Impact of First Microbial Infection on Outcomes in Natural History and Trajectories in Cirrhosis

IntroductionMicrobial infections are frequent complications in cirrhosis, resulting as a common trigger of acute-on-chronic liver failure (ACLF). However, data about impact on long-term are conflicting.AimsTo prospectively evaluate epidemiology of microbial infections, their severity and impact on outcome of decompensated cirrhotics admitted at a Hepatology Unit.Material and methodsAll adult patients admitted at Multivisceral Transplant Unit, Padua, between January 2017 and December 2022 with diagnosis of microbial infection were consecutively enrolled, analysing severity and source of infection. Outcome was assessed both during the first hospitalisation and within 1-yr, prospectively collecting further episodes of acute decompensation (AD) or ACLF, or death / liver transplantation.Results236 admissions with infections in 165 patients were evaluated. Patients were predominantly male (67.9%) with median age of 57.4 years; the prevalent aetiology of cirrhosis was alcohol (47.3%). The most common source of infection was bloodstream (28%), followed by pneumonia and spontaneous bacterial peritonitis. Out of 140 culture-positive infections (59% of total infections), gram positive and multidrug resistant strains were 52% and 43%, respectively. Only 47/165 (28%) patients were infected at admission, 42% presenting with ACLF, whereas remainder developed nosocomial infection. MELD score and qSOFA ≥2 were associated with ACLF development at multivariate analysis. Overall, 38/165 (23%) died during first hospitalisation and 29/165 (17.5%) died of sepsis. Among survivors after first hospitalisation (n. 127), 43 (33%) experienced another microbial infection within a year. A further episode of ACLF occurred in 22% patients, with cumulative mortality significantly higher than those who developed a further episode of AD (51% vs. 20%).ConclusionMicrobial infection is associated with high in-hospital mortality, especially when ACLF occurs. One third of survivors are affected by further infections and experience further admissions for AD or ACLF. The latter condition is associated with detrimental survival.