Clinical features and evolution of bacterial infection-related acute-on-chronic liver failure.

BACKGROUND & AIMS: Bacterial infections can trigger the development of organ failure(s) and acute-on-chronic liver failure (ACLF). Geographic variations in bacteriology and clinical practice could lead to worldwide differences in ACLF epidemiology, phenotypes and associated outcomes. Herein, we aimed to evaluate regional differences in bacterial infection-related ACLF in patients with cirrhosis admitted to hospital. METHODS: This post hoc analysis included 1,175 patients with decompensated cirrhosis (with bacterial infection on admission or nosocomial infection) from 6 geographic regions worldwide. Clinical, laboratory and microbiological data were collected from the diagnosis of infection. Patients were followed-up for organ failure(s) and ACLF development according to the EASL-CLIF criteria from enrolment to discharge/death. RESULTS: A total of 333 patients (28%) had ACLF at diagnosis of infection, while 230 patients developed ACLF after diagnosis of infection, resulting in an overall rate of bacterial infection related-ACLF of 48%, with rates differing amongst different geographic regions (38% in Southern Europe vs. 75% in the Indian subcontinent). Bacterial infection related-ACLF more frequently developed in younger patients (55 ± 13 vs. 58 ± 14 years), males (73% vs. 62%), patients with alcohol-related cirrhosis (59% vs. 45%) and those with a higher baseline MELD score (25 ± 11 vs. 16 ± 5) (all p <0.001). Spontaneous bacterial peritonitis, pneumonia or infections caused by extensively drug resistant (XDR) bacteria were more frequently associated with ACLF development. More patients with ACLF had a positive quick sequential organ failure assessment score and septic shock, resulting in a lower infection resolution rate (all p <0.001). CONCLUSIONS: Bacterial infections, especially with XDR organisms, are associated with the highest risk of ACLF development, accounting for almost half of cases globally. Geographic differences result in variable epidemiology and clinical outcomes. LAY SUMMARY: Bacterial infections can trigger a sudden deterioration in an otherwise stable cirrhotic patient, a condition known as acute-on-chronic liver failure or ACLF. This study has found that the development of ACLF following bacterial infection occurs most commonly in the Indian subcontinent and less so in Southern Europe. The common infections that can trigger ACLF include infection of the abdominal fluid, known as spontaneous bacterial peritonitis, pneumonia and by bacteria that are resistant to multiple antibiotics. Patients who develop ACLF following a bacterial infection have high death rates and are frequently unable to clear the infection.

Epidemiology and Effects of Bacterial Infections in Patients With Cirrhosis Worldwide.

BACKGROUND & AIMS: Bacterial infections are common and life-threatening in patients with cirrhosis. Little is known about the epidemiology of bacterial infections in different regions. We performed a multicenter prospective intercontinental study to assess the prevalence and outcomes of bacterial and fungal infections in patients with cirrhosis. METHODS: We collected data from 1302 hospitalized patients with cirrhosis and bacterial or fungal infections at 46 centers (15 in Asia, 15 in Europe, 11 in South America, and 5 in North America) from October 2015 through September 2016. We obtained demographic, clinical, microbiology, and treatment data at time of diagnosis of infection and during hospitalization. Patients were followed until death, liver transplantation, or discharge. RESULTS: The global prevalence of multidrug-resistant (MDR) bacteria was 34% (95% confidence interval 31%-37%). The prevalence of MDR bacteria differed significantly among geographic areas, with the greatest prevalence in Asia. Independent risk factors for infection with MDR bacteria were infection in Asia (particularly in India), use of antibiotics in the 3 months before hospitalization, prior health care exposure, and site of infection. Infections caused by MDR bacteria were associated with a lower rate of resolution of infection, a higher incidence of shock and new organ failures, and higher in-hospital mortality than those caused by non-MDR bacteria. Administration of adequate empirical antibiotic treatment was independently associated with improved in-hospital and 28-day survival. CONCLUSIONS: In a worldwide study of hospitalized patients, we found a high prevalence of infection with MDR bacteria in patients with cirrhosis. Differences in the prevalence of MDR bacterial infections in different global regions indicate the need for different empirical antibiotic strategies in different continents and countries. While we await new antibiotics, effort should be made to decrease the spread of MDR bacteria in patients with cirrhosis.

Hepatite C crônica: estudo de casos observados em um serviço de referência da região Centro-Oeste do Brasil / Hepatitis C chronic study of cases observed in a service of reference of the region Center-West of Brazil

A hepatite C é uma doença de impacto mundial, uma vez que têm distribuição por todo o globo e mais da metade dos infectados irão desenvolver hepatite crônica. Atualmente é a principal causa de hepatopatia crônica e de indicação de transplante hepático nos países ocidentais. Ainda mais, a terapia antiviral é limitada e ainda não há vacina disponível. Portanto, o estudo dos aspectos clínico-epidemiológicos da infecção é importante, pois pode otimizar ações em saúde com o objetivo de diminuir os agravos de morbimortalidade dessa doença. A fim de conhecer os aspectos clínicos, epidemiológicos e virológicos de indivíduos infectados pela hepatite C crônica, foi desenvolvido um estudo descritivo, do tipo série de casos, com 243 pacientes incluídos. Houve predominância do gênero masculino em 62,6 por cento dos casos. A média de idade dos pacientes por ocasião do diagnóstico foi de 42,9 anos. O principal motivo que determinou o conhecimento do diagnóstico da hepatite foi a doação de sangue (54,9 por cento). Os níveis de ALT foram normais em 44,2 por cento dos pacientes. O genótipo predominante foi o tipo 1 (68,0 por cento). Entre os 150 pacientes biopsiados: 78 por cento apresentavam algum grau de fibrose, 85,3 por cento algum grau de atividade inflamatória e 71,2 por cento evidência de esteatose. Houve maior presença de fibrose entre os pacientes com níveis elevados de ALT (p=0,002), AST (p menor 0,001) e de GGT (p menor 0,001). Centro e dois pacientes foram submetidos ao tratamento, porém apenas 53 foram aderentes e cumpriram o proposto. A taxa de resposta virológica sustentada foi de 37,7 por cento entre os pacientes submetidos à terapêutica de forma regular.