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. 2018 Oct;67(10):1870-1880.
doi: 10.1136/gutjnl-2017-314240. Epub 2017 Aug 28.

Bacterial and fungal infections in acute-on-chronic liver failure: prevalence, characteristics and impact on prognosis

Javier Fernández  1   2 , Juan Acevedo  3 , Reiner Wiest  4 , Thierry Gustot  5 , Alex Amoros  2 , Carme Deulofeu  2 , Enric Reverter  1 , Javier Martínez  6 , Faouzi Saliba  7 , Rajiv Jalan  8 , Tania Welzel  9 , Marco Pavesi  2 , María Hernández-Tejero  1 , Pere Ginès  1   2 , Vicente Arroyo  2 ; European Foundation for the Study of Chronic Liver Failure
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Bacterial and fungal infections in acute-on-chronic liver failure: prevalence, characteristics and impact on prognosis

Javier Fernández et al. Gut. 2018 Oct.

Abstract

Bacterial infection is a frequent trigger of acute-on-chronic liver failure (ACLF), syndrome that could also increase the risk of infection. This investigation evaluated prevalence and characteristics of bacterial and fungal infections causing and complicating ACLF, predictors of follow-up bacterial infections and impact of bacterial infections on survival.

Patients: 407 patients with ACLF and 235 patients with acute decompensation (AD).

Results: 152 patients (37%) presented bacterial infections at ACLF diagnosis; 46%(n=117) of the remaining 255 patients with ACLF developed bacterial infections during follow-up (4 weeks). The corresponding figures in patients with AD were 25% and 18% (p<0.001). Severe infections (spontaneous bacterial peritonitis, pneumonia, severe sepsis/shock, nosocomial infections and infections caused by multiresistant organisms) were more prevalent in patients with ACLF. Patients with ACLF and bacterial infections (either at diagnosis or during follow-up) showed higher grade of systemic inflammation at diagnosis of the syndrome, worse clinical course (ACLF 2-3 at final assessment: 47% vs 26%; p<0.001) and lower 90-day probability of survival (49% vs 72.5%;p<0.001) than patients with ACLF without infection. Bacterial infections were independently associated with mortality in patients with ACLF-1 and ACLF-2. Fungal infections developed in 9 patients with ACLF (2%) and in none with AD, occurred mainly after ACLF diagnosis (78%) and had high 90-day mortality (71%).

Conclusion: Bacterial infections are extremely frequent in ACLF. They are severe and associated with intense systemic inflammation, poor clinical course and high mortality. Patients with ACLF are highly predisposed to develop bacterial infections within a short follow-up period and could benefit from prophylactic strategies.

Keywords: cirrhosis; clinical course; immune paralysis; mortality; prevalence; prognosis; prophylaxis.

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Conflict of interest statement

Competing interests: Rajiv Jalan received research funding from Vital Therapies, has served on Scientific Advisory Board for Conatus Pharma and received lecture fees from Gambro andhas ongoing research collaboration with Gambro, Grifols and is the principal investigator of an Industry sponsored study (Sequana Medical). He is also inventor of a drug, L-ornithine phenyl acetate, which UCL has licensed to Ocera Therapeutics. Pere Ginès has received speaker honorarium and research funding from Grifols, served on the scientific advisory board for Ferring and Sequena and received research funding from Sequena. Vicente Arroyo and Javier Fernandez have received grant and research support from Grifols. All other authors declare that they have no conflict of interest.

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