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Published on: November 6, 2020
Prediction of Fungal Infection Development and Their Impact on Survival Using the NACSELD Cohort
Jasmohan S Bajaj1, Rajender K Reddy2, Puneeta Tandon3
1Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA.
Objectives:
Bacterial infections are associated with negative outcomes in cirrhosis but fungal infections are being increasingly recognized. The objective of this study is to define risk factors for fungal infection development and impact on 30-day survival.
Methods:
In a large, multi-center cirrhotic inpatient cohort, demographics, cirrhosis details, intensive care unit (ICU), organ failures/acute-on-chronic liver failure (ACLF), and 30-day survival were compared between patients without infections and with bacterial infections alone, with those with fungal infections. Variables associated with fungal infection development were determined using multi-variable regression. Ordinal variables (0=no infection, 1=community-acquired bacterial infection, 2=nosocomial bacterial, and 3=fungal infection) were input into a 30-day survival model.
Results:
A total of 2,743 patients (1,691 no infection, 918 bacterial, and 134 fungal infections) were included. Patients with fungal infection, all of which were nosocomial, were more likely to be admitted with bacterial infections, on spontaneous bacterial peritonitis prophylaxis, and have diabetes and advanced cirrhosis. Bacterial infection types did not predict risk for fungal infections. Multi-variable analysis showed male gender to be protective, whereas diabetes, longer stay, ICU admission, acute kidney injury (AKI), and admission bacterial infection were associated with fungal infection development (area under the curve (AUC)=0.82). Fungal infections were associated with significantly higher ACLF, inpatient stay, ICU admission, and worse 30-day survival. The case fatality rate was 30% with most fungal infections but >50% for fungemia and fungal peritonitis. On a multi-variable analysis, age, AKI, model for end-stage liver disease, ICU admission, and ordinal infection variables impaired survival (P<0.0001, AUC=0.83).
Conclusions:
Fungal infections are associated with a poor 30-day survival in hospitalized cirrhotic patients compared with uninfected patients, and those with bacterial infections. Patients with diabetes, AKI, and those with an admission bacterial infection form a high-risk subgroup.
Insights
Fungal infections in cirrhosis patients lead to worse outcomes and lower 30-day survival. Diabetes, acute kidney injury, and prior bacterial infection identify high-risk individuals for fungal infections.
Area of Science:
- Infectious Diseases
- Hepatology
- Critical Care Medicine
Background:
- Bacterial infections negatively impact cirrhosis patients.
- Fungal infections are increasingly recognized in cirrhosis.
- Understanding fungal infection risks is crucial for patient outcomes.
Purpose of the Study:
- To identify risk factors for fungal infection development in cirrhosis patients.
- To assess the impact of fungal infections on 30-day survival.
- To compare outcomes between patients with no infection, bacterial infection, and fungal infection.
Main Methods:
- A multi-center study of 2,743 cirrhotic inpatients.
- Comparison of demographics, cirrhosis severity, ICU stay, organ failures, and survival.
- Multivariable regression to determine fungal infection risk factors and survival predictors.
Main Results:
- Fungal infections were nosocomial, associated with diabetes, prior bacterial infection, and advanced cirrhosis.
- Diabetes, longer hospital stay, ICU admission, and acute kidney injury (AKI) predicted fungal infection.
- Fungal infections significantly increased acute-on-chronic liver failure (ACLF), mortality, and impaired 30-day survival (AUC=0.83).
Conclusions:
- Fungal infections are linked to poor 30-day survival in hospitalized cirrhosis patients.
- Patients with diabetes, AKI, and admission bacterial infection are at high risk.
- Early identification and management of fungal infections are critical in this population.
