Development and external validation of a model to predict multidrug-resistant bacterial infections in patients with cirrhosis.

With the increasing rate of infections caused by multidrug-resistant organisms (MDRO), selecting appropriate empiric antibiotics has become challenging. We aimed to develop and externally validate a model for predicting the risk of MDRO infections in patients with cirrhosis. METHODS: We included patients with cirrhosis and bacterial infections from two prospective studies: a transcontinental study was used for model development and internal validation (n = 1302), and a study from Argentina and Uruguay was used for external validation (n = 472). All predictors were measured at the time of infection. Both culture-positive and culture-negative infections were included. The model was developed using logistic regression with backward stepwise predictor selection. We externally validated the optimism-adjusted model using calibration and discrimination statistics and evaluated its clinical utility. RESULTS: The prevalence of MDRO infections was 19% and 22% in the development and external validation datasets, respectively. The model's predictors were sex, prior antibiotic use, type and site of infection, MELD-Na, use of vasopressors, acute-on-chronic liver failure, and interaction terms. Upon external validation, the calibration slope was 77 (95% CI .48-1.05), and the area under the ROC curve was .68 (95% CI .61-.73). The application of the model significantly changed the post-test probability of having an MDRO infection, identifying patients with nosocomial infection at very low risk (8%) and patients with community-acquired infections at significant risk (36%). CONCLUSION: This model achieved adequate performance and could be used to improve the selection of empiric antibiotics, aligning with other antibiotic stewardship program strategies.

MELD 3.0 adequately predicts mortality and renal replacement therapy requirements in patients with alcohol-associated hepatitis.

Background & Aims: Model for End-Stage Liver Disease (MELD) score better predicts mortality in alcohol-associated hepatitis (AH) but could underestimate severity in women and malnourished patients. Using a global cohort, we assessed the ability of the MELD 3.0 score to predict short-term mortality in AH. Methods: This was a retrospective cohort study of patients admitted to hospital with AH from 2009 to 2019. The main outcome was all-cause 30-day mortality. We compared the AUC using DeLong's method and also performed a time-dependent AUC with competing risks analysis. Results: A total of 2,124 patients were included from 28 centres from 10 countries on three continents (median age 47.2 ± 11.2 years, 29.9% women, 71.3% with underlying cirrhosis). The median MELD 3.0 score at admission was 25 (20-33), with an estimated survival of 73.7% at 30 days. The MELD 3.0 score had a better performance in predicting 30-day mortality (AUC:0.761, 95%CI:0.732-0.791) compared with MELD sodium (MELD-Na; AUC: 0.744, 95% CI: 0.713-0.775; p = 0.042) and Maddrey's discriminant function (mDF) (AUC: 0.724, 95% CI: 0.691-0.757; p = 0.013). However, MELD 3.0 did not perform better than traditional MELD (AUC: 0.753, 95% CI: 0.723-0.783; p = 0.300) and Age-Bilirubin-International Normalised Ratio-Creatinine (ABIC) (AUC:0.757, 95% CI: 0.727-0.788; p = 0.765). These results were consistent in competing-risk analysis, where MELD 3.0 (AUC: 0.757, 95% CI: 0.724-0.790) predicted better 30-day mortality compared with MELD-Na (AUC: 0.739, 95% CI: 0.708-0.770; p = 0.028) and mDF (AUC:0.717, 95% CI: 0.687-0.748; p = 0.042). The MELD 3.0 score was significantly better in predicting renal replacement therapy requirements during admission compared with the other scores (AUC: 0.844, 95% CI: 0.805-0.883). Conclusions: MELD 3.0 demonstrated better performance compared with MELD-Na and mDF in predicting 30-day and 90-day mortality, and was the best predictor of renal replacement therapy requirements during admission for AH. However, further prospective studies are needed to validate its extensive use in AH. Impact and implications: Severe AH has high short-term mortality. The establishment of treatments and liver transplantation depends on mortality prediction. We evaluated the performance of the new MELD 3.0 score to predict short-term mortality in AH in a large global cohort. MELD 3.0 performed better in predicting 30- and 90-day mortality compared with MELD-Na and mDF, but was similar to MELD and ABIC scores. MELD 3.0 was the best predictor of renal replacement therapy requirements. Thus, further prospective studies are needed to support the wide use of MELD 3.0 in AH.

Transfusion practices in cirrhotic patients at a tertiary liver care center from Northern India

Abstract Introduction: Transfusion in cirrhotic patients remains a challenge due to the absence of evidence-based guidelines. Our study aimed to determine the indication of transfusion and the associated transfusion thresholds in cirrhotic patients. Methods: This retrospective observational study was conducted in the Department of Transfusion Medicine at a tertiary care liver center from October 2018 to March 2019. The blood bank and patient records of cirrhotic patients admitted during the study period were retrieved and analyzed to determine the current transfusion practice. Results: A total of 992 cirrhotic patients were included in the study. Blood components were transfused to 402 (40.5%) patients. Sixty-nine (17.2%) patients were transfused to control/treat active bleeding, while 333 (82.8%) were transfused prophylactically. Packed red blood cells (65.4%) was the most commonly transfused blood component, followed by fresh frozen plasma (35.6%), among patients receiving transfusions (therapeutic & prophylactic). The mean pre-transfusion thresholds for: (i) packed red blood cell transfusion: hemoglobin less than 7 g/dL; (ii) fresh frozen plasma transfusion: international normalized ratio over 2.6; (iii) platelet concentrate transfusion: platelet count less than 40,700/µL, and; (iv) cryoprecipitate transfusion: fibrinogen less than 110 mg/dL. The average length of stay of the study population was 5 days (3-9. Conclusion: To conclude, 40.5% of our hospitalized cirrhotic patients were transfused, with the majority of the transfusions being prophylactic (82.8%). Separate guidelines are required for this patient population, as these patients have an altered hemostasis which responds differently to the transfusion of blood components.

Transfusion practices in cirrhotic patients at a tertiary liver care center from Northern India.

INTRODUCTION: Transfusion in cirrhotic patients remains a challenge due to the absence of evidence-based guidelines. Our study aimed to determine the indication of transfusion and the associated transfusion thresholds in cirrhotic patients. METHODS: This retrospective observational study was conducted in the Department of Transfusion Medicine at a tertiary care liver center from October 2018 to March 2019. The blood bank and patient records of cirrhotic patients admitted during the study period were retrieved and analyzed to determine the current transfusion practice. RESULTS: A total of 992 cirrhotic patients were included in the study. Blood components were transfused to 402 (40.5%) patients. Sixty-nine (17.2%) patients were transfused to control/treat active bleeding, while 333 (82.8%) were transfused prophylactically. Packed red blood cells (65.4%) was the most commonly transfused blood component, followed by fresh frozen plasma (35.6%), among patients receiving transfusions (therapeutic & prophylactic). The mean pre-transfusion thresholds for: (i) packed red blood cell transfusion: hemoglobin less than 7g/dL; (ii) fresh frozen plasma transfusion: international normalized ratio over 2.6; (iii) platelet concentrate transfusion: platelet count less than 40,700/µL, and; (iv) cryoprecipitate transfusion: fibrinogen less than 110mg/dL. The average length of stay of the study population was 5 days (3-9). CONCLUSION: To conclude, 40.5% of our hospitalized cirrhotic patients were transfused, with the majority of the transfusions being prophylactic (82.8%). Separate guidelines are required for this patient population, as these patients have an altered hemostasis which responds differently to the transfusion of blood components.