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Nosocomial Infections Are Frequent and Negatively Impact Outcomes in Hospitalized Patients With Cirrhosis

Bajaj, Jasmohan S. MD1; O'Leary, Jacqueline G. MD2,3; Tandon, Puneeta MD4; Wong, Florence MD5; Garcia-Tsao, Guadalupe MD6; Kamath, Patrick S. MD7; Biggins, Scott W. MD8,9; Lai, Jennifer C. MD10; Vargas, Hugo E. MD11; Maliakkal, Benedict MD12,13; Fallon, Michael B. MD14,15; Thuluvath, Paul J. MD16; Subramanian, Ram M. MD17; Thacker, Leroy R. PhD1; Reddy, K. Rajender MD18

American Journal of Gastroenterology: July 2019 - Volume 114 - Issue 7 - p 1091–1100
doi: 10.14309/ajg.0000000000000280

OBJECTIVES: Nosocomial infections (NIs) can be a major cause of morbidity and mortality in cirrhosis. This study aims to define the determinants of NI development and its impact on 30-day outcomes among hospitalized patients with cirrhosis.

METHODS: North American Consortium for the Study of End-Stage Liver Disease enrolled patients with cirrhosis who were admitted nonelectively. Admission variables and 30-day outcomes were compared between patients with and without NI. These were also compared based on whether there was an isolated admission infection, NI, or both. Models were created for NI development using admission variables and for 30-day mortality.

RESULTS: The study included 2,864 patients; of which, 15% (n = 436) developed NI. When comparing NI vs no NI, 1,866 patients were found to be infection free, whereas 562 had admission infections only, 228 had only NI, and 208 had both infections. At admission, patients with NI were more likely to be infected and have advanced cirrhosis. NIs were associated with higher rates of acute-on-chronic liver failure, death, and transplant regardless of admission infections. Patients with NI had higher respiratory infection, urinary tract infection, Clostridium difficile infection, fungal infections, and infection with vancomycin-resistant enterococci compared with patients without NI. Risk factors for NIs were admission infections, model for end-stage liver disease (MELD) > 20, systemic inflammatory response syndrome criteria, proton pump inhibitor, rifaximin, and lactulose use, but the regression model (sensitivity, 0.67; specificity, 0.63) was not robust. Age, alcohol etiology, admission MELD score, lactulose use, acute-on-chronic liver failure, acute kidney injury, intensive care unit, and NI increased the risk of death, whereas rifaximin decreased the risk of death.

DISCUSSION: NIs are prevalent in hospitalized patients with cirrhosis and are associated with poor outcomes. Although higher MELD scores and systemic inflammatory response syndrome are associated with NI, all hospitalized patients with cirrhosis require vigilance and preventive strategies.

1Virginia Commonwealth University and McGuire Virginia Medical Center, Richmond, Virginia, USA;

2Baylor University Medical Center, Dallas, Texas, USA;

3Dallas VA Medical Center, Dallas, Texas, USA;

4University of Alberta, Edmonton, Alberta, Canada;

5University of Toronto, Toronto, Ontario, Canada;

6Yale University School of Medicine New Haven, Connecticut, USA;

7Mayo Clinic School of Medicine, Rochester, Minnesota, USA;

8University of Colorado, Denver, Colorado, USA;

9University of Washington, Seattle, Washington, USA;

10University of California, San Francisco, California, USA;

11Mayo Clinic School of Medicine, Scottsdale, Arizona, USA;

12University of Rochester, Rochester, New York, USA;

13University of Tennessee, Memphis, Tennessee, USA;

14University of Texas, Houston, Texas, USA;

15University of Arizona, Phoenix, Arizona, USA;

16Mercy Medical Center, Baltimore, Maryland, USA;

17Emory University Medical Center, Atlanta, Georgia, USA;

18University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Correspondence: Jasmohan S. Bajaj, MD. E-mail:

SUPPLEMENTARY MATERIAL accompanies this paper at and

Received December 12, 2018

Received in revised form March 07, 2019

Accepted April 15, 2019

© The American College of Gastroenterology 2019. All Rights Reserved.
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