Infection does not increase long-term mortality in patients with acute severe alcoholic hepatitis treated with corticosteroids

Abstract

Aim: To determine whether infection in patients with acute severe alcoholic hepatitis (AAH) treated with corticosteroids is associated with increased mortality.

Methods: Consecutive patients with AAH were treated with steroids and recruited to the study. Clinically relevant infections (body temperature > 38 °C or < 36 °C for more than 4 h, ascitic neutrophil count > 0.25 ×10⁹/L, consolidation on chest radiograph or clinically relevant positive microbiological culture of bodily fluid) were recorded prospectively. Clinical and laboratory parameters were recorded and survival at 90 d and 6 mo was determined. Univariate analysis of factors associated with 90-d mortality was performed and significant variables included in a multivariate analysis.

Results: Seventy-two patients were included in the final analysis (mean age 47.9 years, 26% female, mean discriminant function 53.0). Overall mortality in the group occurred in 15 (21%), 23 (32%) and 31 (43%) at day 28, day 90 and 1 year respectively. 36 (50%) had a clinically relevant infection during their hospitalisation (23 after initiation of steroids). The median time to development of incident infection after commencement of steroids was 10 d. The commonest site of infection was ascites (31%) and bacteraemia (31%) followed by urinary tract (19%) and respiratory tract (8%). Forty-one separate organisms were isolated in 33 patients; the most frequent genus was Escherichia (22%) and Enterococcus (20%). Infection was not associated with 90-d or 1 year mortality but was associated with higher creatinine, model for end-stage liver disease and Lille score. Baseline urea was the only independent predictor of 90-d mortality.

Conclusion: Clinically relevant infections are common in patients with AAH but are not associated with increased 90-d or 1 year mortality.

Keywords: Alcoholic hepatitis; Corticosteroids; Escherichia; Infection; Lille score.

Figure 1

Site and causative bacterial genus of all clinically relevant infections during hospital admission for acute severe alcoholic hepatitis. A: The site of clinically relevant infections (n = 36). The “Other” category includes gastrointestinal tract and cutaneous; B: The causative bacterial genus where identified by microbiological analysis in 41 separate clinically relevant infections. The “Other Genus” group includes Acinebacter (n = 2), Haemophilus (n = 1), Clostridium difficile (n = 2) and norovirus (n = 1); C: Catalase status of identified bacteria (n = 40).

Figure 2

Clinically relevant infection does not significantly affect early or late mortality. Kaplan-Meier survival curves of AAH patients with (n = 9) and without (n = 63) clinically relevant infection at the time of hospital admission at 90 d (A) and 1 year (B); P = 0.26 and P = 0.67 respectively; C: One year survival of AAH patients with (n = 23) and without (n = 48) clinically relevant infection after commencement of steroid treatment (P = 0.93). AAH: Acute severe alcoholic hepatitis.