Garg Pratibha, Verma Nipun, Angrup Archana, Taneja Neelam, Valsan Arun, Reddy Venkata D, Agarwal Jayant, Chaudhary Roma, Kaur Parminder, Rathi Sahaj, De Arka, Premkumar Madhumita, Taneja Sunil, Duseja Ajay
Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Department of Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
J Clin Exp Hepatol. 2024 Jul-Aug;14(4):101352. doi: 10.1016/j.jceh.2024.101352. Epub 2024 Feb 5.
BACKGROUND/AIMS: This study delved into cirrhosis-related infections to unveil their epidemiology, risk factors, and implications for antimicrobial decisions.
We analyzed acutely decompensated cirrhosis patients (n = 971) from North India between 2013-2023 at a tertiary center. Microbiological and clinical features based on infection sites (EASL criteria) and patient outcomes were assessed.
Median age was 45 years; 87% were males with 47% having alcoholic hepatitis. Of these, 675 (69.5%) had infections; 305 (45%) were culture-confirmed. Notably, 71% of confirmed cases were multi-drug resistant organisms (MDRO)-related, chiefly carbapenem-resistant (48%). MDRO prevalence was highest in pulmonary (80.5%) and skin-soft-tissue infections (76.5%). Site-specific distribution and antimicrobials were suggested. Predictive models identified prior hospitalization [OR:2.23 (CI:1.58-3.14)], norfloxacin prophylaxis [OR:2.26 (CI:1.44-3.55)], prior broad-spectrum antibiotic exposure [OR:1.61 (CI:1.12-2.30)], presence of systemic inflammatory response-SIRS [OR:1.75 (CI: 1.23-2.47)], procalcitonin [OR:4.64 (CI:3.36-6.40)], and HE grade [OR:1.41 (CI:1.04-1.90)], with an area under curve; AUC of 0.891 for infection prediction. For MDRO infection prediction, second infection [OR: 7.19 (CI: 4.11-12.56)], norfloxacin prophylaxis [OR: 2.76 (CI: 1.84-4.13)], CLIF-C OF [OR: 1.10 (CI: 1.01-1.20)], prior broad-spectrum antibiotic exposure [OR: 1.66 (CI: 1.07-2.55)], rifaximin [OR: 040 (0.22-0.74)] multisite [OR: 3.67 (CI: 1.07-12.56)], and polymicrobial infection [OR: 4.55 (CI: 1.45-14.17)] yielded an AUC of 0.779 and 93% specificity. Norfloxacin prophylaxis, multisite infection, mechanical ventilation, prior broad-spectrum antibiotic exposure, and infection as acute precipitant predicted carbapenem-resistant infection (AUC: 0.821). Infections (culture-proven or probable), MDROs, carbapenem/pan-drug resistance, and second infections independently linked with mortality ( < 0.001), adjusted for age, leucocytosis, and organ failures. A model incorporating age [HR:1.02 (CI: 1.01-1.03), infection [HR:1.52 (CI: 1.05-2.20)], prior hospitalization [HR:5.33 (CI: 3.75-7.57)], norfloxacin [HR:1.29 (CI: 1.01-1.65)], multisite infection [HR:1.47 (CI:1.06-2.04)], and chronic liver failure consortium-organ failure score; CLIF-C OF [HR:1.17 (CI: 1.11-1.23)] predicted mortality with C-statistics of 0.782 ( < 0.05).
High MDRO burden, especially carbapenem-resistant, necessitates urgent control measures in cirrhosis. Site-specific epidemiology and risk models can guide empirical antimicrobial choices in cirrhosis management.
背景/目的：本研究深入探讨肝硬化相关感染，以揭示其流行病学、危险因素及其对抗菌药物决策的影响。
我们分析了2013年至2023年期间印度北部一家三级中心的971例急性失代偿性肝硬化患者。根据感染部位（欧洲肝脏研究学会标准）评估微生物学和临床特征以及患者预后。
中位年龄为45岁；87%为男性，47%患有酒精性肝炎。其中，675例（69.5%）发生感染；305例（45%）经培养确诊。值得注意的是，71%的确诊病例与多重耐药菌（MDRO）相关，主要是耐碳青霉烯类（48%）。MDRO在肺部感染（80.5%）和皮肤软组织感染（76.5%）中的患病率最高。提出了特定部位的分布及抗菌药物建议。预测模型确定了既往住院史[比值比：2.23（95%置信区间：1.58 - 3.14）]、诺氟沙星预防用药[比值比：2.26（95%置信区间：1.44 - 3.55）]、既往使用广谱抗生素[比值比：1.61（95%置信区间：1.12 - 2.30）]、存在全身炎症反应（SIRS）[比值比：1.75（95%置信区间：1.23 - 2.47）]、降钙素原[比值比：4.64（95%置信区间：3.36 - 6.40）]和肝性脑病分级[比值比：1.41（95%置信区间：1.04 - 1.90）]，感染预测的曲线下面积（AUC）为0.891。对于MDRO感染预测，第二次感染[比值比：7.19（95%置信区间：4.11 - 12.56）]、诺氟沙星预防用药[比值比：2.76（95%置信区间：1.84 - 4.13）]、CLIF - C OF[比值比：1.10（95%置信区间：1.01 - 1.20）]、既往使用广谱抗生素[比值比：1.66（95%置信区间：1.07 - 2.55）]、利福昔明[比值比：0.40（95%置信区间：0.22 - 0.74）]、多部位感染[比值比：3.67（95%置信区间：1.07 - 12.56）]和混合菌感染[比值比：4.55（95%置信区间：
