Afebrile Bacteremia in Adult Emergency Department Patients with Liver Cirrhosis: Clinical Characteristics and Outcomes

Abstract

Hung-Yu chen & Yin-chou Hsu ✉ cirrhotic patients with bacteremia are at an increased risk of organ failure and mortality. in addition, they can develop serious infection without fever because of their impaired immune response. our study aimed to investigate the clinical characteristics and outcomes in afebrile bacteremic patients with liver cirrhosis. A single-center, retrospective cohort study was performed on adult patients who visited the emergency department from January 2015 to December 2018. All patients with bacteremia and diagnosis of liver cirrhosis were enrolled and classified as either afebrile or febrile. In total, 104 bacteremic patients with liver cirrhosis (afebrile: 55 patients and, febrile: 49) were included in the study. Compared with the febrile group, patients in the afebrile group showed a significantly higher rate of inappropriate antibiotics administration (43.6% vs. 20.4%, p = 0.01). They were also at an increased risk of 30-day mortality (40% vs. 18.4%, p = 0.02), intensive care unit transfer (38.2% vs. 18.4%, p = 0.03) and endotracheal intubation (27.3% vs. 10.2%, p = 0.03). The afebrile state was also an independent risk factor associated with 30-day mortality in cirrhotic patients with bacteremia. Clinicians should perform a prudent evaluation in cirrhotic patients and carefully monitor for possible signs of serious infection even in the absence of fever. Patients with liver cirrhosis are prone to develop infection because of their cirrhosis-associated immune dysfunction, increased intestinal mucosa permeability and decreased hepatic bacteria filtration 1. Among these, bacteremia is a serious and systemic infectious disease requiring aggressive treatment and investigation 2. Compared to non-cirrhotic patients, bacteremia in cirrhotic patients shows significantly higher mortality and morbidity risk and prolonged hospitalization 3-5. Patients with fever accompanied by altered mental status and hypotension, may help clinicians to diagnose bacteremia 6. Clinicians frequently rely on the presence of fever to initiate infection workup 7 ; however, fever is a complex and non-specific host defense response against infection, and might be absent in bacteremic syndrome 8. Afebrile bacteremic patients often have atypical clinical manifestations, such as lethargy or confusion 9 , leading to decreased survival and poorer prognosis 10. It is well known that patients with cirrhosis and bacterial infection frequently present with atypical manifestation, such as normothermia 11,12 ; which makes the traditional Systemic Inflammatory Response Syndrome (SIRS) criteria inaccurate in the identification of patients with infection 11,13. It has been proposed that scoring systems focused on organ dysfunction, such as quick Sequential Organ Failure Assessment (qSOFA) score or Chronic Liver Failure Sequential Organ Failure Assessment (CLIF-SOFA) score have better prediction ability in sepsis and prognosis stratification in patients with cirrhosis 13. Despite this, previous studies regarding bacteremia in cirrhot...

Prognostic Effects of Delayed Administration of Appropriate Antimicrobials in Bacteraemic Adults Initially Presenting with Various Body Temperatures

“… 3 , 15 , 26 However, limited studies have investigated the effects of delayed AAT on the short-term survival of bacteraemic patients specifically experiencing afebrile status or hypothermia. 6 Of note, the present cohort study is the first to disclose the different prognostic effects of delayed AAT on bacteraemia patients initially presenting with various BTs. In other words, patients presenting with higher iBTs exhibited more severe adverse effects of delayed administration of appropriate antimicrobials on their short-term mortality.…”

“…First, the performance of BT measurements with central thermometers, such as pulmonary artery catheter, urinary bladder, oesophageal, and rectal thermometers, in all ambulatory patients is infeasible in such overcrowding EDs. As previously suggested, 6 the temporal area was selected as an adequate site for BT measurement for patients attending the ED, but this measurement really limits the external validation of our finding. Second, to avoid categorisation bias due to the defervescence effects of antipyretics and steroids, patients who had accepted these medications prior to their ED arrival were excluded from the study.…”

“… 2–4 However, bacteraemia may initially have atypical manifestations (such as afebrile presentation) in specific populations, such as the elderly 5 and cirrhotic patients. 6 Accordingly, delayed treatment efforts are always the serious concern for treating such patients.…”

“… 7 By contrast, decreases in BTs are associated with declines in humoral and cellular immunity. 8 , 9 In the real world, afebrile bacteraemia was often observed in immunocompromised individuals, 6 and the first-line physician frequently reported the episodes of hypothermia in critically ill patients. 10 Although numerous studies have previously reported that initial hypothermia or afebrile status results in unfavourable outcomes in patients experiencing sepsis or bacteraemia, 6 , 11 the evidence is limited regarding the comparisons of the prognostic effect of delayed AAT between bacteraemia patients with initial presentation of hypothermia, normothermia, and high febrile status.…”

Is qSOFA Suitable for Early Diagnosis of Sepsis Among Bacteremia Patients in Emergency Departments? Time for a Reappraisal of Sepsis-3 Criteria

“…Bacterial growth on blood cultures is the standard for the diagnoses of bacteremia and thus, this information usually delays for numerous days after culture sampling. Notably, bacteremia in the specific individual, such as the elderly ( 30 ) and cirrhotic patients ( 31 ), usually pose a diagnostic challenge for first-line clinicians due to its non-specific presentations at onset in addition to how it can be initially complicated with sepsis or, even, with sequential development of severe sepsis or septic shock ( 32 ). Accordingly, a sepsis criterion with one-size-fits-all populations to accurately recognize septic patients is crucial and essential for clinicians.…”