Nosocomial Infections Are Frequent and Negatively Impact Outcomes in Hospitalized Patients With Cirrhosis

Jasmohan S. Bajaj, Jacqueline G. OʼLeary, Puneeta Tandon, Florence Wong, Guadalupe Garcia-Tsao, Patrick Sequeira Kamath, Scott W. Biggins, Jennifer C. Lai, Hugo E Vargas, Benedict Maliakkal, Michael B. Fallon, Paul J. Thuluvath, Ram M. Subramanian, Leroy R. Thacker, K. Rajender Reddy

Research output: Contribution to journalArticle

Abstract

OBJECTIVES: Nosocomial infections (NIs) can be a major cause of morbidity and mortality in cirrhosis. This study aims to define the determinants of NI development and its impact on 30-day outcomes among hospitalized patients with cirrhosis. METHODS: North American Consortium for the Study of End-Stage Liver Disease enrolled patients with cirrhosis who were admitted nonelectively. Admission variables and 30-day outcomes were compared between patients with and without NI. These were also compared based on whether there was an isolated admission infection, NI, or both. Models were created for NI development using admission variables and for 30-day mortality. RESULTS: The study included 2,864 patients; of which, 15% (n = 436) developed NI. When comparing NI vs no NI, 1,866 patients were found to be infection free, whereas 562 had admission infections only, 228 had only NI, and 208 had both infections. At admission, patients with NI were more likely to be infected and have advanced cirrhosis. NIs were associated with higher rates of acute-on-chronic liver failure, death, and transplant regardless of admission infections. Patients with NI had higher respiratory infection, urinary tract infection, Clostridium difficile infection, fungal infections, and infection with vancomycin-resistant enterococci compared with patients without NI. Risk factors for NIs were admission infections, model for end-stage liver disease (MELD) > 20, systemic inflammatory response syndrome criteria, proton pump inhibitor, rifaximin, and lactulose use, but the regression model (sensitivity, 0.67; specificity, 0.63) was not robust. Age, alcohol etiology, admission MELD score, lactulose use, acute-on-chronic liver failure, acute kidney injury, intensive care unit, and NI increased the risk of death, whereas rifaximin decreased the risk of death. DISCUSSION: NIs are prevalent in hospitalized patients with cirrhosis and are associated with poor outcomes. Although higher MELD scores and systemic inflammatory response syndrome are associated with NI, all hospitalized patients with cirrhosis require vigilance and preventive strategies.

Original languageEnglish (US)
Pages (from-to)1091-1100
Number of pages10
JournalThe American Journal of Gastroenterology
Volume114
Issue number7
DOIs
StatePublished - Jul 1 2019

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Cross Infection
Fibrosis
End Stage Liver Disease
Infection
rifaximin
Lactulose
Systemic Inflammatory Response Syndrome
Clostridium Infections
Clostridium difficile
Mortality
Mycoses
Proton Pump Inhibitors
Acute Kidney Injury
Urinary Tract Infections
Respiratory Tract Infections
Intensive Care Units

ASJC Scopus subject areas

  • Hepatology
  • Gastroenterology

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Nosocomial Infections Are Frequent and Negatively Impact Outcomes in Hospitalized Patients With Cirrhosis. / Bajaj, Jasmohan S.; OʼLeary, Jacqueline G.; Tandon, Puneeta; Wong, Florence; Garcia-Tsao, Guadalupe; Kamath, Patrick Sequeira; Biggins, Scott W.; Lai, Jennifer C.; Vargas, Hugo E; Maliakkal, Benedict; Fallon, Michael B.; Thuluvath, Paul J.; Subramanian, Ram M.; Thacker, Leroy R.; Reddy, K. Rajender.

In: The American Journal of Gastroenterology, Vol. 114, No. 7, 01.07.2019, p. 1091-1100.

Research output: Contribution to journalArticle

Bajaj, JS, OʼLeary, JG, Tandon, P, Wong, F, Garcia-Tsao, G, Kamath, PS, Biggins, SW, Lai, JC, Vargas, HE, Maliakkal, B, Fallon, MB, Thuluvath, PJ, Subramanian, RM, Thacker, LR & Reddy, KR 2019, 'Nosocomial Infections Are Frequent and Negatively Impact Outcomes in Hospitalized Patients With Cirrhosis', The American Journal of Gastroenterology, vol. 114, no. 7, pp. 1091-1100. https://doi.org/10.14309/ajg.0000000000000280
Bajaj, Jasmohan S. ; OʼLeary, Jacqueline G. ; Tandon, Puneeta ; Wong, Florence ; Garcia-Tsao, Guadalupe ; Kamath, Patrick Sequeira ; Biggins, Scott W. ; Lai, Jennifer C. ; Vargas, Hugo E ; Maliakkal, Benedict ; Fallon, Michael B. ; Thuluvath, Paul J. ; Subramanian, Ram M. ; Thacker, Leroy R. ; Reddy, K. Rajender. / Nosocomial Infections Are Frequent and Negatively Impact Outcomes in Hospitalized Patients With Cirrhosis. In: The American Journal of Gastroenterology. 2019 ; Vol. 114, No. 7. pp. 1091-1100.
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AU - OʼLeary, Jacqueline G.

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AU - Wong, Florence

AU - Garcia-Tsao, Guadalupe

AU - Kamath, Patrick Sequeira

AU - Biggins, Scott W.

AU - Lai, Jennifer C.

AU - Vargas, Hugo E

AU - Maliakkal, Benedict

AU - Fallon, Michael B.

AU - Thuluvath, Paul J.

AU - Subramanian, Ram M.

AU - Thacker, Leroy R.

AU - Reddy, K. Rajender

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N2 - OBJECTIVES: Nosocomial infections (NIs) can be a major cause of morbidity and mortality in cirrhosis. This study aims to define the determinants of NI development and its impact on 30-day outcomes among hospitalized patients with cirrhosis. METHODS: North American Consortium for the Study of End-Stage Liver Disease enrolled patients with cirrhosis who were admitted nonelectively. Admission variables and 30-day outcomes were compared between patients with and without NI. These were also compared based on whether there was an isolated admission infection, NI, or both. Models were created for NI development using admission variables and for 30-day mortality. RESULTS: The study included 2,864 patients; of which, 15% (n = 436) developed NI. When comparing NI vs no NI, 1,866 patients were found to be infection free, whereas 562 had admission infections only, 228 had only NI, and 208 had both infections. At admission, patients with NI were more likely to be infected and have advanced cirrhosis. NIs were associated with higher rates of acute-on-chronic liver failure, death, and transplant regardless of admission infections. Patients with NI had higher respiratory infection, urinary tract infection, Clostridium difficile infection, fungal infections, and infection with vancomycin-resistant enterococci compared with patients without NI. Risk factors for NIs were admission infections, model for end-stage liver disease (MELD) > 20, systemic inflammatory response syndrome criteria, proton pump inhibitor, rifaximin, and lactulose use, but the regression model (sensitivity, 0.67; specificity, 0.63) was not robust. Age, alcohol etiology, admission MELD score, lactulose use, acute-on-chronic liver failure, acute kidney injury, intensive care unit, and NI increased the risk of death, whereas rifaximin decreased the risk of death. DISCUSSION: NIs are prevalent in hospitalized patients with cirrhosis and are associated with poor outcomes. Although higher MELD scores and systemic inflammatory response syndrome are associated with NI, all hospitalized patients with cirrhosis require vigilance and preventive strategies.

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