Bacteraemia, sepsis and antibiotic resistance in Australian patients with cirrhosis: a population-based study

Abstract

ObjectiveMultiple factors predispose patients with cirrhosis to sepsis and/or bacteraemia and this has a high mortality rate. Within different geographical regions there are marked differences in the prevalence of infection with multidrug-resistant organisms (MDR). This study examined risk factors for and outcomes of sepsis/bacteraemia in public hospital admissions with cirrhosis in the state of Queensland, Australia, over the last decade, along with the bacterial pathogens responsible and their antibiotic susceptibility profiles.DesignA population-based retrospective cohort study of public hospital admissions was conducted from 1 January 2008 to 31 December 2017. Hospital admissions for patients with a diagnosis of cirrhosis were categorised by the presence or absence of sepsis/bacteraemia. Clinical and sociodemographic information including cirrhosis aetiology, complications and comorbidities, and in-hospital mortality were examined using bivariate and multivariate analyses. In patients with bacteraemia, the type and prevalence of bacteria and antibiotic resistance was assessed.ResultsSepsis/bacteraemia was present in 3951 of 103 165 hospital admissions with a diagnosis of cirrhosis. Factors associated with sepsis/bacteraemia included disease aetiology, particularly primary sclerosing cholangitis (adj-OR 15.09, 95% CI 12.24 to 18.60), alcohol (adj-OR 2.90, 95% CI 2.71 to 3.09), Charlson Comorbidity Index ≥3 (adj-OR 3.54, 95% CI 3.19 to 3.93) and diabetes (adj-OR 1.87, 95% CI 1.74 to 2.01). Overall case-fatality rate among admissions with sepsis/bacteraemia was 27.7% (95% CI 26.3% to 29.1%) vs 3.7% (95% CI 3.6% to 3.8%) without sepsis/bacteraemia. In-hospital death was significantly associated with sepsis/bacteraemia (adj-OR 6.50, 95% CI 5.95 to 7.11). The most common organisms identified were Escherichia coli and Staphylococcus aureus, present in 22.9% and 18.1%, respectively, of the 2265 admissions with a positive blood culture. The prevalence of MDR bacteria was low (5.6%)ConclusionMorbidity and mortality related to sepsis/bacteraemia in patients with cirrhosis remains a critical clinical problem.

Impact of multidrug resistance on the management of bacterial infections in cirrhosis

“…However, a recent retrospective cohort study has demonstrated a low prevalence of MDRO in blood cultures of patients with cirrhosis hospitalized in Australia (5.6% of admissions). Despite the low prevalence, the study has shown a significant increase in infections caused by MDRO over a decade[ 18 ], similarly to what had been previously verified in Europe[ 10 ].…”

“…, hospitalization or short-term admission for at least 2 d in the previous 90 d, residence in a nursing home or a long-term care facility, or chronic hemodialysis) and community-acquired infections (20% and 0%, respectively)[ 22 ]. Similarly, an intercontinental study evaluated 1302 infected cirrhotic patients and confirmed that infections caused by MDRO were associated with a lower efficacy (40% vs 68%) and a longer duration (12 d[ 7 - 18 ] vs 10 d[ 7 - 15 ]) of empirical antibiotic treatment. Furthermore, patients with bacterial infections by multi-resistant strains had a higher incidence of septic shock (27% vs 13%) and higher in-hospital and 28-d mortality rate (31% vs 21% and 34% vs 22%, respectively)[ 7 ].…”

Epidemiology of ascites fluid infections in patients with cirrhosis in Queensland, Australia from 2008 to 2017

“…We recently reported on the incidence of bacteremia, sepsis and antibiotic resistance to bloodstream infections in the same cohort analysed here. [ 30 ]…”

“…We recently reported on the incidence of bacteremia, sepsis and antibiotic resistance to bloodstream infections in the same cohort analysed here. [30] Infection in AF, including SBP and bacterascites, is one of the most common infections in patients with cirrhosis and is associated with 18% to 40% in-hospital mortality. [31] We observed a relatively high in-hospital mortality rate in SBPpositive (28%) compared to SBP-negative admissions, but report a significant decrease in in-hospital morality over the 10-year study period.…”

Development of a nomogram for predicting in-hospital mortality in patients with liver cirrhosis and sepsis

“…Once sepsis occurs in patients with liver cirrhosis there is a significant increase in short and long-term mortality 13 . Also in-hospital mortality is significantly higher [27.7% (26.3–29.1%) vs. 3.7% (3.6–3.8%)] 14 . Although more studies exist on sepsis in the past, there is still a lack of research on sepsis in patients with cirrhosis 15 .…”