Hospital-acquired bloodstream infections in critically ill cirrhotic patients: a post-hoc analysis of the EUROBACT-2 international cohort study

Hannah Wozniak^{1

2}, Alexis Tabah^{3

4

5

6}, François Barbier⁷, Stéphane Ruckly^{8

9}, Ambre Loiodice⁹, Murat Akova¹⁰, Marc Leone¹¹, Andrew Conway Morris^{12

13

14}, Matteo Bassetti¹⁵, Kostoula Arvaniti¹⁶, Ricard Ferrer¹⁷, Liesbet de Bus^{18

19}, Jose Artur Paiva^{20

21}, Hendrik Bracht²², Adam Mikstacki^{23

24}, Adel Alsisi^{25

26}, Liana Valeanu²⁷, Josef Prazak²⁸, Jean-François Timsit^{29

30}, Niccolò Buetti^{29

31}; EUROBACT-2 Study Group, ESICM, ESCMID ESGCIP and the OUTCOMEREA Network

Affiliations

¹ Division of Critical Care, Department of Acute Medicine, University Hospital of Geneva, University of Geneva, Geneva, Switzerland. Hannah.wozniak@hcuge.ch.
² Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada. Hannah.wozniak@hcuge.ch.
³ Intensive Care Unit, Redcliffe Hospital, Brisbane, Australia.
⁴ Queensland Critical Care Research Network (QCCRN), Brisbane, QLD, Australia.
⁵ Queensland University of Technology, Brisbane, QLD, Australia.
⁶ Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.
⁷ Service de Médecine Intensive-Réanimation, Centre Hospitalier Régional d'Orléans, Orléans, France.
⁸ Université de Paris, INSERM, IAME UMR 1137, Paris, 75018, France.
⁹ ICUREsearch, Biometry, Fontaine, 38600, France.
¹⁰ Department of Infectious Diseases, Hacettepe University School of Medicine, Ankara, Turkey.
¹¹ Department of Anesthesiology and Intensive Care Unit, Hospital Nord, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Marseille, France.
¹² Division of Anaesthesia, Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK.
¹³ Division of Immunology, Department of Pathology, University of Cambridge, Tennis Court Road, Cambridge, Cb2 1QP, UK.
¹⁴ JVF Intensive Care Unit, Addenbrooke's Hospital, Cambridge, Hills Road, Cambridge, CB2 0QQ, UK.
¹⁵ Infectious Diseases Clinic, Department of Health Sciences, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy.
¹⁶ Intensive Care Unit, Papageorgiou University Affiliated Hospital, Thessaloníki, Greece.
¹⁷ Intensive Care Department, SODIR-VHIR Research Group, Vall d'Hebron University Hospital, Barcelona, Spain.
¹⁸ Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium.
¹⁹ Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.
²⁰ Intensive Care Medicine Department, Centro Hospitalar Universitário São João (CHUSJ), Porto, Portugal.
²¹ Department of Medicine, Faculty of Medicine, University of Porto (FMUP), Porto, Portugal.
²² Central Interdisciplinary Emergency Medicine, University Hospital Ulm, Ulm, Germany.
²³ Faculty of Health Sciences, Poznan University of Medical Sciences, Poznan, Poland.
²⁴ Department of Anaesthesiology and Intensive Therapy, Regional Hospital in Poznan, Poznan, Poland.
²⁵ ICU Department, Prime Hospital, Dubai, United Arab Emirates.
²⁶ Critical Care Department, Faculty of Medicine, Cairo University, Cairo, Egypt.
²⁷ Cardiac Anesthesiology and Intensive Care Department I, Emergency Institute for Cardiovascular Diseases Prof. Dr. C. C. Iliescu, Bucharest, Romania.
²⁸ Department of Intensive Care Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland.
²⁹ Université Paris- Cité, INSERM, IAME UMR 1137, Paris, 75018, France.
³⁰ Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, Paris, France.
³¹ Infection Control Program and World Health Organization Collaborating Centre on Patient Safety, Faculty of Medicine, University Hospitals, University of Geneva, Geneva, Switzerland.

PMID: 38698291
PMCID: PMC11065852
DOI: 10.1186/s13613-024-01299-x

Hospital-acquired bloodstream infections in critically ill cirrhotic patients: a post-hoc analysis of the EUROBACT-2 international cohort study

Hannah Wozniak et al. Ann Intensive Care. 2024.

. 2024 May 2;14(1):70.

doi: 10.1186/s13613-024-01299-x.

Authors

Affiliations

¹ Division of Critical Care, Department of Acute Medicine, University Hospital of Geneva, University of Geneva, Geneva, Switzerland. Hannah.wozniak@hcuge.ch.
² Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada. Hannah.wozniak@hcuge.ch.
³ Intensive Care Unit, Redcliffe Hospital, Brisbane, Australia.
⁴ Queensland Critical Care Research Network (QCCRN), Brisbane, QLD, Australia.
⁵ Queensland University of Technology, Brisbane, QLD, Australia.
⁶ Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.
⁷ Service de Médecine Intensive-Réanimation, Centre Hospitalier Régional d'Orléans, Orléans, France.
⁸ Université de Paris, INSERM, IAME UMR 1137, Paris, 75018, France.
⁹ ICUREsearch, Biometry, Fontaine, 38600, France.
¹⁰ Department of Infectious Diseases, Hacettepe University School of Medicine, Ankara, Turkey.
¹¹ Department of Anesthesiology and Intensive Care Unit, Hospital Nord, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Marseille, France.
¹² Division of Anaesthesia, Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK.
¹³ Division of Immunology, Department of Pathology, University of Cambridge, Tennis Court Road, Cambridge, Cb2 1QP, UK.
¹⁴ JVF Intensive Care Unit, Addenbrooke's Hospital, Cambridge, Hills Road, Cambridge, CB2 0QQ, UK.
¹⁵ Infectious Diseases Clinic, Department of Health Sciences, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy.
¹⁶ Intensive Care Unit, Papageorgiou University Affiliated Hospital, Thessaloníki, Greece.
¹⁷ Intensive Care Department, SODIR-VHIR Research Group, Vall d'Hebron University Hospital, Barcelona, Spain.
¹⁸ Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium.
¹⁹ Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.
²⁰ Intensive Care Medicine Department, Centro Hospitalar Universitário São João (CHUSJ), Porto, Portugal.
²¹ Department of Medicine, Faculty of Medicine, University of Porto (FMUP), Porto, Portugal.
²² Central Interdisciplinary Emergency Medicine, University Hospital Ulm, Ulm, Germany.
²³ Faculty of Health Sciences, Poznan University of Medical Sciences, Poznan, Poland.
²⁴ Department of Anaesthesiology and Intensive Therapy, Regional Hospital in Poznan, Poznan, Poland.
²⁵ ICU Department, Prime Hospital, Dubai, United Arab Emirates.
²⁶ Critical Care Department, Faculty of Medicine, Cairo University, Cairo, Egypt.
²⁷ Cardiac Anesthesiology and Intensive Care Department I, Emergency Institute for Cardiovascular Diseases Prof. Dr. C. C. Iliescu, Bucharest, Romania.
²⁸ Department of Intensive Care Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland.
²⁹ Université Paris- Cité, INSERM, IAME UMR 1137, Paris, 75018, France.
³⁰ Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, Paris, France.
³¹ Infection Control Program and World Health Organization Collaborating Centre on Patient Safety, Faculty of Medicine, University Hospitals, University of Geneva, Geneva, Switzerland.

PMID: 38698291
PMCID: PMC11065852
DOI: 10.1186/s13613-024-01299-x

Abstract

Background: Hospital-acquired bloodstream infections are common in the intensive care unit (ICU) and have a high mortality rate. Patients with cirrhosis are especially susceptible to infections, yet there is a knowledge gap in the epidemiological distinctions in hospital-acquired bloodstream infections between cirrhotic and non-cirrhotic patients in the ICU. It has been suggested that cirrhotic patients, present a trend towards more gram-positive infections, and especially enterococcal infections. This study aims to describe epidemiological differences in hospital-acquired bloodstream infections between cirrhotic and non-cirrhotic patients hospitalized in the ICU regarding infection sources, microorganisms and mortality.

Methods: Using prospective Eurobact-2 international cohort study data, we compared hospital-acquired bloodstream infections sources and microorganisms in cirrhotic and non-cirrhotic patients. The association between Enterococcus faecium and cirrhosis was studied using a multivariable mixed logistic regression. The association between cirrhosis and mortality was assessed by a multivariable frailty Cox model.

Results: Among the 1059 hospital-acquired bloodstream infections patients included from 101 centers, 160 had cirrhosis. Hospital-acquired bloodstream infection source in cirrhotic patients was primarily abdominal (35.6%), while it was pulmonary (18.9%) for non-cirrhotic (p < 0.01). Gram-positive hospital-acquired bloodstream infections accounted for 42.3% in cirrhotic patients compared to 33.2% in non-cirrhotic patients (p = 0.02). Hospital-acquired bloodstream infections in cirrhotic patients were most frequently caused by Klebsiella spp (16.5%), coagulase-negative Staphylococci (13.7%) and E. faecium (11.5%). E. faecium bacteremia was more frequent in cirrhotic patients (11.5% versus 4.5%, p < 0.01). After adjusting for possible confounding factors, cirrhosis was associated with higher E. faecium hospital-acquired bloodstream infections risk (Odds ratio 2.5, 95% CI 1.3-4.5, p < 0.01). Cirrhotic patients had increased mortality compared to non-cirrhotic patients (Hazard Ratio 1.3, 95% CI 1.01-1.7, p = 0.045).

Conclusions: Critically ill cirrhotic patients with hospital-acquired bloodstream infections exhibit distinct epidemiology, with more Gram-positive infections and particularly Enterococcus faecium.

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Conflict of interest statement

M. Bassetti reports COI out of the submitted work including research grants and/or personal fees for advisor/consultant and/or speaker/chairman from Angelini, BioMérieux, Cidara, Menarini, MSD, Pfizer, and Shionogi. F Barbier reports COI out of the submitted work including lecture fees from MSD and BioMérieux, conference invitation from Pfizer. J.-F. Timsit reports COI out of the submitted work, including ad boards (Pfizer, PSD, ASPEN, Gilead), lectures (BioMérieux, MSD, Pfizer, Shionogi, Mundipharma, Gilead, Qiagen) and research grants (MSD, Pfizer, Thermo Fischer Scientific).

Figures

**Fig. 1**
The distribution of microorganisms between cirrhotic and non-cirrhotic patients was compared, with the results reported as the number of each microorganism in the two different patient groups. The Fisher’s exact test was used for the comparison, revealing a significant difference in microorganism distribution between cirrhotic and non-cirrhotic patients (p = 0.01)

**Fig. 2**
Kaplan-Meier survival curves were used to analyze survival until Day 28 for all HABSIs and for *Enterococcus faecium* HABSI in cirrhotic and non-cirrhotic patients. Statistical analysis of the Kaplan-Meier curve (log-rank test) showed a lower probability of survival in cirrhotic patients with HABSI (p = 0.04) and no significant difference in cirrhotic patients with *E. faecium* HABSI compared to non-cirrhotic patients (p = 0.46)

See this image and copyright information in PMC

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Hospital-acquired bloodstream infections in critically ill cirrhotic patients: a post-hoc analysis of the EUROBACT-2 international cohort study

Affiliations

Hospital-acquired bloodstream infections in critically ill cirrhotic patients: a post-hoc analysis of the EUROBACT-2 international cohort study

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

References

LinkOut - more resources

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Miscellaneous