Lung Infection Affects Access to Treatment and Short-Term Outcome in Patients With Severe Alcohol-Related Hepatitis Treated With Corticosteroids.
Journal
The American journal of gastroenterology
ISSN: 1572-0241
Titre abrégé: Am J Gastroenterol
Pays: United States
ID NLM: 0421030
Informations de publication
Date de publication:
01 07 2022
01 07 2022
Historique:
received:
15
10
2021
accepted:
01
03
2022
pubmed:
30
3
2022
medline:
1
7
2022
entrez:
29
3
2022
Statut:
ppublish
Résumé
Severe alcohol-related hepatitis (AH) is associated with an increased risk of infection, but the impact of pneumonia has not been specifically analyzed in a specific cohort. All patients admitted for severe AH between 2002 and 2020 were prospectively included. Systematic screening for infection was performed at admission and renewed in the case of clinical suspicion. We included 614 patients (60.4% men, mean age 49.9 years, median model for end-stage liver disease [MELD] 25.2, bilirubin 18.1 mg/dL), 202 (32.9%) with infections at admission (73 lung infections). Encephalopathy ( P = 0.006), MELD score ( P = 0.0002), and tobacco exposure (past vs never smokers: P = 0.002 or active vs past smokers: P = 0.005) were associated with lung infection at admission on multivariate analysis. Factors independently associated with death before steroid initiation were encephalopathy ( P = 0.003), MELD score ( P = 0.05), and especially lung infection ( P < 0.0001). Thus, patients with a lung infection had a lower probability of receiving steroids than those with other infections and noninfected patients: 54.8 vs 88.4 vs 98.1% ( P < 0.0001). One hundred forty-six of the 558 patients who received corticosteroids developed infection, including 57 (39.04%) pneumonias. The risk of respiratory and nonrespiratory infection was higher in nonresponders to steroids (Lille score ≥0.45) than in responders: 13% vs 7.6%, P = 0.03 and 27.9% vs 10.6%, P < 0.001, respectively. The variables independently associated with 3-month mortality after steroid initiation were lung infection ( P = 0.004), nonresponse to steroids ( P < 0.0001), MELD score ( P = 0.0003), ascites ( P = 0.003), and encephalopathy ( P = 0.018), whereas nonrespiratory infections were not ( P = 0.91). Lung infection is frequent during severe AH and influences mortality at admission and after steroid initiation. These results emphasize the need for specific management of lung infection during the course of AH.
Identifiants
pubmed: 35347088
doi: 10.14309/ajg.0000000000001750
pii: 00000434-202207000-00022
doi:
Substances chimiques
Adrenal Cortex Hormones
0
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
1097-1105Commentaires et corrections
Type : CommentIn
Informations de copyright
Copyright © 2022 by The American College of Gastroenterology.
Références
Louvet A, Thursz MR, Kim DJ, et al. Corticosteroids reduce risk of death within 28 days for patients with severe alcoholic hepatitis, compared with pentoxifylline or placebo-a meta-analysis of individual data from controlled trials. Gastroenterology 2018;155(2):458–68.e8.
Louvet A, Naveau S, Abdelnour M, et al. The Lille model: A new tool for therapeutic strategy in patients with severe alcoholic hepatitis treated with steroids. Hepatology 2007;45(6):1348–54.
Louvet A, Wartel F, Castel H, et al. Infection in patients with severe alcoholic hepatitis treated with steroids: Early response to therapy is the key factor. Gastroenterology 2009;137(2):541–8.
Gustot T, Fernandez J, Szabo G, et al. Sepsis in alcohol-related liver disease. J Hepatol 2017;67(5):1031–50.
Llopis M, Cassard AM, Wrzosek L, et al. Intestinal microbiota contributes to individual susceptibility to alcoholic liver disease. Gut 2016;65(5):830–9.
Claria J, Stauber RE, Coenraad MJ, et al. Systemic inflammation in decompensated cirrhosis: Characterization and role in acute-on-chronic liver failure. Hepatology 2016;64(4):1249–64.
Markwick LJ, Riva A, Ryan JM, et al. Blockade of PD1 and TIM3 restores innate and adaptive immunity in patients with acute alcoholic hepatitis. Gastroenterology 2015;148(3):590–602.e10.
Mookerjee RP, Stadlbauer V, Lidder S, et al. Neutrophil dysfunction in alcoholic hepatitis superimposed on cirrhosis is reversible and predicts the outcome. Hepatology 2007;46(3):831–40.
Boussif A, Rolas L, Weiss E, et al. Impaired intracellular signaling, myeloperoxidase release and bactericidal activity of neutrophils from patients with alcoholic cirrhosis. J Hepatol 2016;64(5):1041–8.
Artru F, Bou Saleh M, Maggiotto F, et al. IL-33/ST2 pathway regulates neutrophil migration and predicts outcome in patients with severe alcoholic hepatitis. J Hepatol 2020;72(6):1052–61.
Kershaw CD, Guidot DM. Alcoholic lung disease. Alcohol Res Health 2008;31(1):66–75.
Samokhvalov AV, Irving HM, Rehm J. Alcohol consumption as a risk factor for pneumonia: A systematic review and meta-analysis. Epidemiol Infect 2010;138(12):1789–95.
Jalan R, Saliba F, Pavesi M, et al. Development and validation of a prognostic score to predict mortality in patients with acute-on-chronic liver failure. J Hepatol 2014;61(5):1038–47.
Fernandez J, Acevedo J, Wiest R, et al. Bacterial and fungal infections in acute-on-chronic liver failure: Prevalence, characteristics and impact on prognosis. Gut 2018;67(10):1870–80.
Wong F, Piano S, Singh V, et al. Clinical features and evolution of bacterial infection-related acute-on-chronic liver failure. J Hepatol 2021;74(2):330–9.
Thursz MR, Richardson P, Allison M, et al. Prednisolone or pentoxifylline for alcoholic hepatitis. N Engl J Med 2015;372(17):1619–28.
Faria LC, Ichai P, Saliba F, et al. Pneumocystis pneumonia: An opportunistic infection occurring in patients with severe alcoholic hepatitis. Eur J Gastroenterol Hepatol 2008;20(1):26–8.
Gustot T, Maillart E, Bocci M, et al. Invasive aspergillosis in patients with severe alcoholic hepatitis. J Hepatol 2014;60(2):267–74.
Fernandez J, Navasa M, Gomez J, et al. Bacterial infections in cirrhosis: Epidemiological changes with invasive procedures and norfloxacin prophylaxis. Hepatology 2002;35(1):140–8.
Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med 2019;200(7):e45–67.
Grief SN, Loza JK. Guidelines for the evaluation and treatment of pneumonia. Prim Care 2018;45(3):485–503.
Jain S, Self WH, Wunderink RG, et al. Community-acquired pneumonia requiring hospitalization among U.S. adults. N Engl J Med 2015;373(5):415–27.
Hmoud BS, Patel K, Bataller R, et al. Corticosteroids and occurrence of and mortality from infections in severe alcoholic hepatitis: A meta-analysis of randomized trials. Liver Int 2016;36(5):721–8.
Fernandez J, Acevedo J, Castro M, et al. Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: A prospective study. Hepatology 2012;55(5):1551–61.
Parker R, Im G, Jones F, et al. Clinical and microbiological features of infection in alcoholic hepatitis: An international cohort study. J Gastroenterol 2017;52(11):1192–200.
Wernlund PG, Stoy S, Lemming L, et al. Blood culture-positive infections in patients with alcoholic hepatitis. Scand J Infect Dis 2014;46(12):902–5.
Arab JP, Sehrawat TS, Simonetto DA, et al. An open-label, dose-escalation study to assess the safety and efficacy of IL-22 agonist F-652 in patients with alcohol-associated hepatitis. Hepatology 2020;72(2):441–53.