Exploring the Prevalence, Predictors, and Impact of Bacterial Infections to Guide Empiric Antimicrobial Decisions in Cirrhosis (EPIC-AD).

ABSTRACT

Background/Aims: This study delved into cirrhosis-related infections to unveil their epidemiology, risk factors, and implications for antimicrobial decisions. Methods: We analyzed acutely decompensated cirrhosis patients (n = 971) from North India between 2013-2023 at a tertiary center. Microbiological and clinical features based on infection sites (EASL criteria) and patient outcomes were assessed. Results: Median age was 45 years; 87% were males with 47% having alcoholic hepatitis. Of these, 675 (69.5%) had infections; 305 (45%) were culture-confirmed. Notably, 71% of confirmed cases were multi-drug resistant organisms (MDRO)-related, chiefly carbapenem-resistant (48%). MDRO prevalence was highest in pulmonary (80.5%) and skin-soft-tissue infections (76.5%). Site-specific distribution and antimicrobials were suggested. Predictive models identified prior hospitalization [OR2.23 (CI1.58-3.14)], norfloxacin prophylaxis [OR2.26 (CI1.44-3.55)], prior broad-spectrum antibiotic exposure [OR1.61 (CI1.12-2.30)], presence of systemic inflammatory response-SIRS [OR1.75 (CI 1.23-2.47)], procalcitonin [OR4.64 (CI3.36-6.40)], and HE grade [OR1.41 (CI1.04-1.90)], with an area under curve; AUC of 0.891 for infection prediction. For MDRO infection prediction, second infection [OR 7.19 (CI 4.11-12.56)], norfloxacin prophylaxis [OR 2.76 (CI 1.84-4.13)], CLIF-C OF [OR 1.10 (CI 1.01-1.20)], prior broad-spectrum antibiotic exposure [OR 1.66 (CI 1.07-2.55)], rifaximin [OR 040 (0.22-0.74)] multisite [OR 3.67 (CI 1.07-12.56)], and polymicrobial infection [OR 4.55 (CI 1.45-14.17)] yielded an AUC of 0.779 and 93% specificity. Norfloxacin prophylaxis, multisite infection, mechanical ventilation, prior broad-spectrum antibiotic exposure, and infection as acute precipitant predicted carbapenem-resistant infection (AUC 0.821). Infections (culture-proven or probable), MDROs, carbapenem/pan-drug resistance, and second infections independently linked with mortality (P < 0.001), adjusted for age, leucocytosis, and organ failures. A model incorporating age [HR1.02 (CI 1.01-1.03), infection [HR1.52 (CI 1.05-2.20)], prior hospitalization [HR5.33 (CI 3.75-7.57)], norfloxacin [HR1.29 (CI 1.01-1.65)], multisite infection [HR1.47 (CI1.06-2.04)], and chronic liver failure consortium-organ failure score; CLIF-C OF [HR1.17 (CI 1.11-1.23)] predicted mortality with C-statistics of 0.782 (P < 0.05). Conclusion: High MDRO burden, especially carbapenem-resistant, necessitates urgent control measures in cirrhosis. Site-specific epidemiology and risk models can guide empirical antimicrobial choices in cirrhosis management.