Second infections independently increase mortality in hospitalized patients With cirrhosis: The north American Consortium for the study of end-stage liver disease (NACSELD) experience

Jasmohan S. Bajaj, Jacqueline G. O'Leary, K. Rajender Reddy, Florence Wong, Jody C. Olson, Ram M. Subramanian, Geri Brown, Nicole A. Noble, Leroy R. Thacker, Patrick S. Kamath

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Abstract

Bacterial infections are an important cause of mortality in cirrhosis, but there is a paucity of multicenter studies. The aim was to define factors predisposing to infection-related mortality in hospitalized patients with cirrhosis. A prospective, cohort study of patients with cirrhosis with infections was performed at eight North American tertiary-care hepatology centers. Data were collected on admission vitals, disease severity (model for endstage liver disease [MELD] and sequential organ failure [SOFA] scores), first infection site, type (community-acquired, healthcare-associated [HCA] or nosocomial), and second infection occurrence during hospitalization. The outcome was mortality within 30 days. A multivariate logistic regression model predicting mortality was created. 207 patients (55 years, 60% men, MELD 20) were included. Most first infections were HCA (71%), then nosocomial (15%) and community-acquired (14%). Urinary tract infections (52%), spontaneous bacterial peritonitis (SBP, 23%) and spontaneous bacteremia (21%) formed the majority of the first infections. Second infections were seen in 50 (24%) patients and were largely preventable: respiratory, including aspiration (28%), urinary, including catheter-related (26%), fungal (14%), and Clostridium difficile (12%) infections. Forty-nine patients (23.6%) who died within 30 days had higher admission MELD (25 versus 18, P < 0.0001), lower serum albumin (2.4 g/dL versus 2.8 g/dL, P = 0.002), and second infections (49% versus 16%, P < 0.0001) but equivalent SOFA scores (9.2 versus 9.9, P = 0.86). The case fatality rate was highest for C. difficile (40%), respiratory (37.5%), and spontaneous bacteremia (37%), and lowest for SBP (17%) and urinary infections (15%). The model for mortality included admission MELD (odds ratio [OR]: 1.12), heart rate (OR: 1.03) albumin (OR: 0.5), and second infection (OR: 4.42) as significant variables. Conclusion: Potentially preventable second infections are predictors of mortality independent of liver disease severity in this multicenter cirrhosis cohort.

Original languageEnglish (US)
Pages (from-to)2328-2335
Number of pages8
JournalHepatology
Volume56
Issue number6
DOIs
StatePublished - Dec 2012

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End Stage Liver Disease
Fibrosis
Mortality
Infection
Liver Diseases
Odds Ratio
Organ Dysfunction Scores
Clostridium difficile
Cross Infection
Bacteremia
Respiratory Aspiration
Logistic Models
Community Health Services
Urinary Catheters
Gastroenterology
Peritonitis
Bacterial Infections
Tertiary Care Centers
Urinary Tract Infections
Serum Albumin

ASJC Scopus subject areas

  • Hepatology

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Second infections independently increase mortality in hospitalized patients With cirrhosis : The north American Consortium for the study of end-stage liver disease (NACSELD) experience. / Bajaj, Jasmohan S.; O'Leary, Jacqueline G.; Reddy, K. Rajender; Wong, Florence; Olson, Jody C.; Subramanian, Ram M.; Brown, Geri; Noble, Nicole A.; Thacker, Leroy R.; Kamath, Patrick S.

In: Hepatology, Vol. 56, No. 6, 12.2012, p. 2328-2335.

Research output: Contribution to journalArticle

Bajaj, Jasmohan S. ; O'Leary, Jacqueline G. ; Reddy, K. Rajender ; Wong, Florence ; Olson, Jody C. ; Subramanian, Ram M. ; Brown, Geri ; Noble, Nicole A. ; Thacker, Leroy R. ; Kamath, Patrick S. / Second infections independently increase mortality in hospitalized patients With cirrhosis : The north American Consortium for the study of end-stage liver disease (NACSELD) experience. In: Hepatology. 2012 ; Vol. 56, No. 6. pp. 2328-2335.
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title = "Second infections independently increase mortality in hospitalized patients With cirrhosis: The north American Consortium for the study of end-stage liver disease (NACSELD) experience",
abstract = "Bacterial infections are an important cause of mortality in cirrhosis, but there is a paucity of multicenter studies. The aim was to define factors predisposing to infection-related mortality in hospitalized patients with cirrhosis. A prospective, cohort study of patients with cirrhosis with infections was performed at eight North American tertiary-care hepatology centers. Data were collected on admission vitals, disease severity (model for endstage liver disease [MELD] and sequential organ failure [SOFA] scores), first infection site, type (community-acquired, healthcare-associated [HCA] or nosocomial), and second infection occurrence during hospitalization. The outcome was mortality within 30 days. A multivariate logistic regression model predicting mortality was created. 207 patients (55 years, 60{\%} men, MELD 20) were included. Most first infections were HCA (71{\%}), then nosocomial (15{\%}) and community-acquired (14{\%}). Urinary tract infections (52{\%}), spontaneous bacterial peritonitis (SBP, 23{\%}) and spontaneous bacteremia (21{\%}) formed the majority of the first infections. Second infections were seen in 50 (24{\%}) patients and were largely preventable: respiratory, including aspiration (28{\%}), urinary, including catheter-related (26{\%}), fungal (14{\%}), and Clostridium difficile (12{\%}) infections. Forty-nine patients (23.6{\%}) who died within 30 days had higher admission MELD (25 versus 18, P < 0.0001), lower serum albumin (2.4 g/dL versus 2.8 g/dL, P = 0.002), and second infections (49{\%} versus 16{\%}, P < 0.0001) but equivalent SOFA scores (9.2 versus 9.9, P = 0.86). The case fatality rate was highest for C. difficile (40{\%}), respiratory (37.5{\%}), and spontaneous bacteremia (37{\%}), and lowest for SBP (17{\%}) and urinary infections (15{\%}). The model for mortality included admission MELD (odds ratio [OR]: 1.12), heart rate (OR: 1.03) albumin (OR: 0.5), and second infection (OR: 4.42) as significant variables. Conclusion: Potentially preventable second infections are predictors of mortality independent of liver disease severity in this multicenter cirrhosis cohort.",
author = "Bajaj, {Jasmohan S.} and O'Leary, {Jacqueline G.} and Reddy, {K. Rajender} and Florence Wong and Olson, {Jody C.} and Subramanian, {Ram M.} and Geri Brown and Noble, {Nicole A.} and Thacker, {Leroy R.} and Kamath, {Patrick S.}",
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T1 - Second infections independently increase mortality in hospitalized patients With cirrhosis

T2 - The north American Consortium for the study of end-stage liver disease (NACSELD) experience

AU - Bajaj, Jasmohan S.

AU - O'Leary, Jacqueline G.

AU - Reddy, K. Rajender

AU - Wong, Florence

AU - Olson, Jody C.

AU - Subramanian, Ram M.

AU - Brown, Geri

AU - Noble, Nicole A.

AU - Thacker, Leroy R.

AU - Kamath, Patrick S.

PY - 2012/12

Y1 - 2012/12

N2 - Bacterial infections are an important cause of mortality in cirrhosis, but there is a paucity of multicenter studies. The aim was to define factors predisposing to infection-related mortality in hospitalized patients with cirrhosis. A prospective, cohort study of patients with cirrhosis with infections was performed at eight North American tertiary-care hepatology centers. Data were collected on admission vitals, disease severity (model for endstage liver disease [MELD] and sequential organ failure [SOFA] scores), first infection site, type (community-acquired, healthcare-associated [HCA] or nosocomial), and second infection occurrence during hospitalization. The outcome was mortality within 30 days. A multivariate logistic regression model predicting mortality was created. 207 patients (55 years, 60% men, MELD 20) were included. Most first infections were HCA (71%), then nosocomial (15%) and community-acquired (14%). Urinary tract infections (52%), spontaneous bacterial peritonitis (SBP, 23%) and spontaneous bacteremia (21%) formed the majority of the first infections. Second infections were seen in 50 (24%) patients and were largely preventable: respiratory, including aspiration (28%), urinary, including catheter-related (26%), fungal (14%), and Clostridium difficile (12%) infections. Forty-nine patients (23.6%) who died within 30 days had higher admission MELD (25 versus 18, P < 0.0001), lower serum albumin (2.4 g/dL versus 2.8 g/dL, P = 0.002), and second infections (49% versus 16%, P < 0.0001) but equivalent SOFA scores (9.2 versus 9.9, P = 0.86). The case fatality rate was highest for C. difficile (40%), respiratory (37.5%), and spontaneous bacteremia (37%), and lowest for SBP (17%) and urinary infections (15%). The model for mortality included admission MELD (odds ratio [OR]: 1.12), heart rate (OR: 1.03) albumin (OR: 0.5), and second infection (OR: 4.42) as significant variables. Conclusion: Potentially preventable second infections are predictors of mortality independent of liver disease severity in this multicenter cirrhosis cohort.

AB - Bacterial infections are an important cause of mortality in cirrhosis, but there is a paucity of multicenter studies. The aim was to define factors predisposing to infection-related mortality in hospitalized patients with cirrhosis. A prospective, cohort study of patients with cirrhosis with infections was performed at eight North American tertiary-care hepatology centers. Data were collected on admission vitals, disease severity (model for endstage liver disease [MELD] and sequential organ failure [SOFA] scores), first infection site, type (community-acquired, healthcare-associated [HCA] or nosocomial), and second infection occurrence during hospitalization. The outcome was mortality within 30 days. A multivariate logistic regression model predicting mortality was created. 207 patients (55 years, 60% men, MELD 20) were included. Most first infections were HCA (71%), then nosocomial (15%) and community-acquired (14%). Urinary tract infections (52%), spontaneous bacterial peritonitis (SBP, 23%) and spontaneous bacteremia (21%) formed the majority of the first infections. Second infections were seen in 50 (24%) patients and were largely preventable: respiratory, including aspiration (28%), urinary, including catheter-related (26%), fungal (14%), and Clostridium difficile (12%) infections. Forty-nine patients (23.6%) who died within 30 days had higher admission MELD (25 versus 18, P < 0.0001), lower serum albumin (2.4 g/dL versus 2.8 g/dL, P = 0.002), and second infections (49% versus 16%, P < 0.0001) but equivalent SOFA scores (9.2 versus 9.9, P = 0.86). The case fatality rate was highest for C. difficile (40%), respiratory (37.5%), and spontaneous bacteremia (37%), and lowest for SBP (17%) and urinary infections (15%). The model for mortality included admission MELD (odds ratio [OR]: 1.12), heart rate (OR: 1.03) albumin (OR: 0.5), and second infection (OR: 4.42) as significant variables. Conclusion: Potentially preventable second infections are predictors of mortality independent of liver disease severity in this multicenter cirrhosis cohort.

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