Gastroenterology

Gastroenterology

Volume 139, Issue 4, October 2010, Pages 1246-1256.e5
Gastroenterology

Clinical—Liver, Pancreas, and Biliary Tract
Infections in Patients With Cirrhosis Increase Mortality Four-Fold and Should Be Used in Determining Prognosis

https://doi.org/10.1053/j.gastro.2010.06.019Get rights and content

Background & Aims

A staged prognostic model of cirrhosis based on varices, ascites, and bleeding has been proposed. We analyzed data on infections in patients with cirrhosis to determine whether it is also a prognostic factor.

Methods

Studies were identified by MEDLINE, EMBASE, COCHRANE, and ISI Web of Science searches (1978–2009); search terms included sepsis, infection, mortality, and cirrhosis. Studies (n = 178) reporting more than 10 patients and mortality data were evaluated (225 cohorts, 11,987 patients). Mortality after 1, 3, and 12 months was compared with severity, site, microbial cause of infection, etiology of cirrhosis, and publication year. Pooled odds ratio of death was compared for infected versus noninfected groups (18 cohorts, 2317 patients).

Results

Overall median mortality of infected patients was 38%: 30.3% at 1 month and 63% at 12 months. Pooled odds ratio for death of infected versus noninfected patients was 3.75 (95% confidence interval, 2.12–4.23). In 101 studies that reported spontaneous bacterial peritonitis (7062 patients), the median mortality was 43.7%: 31.5% at 1 month and 66.2% at 12 months. In 30 studies that reported bacteremia (1437 patients), the median mortality rate was 42.2%. Mortality before 2000 was 47.7% and after 2000 was 32.3% (P = .023); mortality was reduced only at 30 days after spontaneous bacterial peritonitis (49% vs 31.5%; P = .005).

Conclusions

In patients with cirrhosis, infections increase mortality 4-fold; 30% of patients die within 1 month after infection and another 30% die by 1 year. Prospective studies with prolonged follow-up evaluation and to evaluate preventative strategies are needed.

Section snippets

Materials and Methods

All studies reporting on the clinical course of cirrhosis after infection were considered eligible for this review, irrespective of the publication language, if they fulfilled the following criteria: (1) inclusion of adult patients with cirrhosis independent of etiology; and (2) reported the number of deaths in infected patients, or a survival analysis. Exclusion criteria were studies with the following: (1) no separate analysis of patients with or without cirrhosis; (2) no separate analysis of

Study Characteristics

The search yielded 10,508 references, with 12 derived from abstracts and references of the reports. There were 10,153 exclusions after reading the title and/or abstract because they were not relevant; from the remainder, 177 were excluded after reading the reports because they did not meet inclusion/exclusion criteria. Therefore, 178 studies were included (88 published from 2000 onward). There were 225 cohorts in total because some studies had separate cohorts with infection. Detailed

Discussion

The natural history of cirrhosis is characterized by an asymptomatic phase termed compensated cirrhosis, followed by a rapidly progressive phase marked by the development of complications of portal hypertension and/or liver dysfunction (ascites, variceal bleeding, portosystemic encephalopathy, jaundice), termed decompensated cirrhosis. These complications further worsen mortality. This 2-stage model has been modified by D'Amico et al,5 who presented evidence for 4 stages of cirrhosis: 2 stages

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    Conflicts of interest The authors disclose no conflicts.

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