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

(2021) JOURNAL OF HEPATOLOGY. 74(2). p.330-339
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Abstract
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. (C) 2020 Published by Elsevier B.V. on behalf of European Association for the Study of the Liver.
Keywords
Sepsis, Liver transplantation, Antibiotic resistance, MDR, XDR, ACLF, Cirrhosis, MORTALITY, CIRRHOSIS

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MLA
Wong, F., et al. “Clinical Features and Evolution of Bacterial Infection-Related Acute-on-Chronic Liver Failure.” JOURNAL OF HEPATOLOGY, vol. 74, no. 2, 2021, pp. 330–39, doi:10.1016/j.jhep.2020.07.046.
APA
Wong, F., Piano, S., Singh, V., Bartoletti, M., Maiwall, R., Alessandria, C., … Club of Ascites Global Study Group, I. (2021). Clinical features and evolution of bacterial infection-related acute-on-chronic liver failure. JOURNAL OF HEPATOLOGY, 74(2), 330–339. https://doi.org/10.1016/j.jhep.2020.07.046
Chicago author-date
Wong, F, S Piano, V Singh, M Bartoletti, R Maiwall, C Alessandria, J Fernandez, et al. 2021. “Clinical Features and Evolution of Bacterial Infection-Related Acute-on-Chronic Liver Failure.” JOURNAL OF HEPATOLOGY 74 (2): 330–39. https://doi.org/10.1016/j.jhep.2020.07.046.
Chicago author-date (all authors)
Wong, F, S Piano, V Singh, M Bartoletti, R Maiwall, C Alessandria, J Fernandez, EC Soares, DJ Kim, SE Kim, M Marino, J Vorobioff, Barea RCR, M Merli, L Elkrief, V Vargas, A Krag, SP Singh, LA Lesmana, C Toledo, S Marciano, Xavier Verhelst, N Intagliata, L Rabinowich, L Colombato, SG Kim, A Gerbes, F Durand, JP Roblero, T Bruns, EL Yoon, M Girala, NT Pyrsopoulos, TH Kim, SY Yim, A Juanola, A Gadano, P Angeli, and International Club of Ascites Global Study Group. 2021. “Clinical Features and Evolution of Bacterial Infection-Related Acute-on-Chronic Liver Failure.” JOURNAL OF HEPATOLOGY 74 (2): 330–339. doi:10.1016/j.jhep.2020.07.046.
Vancouver
1.
Wong F, Piano S, Singh V, Bartoletti M, Maiwall R, Alessandria C, et al. Clinical features and evolution of bacterial infection-related acute-on-chronic liver failure. JOURNAL OF HEPATOLOGY. 2021;74(2):330–9.
IEEE
[1]
F. Wong et al., “Clinical features and evolution of bacterial infection-related acute-on-chronic liver failure,” JOURNAL OF HEPATOLOGY, vol. 74, no. 2, pp. 330–339, 2021.
@article{8689644,
  abstract     = {{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. (C) 2020 Published by Elsevier B.V. on behalf of European Association for the Study of the Liver.}},
  author       = {{Wong, F and Piano, S and Singh, V and Bartoletti, M and Maiwall, R and Alessandria, C and Fernandez, J and Soares, EC and Kim, DJ and Kim, SE and Marino, M and Vorobioff, J and RCR, Barea and Merli, M and Elkrief, L and Vargas, V and Krag, A and Singh, SP and Lesmana, LA and Toledo, C and Marciano, S and Verhelst, Xavier and Intagliata, N and Rabinowich, L and Colombato, L and Kim, SG and Gerbes, A and Durand, F and Roblero, JP and Bruns, T and Yoon, EL and Girala, M and Pyrsopoulos, NT and Kim, TH and Yim, SY and Juanola, A and Gadano, A and Angeli, P and Club of Ascites Global Study Group, International}},
  issn         = {{0168-8278}},
  journal      = {{JOURNAL OF HEPATOLOGY}},
  keywords     = {{Sepsis,Liver transplantation,Antibiotic resistance,MDR,XDR,ACLF,Cirrhosis,MORTALITY,CIRRHOSIS}},
  language     = {{eng}},
  number       = {{2}},
  pages        = {{330--339}},
  title        = {{Clinical features and evolution of bacterial infection-related acute-on-chronic liver failure}},
  url          = {{http://dx.doi.org/10.1016/j.jhep.2020.07.046}},
  volume       = {{74}},
  year         = {{2021}},
}

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