Cirrhosis and fungal infections‐a cocktail for catastrophe: A systematic review and meta‐analysis with machine learning

Abstract

Objectives We evaluated the magnitude and factors contributing to poor outcomes among cirrhosis patients with fungal infections (FIs). Methods We searched PubMed, Embase, Ovid and WOS and included articles reporting mortality in cirrhosis with FIs. We pooled the point and relative‐risk (RR) estimates of mortality on random‐effects meta‐analysis and explored their heterogeneity (I 2) on subgroups, meta‐regression and machine learning (ML). We assessed the study quality through New‐Castle‐Ottawa Scale and estimate‐asymmetry through Eggers regression. (CRD42019142782). Results Of 4345, 34 studies (2134 patients) were included (good/fair/poor quality: 12/21/1). Pooled mortality of FIs was 64.1% (95% CI: 55.4–72.0, I 2: 87%, p < .01), which was 2.1 times higher than controls (95% CI: 1.8–2.5, I 2:89%, p < .01). Higher CTP (MD: +0.52, 95% CI: 0.27–0.77), MELD (MD: +2.75, 95% CI: 1.21–4.28), organ failures and increased hospital stay (30 vs. 19 days) were reported among cases with FIs. Patients with ACLF (76.6%, RR: 2.3) and ICU‐admission (70.4%, RR: 1.6) had the highest mortality. The risk was maximum for pulmonary FIs (79.4%, RR: 1.8), followed by peritoneal FIs (68.3%, RR: 1.7) and fungemia (55%, RR: 1.7). The mortality was higher in FIs than in bacterial (RR: 1.7) or no infections (RR: 2.9). Estimate asymmetry was evident (p < 0.05). Up to 8 clusters and 5 outlier studies were identified on ML, and the estimate‐heterogeneity was eliminated by excluding such studies. Conclusions A substantially worse prognosis, poorer than bacterial infections in cirrhosis patients with FIs, indicates an unmet need for improving fungal diagnostics and therapeutics in this population. ACLF and ICU admission should be included in the host criteria for defining IFIs.

Clinical Characteristics and Early Diagnosis of Spontaneous Fungal Peritonitis/Fungiascites in Hospitalized Cirrhotic Patients with Ascites: A Case–Control Study

“…SFP/fungiascites are a devastating complication in cirrhosis with ascites, posing a great challenge for both diagnosis and therapy. To our knowledge, this is the largest study on SFP/fungiascites to date [16,17]. We described the clinical characteristics and evaluated the potential risk factors of the short-term mortality of patients with SFP/fungiascites.…”

Navigating the Labyrinth: Intensive Care Challenges for Patients with Acute-on-Chronic Liver Failure

“…A recent meta-analysis evaluated contributing factors for fungal infections (FIs) in patients with cirrhosis [65]. The authors analyzed 34 studies involving a total of 2134 patients.…”

“…The highest mortality (76.6%) was observed in patients with ACLF and FIs. Patients with aspergillosis of the lung had a mortality rate of 79.4%, peritoneal FIs of 68.3%, and bloodstream FIs of 55% [65]. It seems reasonable to begin antifungal and antibiotic treatment for patients with ACLF as soon as they are admitted to the ICU.…”