Isolated bacterial infection without decompensation has no impact on survival of compensated patients with cirrhosis

Abstract

Background & Aims: Bacterial infections (BI) affect the natural course of cirrhosis and were suggested to be a landmark event marking the transition to the decompensated stage. Our specific aim was to evaluate the impact of BI on the natural history of compensated cirrhosis. Methods: We analyzed 858 patients with cirrhosis, evaluated for the INCA trial (EudraCT 2013-001626-26) in 2 academic medical centers between February 2014 and May 2019. Only patients with previously compensated disease were included. They were divided into 4 groups: compensated without BI, compensated with BI, 1st decompensation without BI, and 1st decompensation with BI. Results: About 425 patients (median 61 [53-69] years) were included in the final prospective analysis. At baseline, 257 patients were compensated (12 [4.7%] with BI), whereas 168 patients presented with their 1st decompensation (42 [25.0%] with BI).In patients who remained compensated MELD scores were similar in those with and without BI. Patients with their first decompensation and BI had higher MELD scores than those without BI. Amongst patients who remained compensated, BI had no influence on transplant-free survival, whereas patients with their 1st decompensation and concurrent BI had significantly reduced transplant-free survival as compared with those without BI. The development of BI or decompensation during follow-up had a greater impact on survival than each of these complications at baseline. Conclusions:In compensated patients with cirrhosis, the 1st decompensation associated to BI has worse survival than decompensation without BI. By contrast, BI without decompensation does not negatively impact survival of patients with compensated cirrhosis.

Infections increase the risk of decompensation and death in patients with early alcohol-related liver disease

“…, bacterial infections in patients with cirrhosis of mixed etiologies who remained compensated did not have an impact on survival. 28 This conflicts with our study, where infections increased the risk of death in the full cohort of patients with ALD, both after decompensation and in patients who never decompensated. The impact of infections on survival was, however, lower in compensated patients than in those who died after decompensating.…”

Reply to: “First things first! Can bacterial infections be considered as decompensating events per se?”

“…By accounting only for BIs occurring +/-14 days from decompensation, it is unclear whether some BIs occurring after decompensation were considered precipitants but not BIs occurring >14 days before. (5) On the other hand, in keeping with previous studies,(4) we also show that BIs increase the risk of death in compensated cirrhosis. However, our study provides relevant additional insight by showing that the great majority of patients who died after developing BIs had clinical decompensation of cirrhosis before death.…”

First things first! Can bacterial infections be considered as decompensating events per se?

“…We have approached this question in our recent paper, in which the impact of BI in patients with cirrhosis who were previously compensated (including both patients with and without CSPH) was evaluated. 5 We also observed a reduction in survival among those patients who developed infections, however this was only seen in the subgroup of patients who simultaneously presented their first decompensation at the time of inclusion. BI in patients who remained compensated had no impact on survival.…”