p=0.020）、慢性肝脏衰竭联盟急性失代偿评分（sHR=1.05；p=0.001）和 C 反应蛋白（sHR=1.01；p=0.034）被发现是住院死亡率的独立预测因子。与无 Sepsis-3 的患者相比，Sepsis-3 的患者发生慢加急性肝衰竭、感染性休克和转入 ICU 的发生率更高。
Sepsis-3 标准比 SIRS 标准更能准确预测肝硬化患者感染的严重程度。qSOFA 是一种有用的床边工具，可评估这些患者发生不良结局的风险。有 Sepsis-3 和阳性 qSOFA 的患者需要更强化的管理和严格的监测。
