Hospital-acquired bloodstream infections in critically ill cirrhotic patients: a post-hoc analysis of the EUROBACT-2 international cohort study.

Journal

Annals of intensive care
ISSN: 2110-5820
Titre abrégé: Ann Intensive Care
Pays: Germany
ID NLM: 101562873

Informations de publication

Date de publication:
02 May 2024
Historique:
received: 12 12 2023
accepted: 19 04 2024
medline: 3 5 2024
pubmed: 3 5 2024
entrez: 2 5 2024
Statut: epublish

Résumé

Hospital-acquired bloodstream infections are common in the intensive care unit (ICU) and have a high mortality rate. Patients with cirrhosis are especially susceptible to infections, yet there is a knowledge gap in the epidemiological distinctions in hospital-acquired bloodstream infections between cirrhotic and non-cirrhotic patients in the ICU. It has been suggested that cirrhotic patients, present a trend towards more gram-positive infections, and especially enterococcal infections. This study aims to describe epidemiological differences in hospital-acquired bloodstream infections between cirrhotic and non-cirrhotic patients hospitalized in the ICU regarding infection sources, microorganisms and mortality. Using prospective Eurobact-2 international cohort study data, we compared hospital-acquired bloodstream infections sources and microorganisms in cirrhotic and non-cirrhotic patients. The association between Enterococcus faecium and cirrhosis was studied using a multivariable mixed logistic regression. The association between cirrhosis and mortality was assessed by a multivariable frailty Cox model. Among the 1059 hospital-acquired bloodstream infections patients included from 101 centers, 160 had cirrhosis. Hospital-acquired bloodstream infection source in cirrhotic patients was primarily abdominal (35.6%), while it was pulmonary (18.9%) for non-cirrhotic (p < 0.01). Gram-positive hospital-acquired bloodstream infections accounted for 42.3% in cirrhotic patients compared to 33.2% in non-cirrhotic patients (p = 0.02). Hospital-acquired bloodstream infections in cirrhotic patients were most frequently caused by Klebsiella spp (16.5%), coagulase-negative Staphylococci (13.7%) and E. faecium (11.5%). E. faecium bacteremia was more frequent in cirrhotic patients (11.5% versus 4.5%, p < 0.01). After adjusting for possible confounding factors, cirrhosis was associated with higher E. faecium hospital-acquired bloodstream infections risk (Odds ratio 2.5, 95% CI 1.3-4.5, p < 0.01). Cirrhotic patients had increased mortality compared to non-cirrhotic patients (Hazard Ratio 1.3, 95% CI 1.01-1.7, p = 0.045). Critically ill cirrhotic patients with hospital-acquired bloodstream infections exhibit distinct epidemiology, with more Gram-positive infections and particularly Enterococcus faecium.

Sections du résumé

BACKGROUND BACKGROUND
Hospital-acquired bloodstream infections are common in the intensive care unit (ICU) and have a high mortality rate. Patients with cirrhosis are especially susceptible to infections, yet there is a knowledge gap in the epidemiological distinctions in hospital-acquired bloodstream infections between cirrhotic and non-cirrhotic patients in the ICU. It has been suggested that cirrhotic patients, present a trend towards more gram-positive infections, and especially enterococcal infections. This study aims to describe epidemiological differences in hospital-acquired bloodstream infections between cirrhotic and non-cirrhotic patients hospitalized in the ICU regarding infection sources, microorganisms and mortality.
METHODS METHODS
Using prospective Eurobact-2 international cohort study data, we compared hospital-acquired bloodstream infections sources and microorganisms in cirrhotic and non-cirrhotic patients. The association between Enterococcus faecium and cirrhosis was studied using a multivariable mixed logistic regression. The association between cirrhosis and mortality was assessed by a multivariable frailty Cox model.
RESULTS RESULTS
Among the 1059 hospital-acquired bloodstream infections patients included from 101 centers, 160 had cirrhosis. Hospital-acquired bloodstream infection source in cirrhotic patients was primarily abdominal (35.6%), while it was pulmonary (18.9%) for non-cirrhotic (p < 0.01). Gram-positive hospital-acquired bloodstream infections accounted for 42.3% in cirrhotic patients compared to 33.2% in non-cirrhotic patients (p = 0.02). Hospital-acquired bloodstream infections in cirrhotic patients were most frequently caused by Klebsiella spp (16.5%), coagulase-negative Staphylococci (13.7%) and E. faecium (11.5%). E. faecium bacteremia was more frequent in cirrhotic patients (11.5% versus 4.5%, p < 0.01). After adjusting for possible confounding factors, cirrhosis was associated with higher E. faecium hospital-acquired bloodstream infections risk (Odds ratio 2.5, 95% CI 1.3-4.5, p < 0.01). Cirrhotic patients had increased mortality compared to non-cirrhotic patients (Hazard Ratio 1.3, 95% CI 1.01-1.7, p = 0.045).
CONCLUSIONS CONCLUSIONS
Critically ill cirrhotic patients with hospital-acquired bloodstream infections exhibit distinct epidemiology, with more Gram-positive infections and particularly Enterococcus faecium.

Identifiants

DOI: 10.1186/s13613-024-01299-x PMID: 38698291
pubmed: 38698291
doi: 10.1186/s13613-024-01299-x
pii: 10.1186/s13613-024-01299-x
doi:

Types de publication

Journal Article

Langues

eng

Pagination

70

Informations de copyright

© 2024. The Author(s).

Références

Tabah A, Koulenti D, Laupland K, Misset B, Valles J, Bruzzi De Carvalho F, et al. Characteristics and determinants of outcome of hospital-acquired bloodstream infections in intensive care units: the EUROBACT International Cohort Study. Intensive Care Med. 2012;38:1930–45. https://doi.org/10.1007/s00134-012-2695-9
doi: 10.1007/s00134-012-2695-9 pubmed: 23011531
Tabah A, Buetti N, Staiquly Q, Ruckly S, Akova M, Aslan AT, et al. Epidemiology and outcomes of hospital-acquired bloodstream infections in intensive care unit patients: the EUROBACT-2 international cohort study. Intensive Care Med. 2023;49:178–90. https://doi.org/10.1007/s00134-022-06944-2
doi: 10.1007/s00134-022-06944-2 pubmed: 36764959 pmcid: 9916499
Merli M, Lucidi C, Giannelli V, Giusto M, Riggio O, Falcone M, et al. Cirrhotic patients are at risk for health care-associated bacterial infections. Clin Gastroenterol Hepatol. 2010;8:979–e9851. https://doi.org/10.1016/j.cgh.2010.06.024
doi: 10.1016/j.cgh.2010.06.024 pubmed: 20621200
Bajaj JS, OʼLeary JG, Tandon P, Wong F, Garcia-Tsao G, Kamath PS, Biggins SW, Lai JC, Vargas HE, Maliakkal B, Fallon MB, Thuluvath PJ, Subramanian RM, Thacker LRRK. Outcomes in hospitalized patients with nosocomial infections are frequent and negatively impact outcomes in hospitalized patients with cirrhosis. Am J Gastroenterol. 2019;3:1091–100. https://doi.org/10.14309/ajg.0000000000000280.Nosocomial
doi: 10.14309/ajg.0000000000000280.Nosocomial
D’oliveira RAC, Pereira LCD, Codes L, Rocha M, de Bittencourt S. Analysis of healthcare associated and hospital acquired infections in critically ill patients with cirrhosis. Arq Gastroenterol. 2022;59:102–9. https://doi.org/10.1590/S0004-2803.202200001-18
doi: 10.1590/S0004-2803.202200001-18 pubmed: 35442319
Bunchorntavakul C, Chamroonkul N, Chavalitdhamrong D. Bacterial infections in cirrhosis: a critical review and practical guidance. World J Hepatol. 2016;8:307–21. https://doi.org/10.4254/wjh.v8.i6.307
doi: 10.4254/wjh.v8.i6.307 pubmed: 26962397 pmcid: 4766259
Fernández J, Acevedo J, Castro M, Garcia O, Rodríguez de Lope C, Roca D, et al. Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study. Hepatology. 2012;55:1551–61. https://doi.org/10.1002/hep.25532
doi: 10.1002/hep.25532 pubmed: 22183941
Bartoletti M, Giannella M, Lewis RE, Viale P. Bloodstream infections in patients with liver cirrhosis. Virulence. 2016;7:309–19. https://doi.org/10.1080/21505594.2016.1141162
doi: 10.1080/21505594.2016.1141162 pubmed: 26864729 pmcid: 4871664
Bartoletti M, Giannella M, Caraceni P, Domenicali M, Ambretti S, Tedeschi S, et al. Epidemiology and outcomes of bloodstream infection in patients with cirrhosis. J Hepatol. 2014;61:51–8. https://doi.org/10.1016/j.jhep.2014.03.021
doi: 10.1016/j.jhep.2014.03.021 pubmed: 24681345
Xie Y, Tu B, Xu Z, Xin Z, Bi J, Zhao M, et al. Bacterial distributions and prognosis of bloodstream infections in patients with liver cirrhosis. Sci Rep. 2017;7:1–9. https://doi.org/10.1038/s41598-017-11587-1
doi: 10.1038/s41598-017-11587-1
Johnson AL, Ratnasekera IU, Irvine KM, Henderson A, Powell EE, Valery PC. Bacteraemia, sepsis and antibiotic resistance in Australian patients with cirrhosis : a population-­based study. BMJ Open Gastroenterol 2021;Dec;8(1):1–12. https://doi.org/10.1136/bmjgast-2021-000695
White K, Tabah A, Ramanan M, Shekar K, Edwards F, Laupland KB. 90-day case-fatality in critically ill patients with chronic liver Disease Influenced by Presence of Portal Hypertension, results from a Multicentre Retrospective Cohort Study. J Intensive Care Med. 2023;38:5–10. https://doi.org/10.1177/08850666221100408
doi: 10.1177/08850666221100408 pubmed: 35892180
Brandolini M, Corbella M, De Silvestri A, Tinelli C, Albonico G, Albertini R, et al. Epidemiological characteristics of bloodstream infections in patients with different degrees of liver disease. Infection. 2015;43:561–7. https://doi.org/10.1007/s15010-015-0794-6
doi: 10.1007/s15010-015-0794-6 pubmed: 25976737
Westphal J, Jehl F, Vetter D, Pharmacological. Toxicologic, and Microbiological considerations in the choice of initial antibiotic therapy for serious infections in patients with cirrhosis of the liver. Clin Infect Dis 1994:324–35.
Bartoletti M, Giannella M, Lewis R, Caraceni P, Tedeschi S, Paul M, et al. A prospective multicentre study of the epidemiology and outcomes of bloodstream infection in cirrhotic patients. Clin Microbiol Infect. 2018;24:4–11. https://doi.org/10.1016/j.cmi.2017.08.001
doi: 10.1016/j.cmi.2017.08.001
Kim M, Cardoso FS, Pawlowski A, Wunderink R, Ladner DP, Abraldes JG, et al. The impact of multidrug-resistant microorganisms on critically ill patients with cirrhosis in the intensive care unit: a cohort study. Hepatol Commun. 2023;7:e0038–0038. https://doi.org/10.1097/hc9.0000000000000038
doi: 10.1097/hc9.0000000000000038 pubmed: 36669500 pmcid: 10019237
Dong Y, Sun D, Wang Y, Du Q, Zhang Y, Han R, et al. Evaluation of the current guidelines for antibacterial therapy strategies in patients with cirrhosis or liver failure. BMC Infect Dis. 2022;22:1–14. https://doi.org/10.1186/s12879-021-07018-2
doi: 10.1186/s12879-021-07018-2
Angeli P, Bernardi M, Villanueva C, Francoz C, Mookerjee RP, Trebicka J, et al. EASL Clinical Practice guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018;69:406–60. https://doi.org/10.1016/j.jhep.2018.03.024
doi: 10.1016/j.jhep.2018.03.024
Hoenigl M, Wagner J, Raggam RB, Prueller F, Prattes J, Eigl S, et al. Characteristics of hospital-acquired and community-onset blood stream infections, South-East Austria. PLoS ONE. 2014;9:4–9. https://doi.org/10.1371/journal.pone.0104702
doi: 10.1371/journal.pone.0104702
Buetti N, Tabah A, Loiodice A, Ruckly S, Aslan AT. Different epidemiology of bloodstream infections in COVID – 19 compared to non – COVID – 19 critically ill patients: a descriptive analysis of the Eurobact II study. Crit Care. 2022;18:1–12. https://doi.org/10.1186/s13054-022-04166-y
doi: 10.1186/s13054-022-04166-y
Gharaibeh A, Koppikar S, Bonilla-Escobar J. Strengthening the reporting of Observational studies in Epidemiology (STROBE) in the International Journal of Medical Students. Int J Med Students. 2014;2:36–7. https://doi.org/10.5195/ijms.2014.76
doi: 10.5195/ijms.2014.76
Charlson ME, Pompei P, Ales KLMC. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83.
doi: 10.1016/0021-9681(87)90171-8 pubmed: 3558716
Uda A, Shigemura K, Kitagawa K, Osawa K, Onuma K, Yan Y, et al. Risk factors for the acquisition of enterococcus faecium infection and mortality in patients with enterococcal bacteremia: a 5-year retrospective analysis in a tertiary care university hospital. Antibiotics. 2021;10:1–11. https://doi.org/10.3390/antibiotics10010064
doi: 10.3390/antibiotics10010064
Billington EO, Phang SH, Gregson DB, Pitout JDD, Ross T, Church DL, et al. Incidence, risk factors, and outcomes for Enterococcus spp. blood stream infections: a population-based study. Int J Infect Dis. 2014;26. https://doi.org/10.1016/j.ijid.2014.02.012
Buetti N, Marschall J, Timsit JF, Atkinson A, Kronenberg A, Sommerstein R, et al. Distribution of pathogens and antimicrobial resistance in bacteraemia according to hospitalization duration: a nationwide surveillance study in Switzerland. Clin Microbiol Infect. 2021;27:1820–5. https://doi.org/10.1016/j.cmi.2021.04.025
doi: 10.1016/j.cmi.2021.04.025 pubmed: 33933567
Cressman AM, MacFadden DR, Verma AA, Razak FDN. Empiric antibiotic treatment thresholds for serious bacterial infections: a scenario-based Survey Study. Clin Infect Dis. 2019;2019:1–24.
Morvan AC, Hengy B, Garrouste-Orgeas M, Ruckly S, Forel JM, Argaud L, et al. Impact of species and antibiotic therapy of enterococcal peritonitis on 30-day mortality in critical care - an analysis of the OUTCOMEREA database. Crit Care. 2019;23:1–10. https://doi.org/10.1186/s13054-019-2581-8
doi: 10.1186/s13054-019-2581-8
Theocharidou E, Agarwal B, Jeffrey G, Jalan R, Harrison D, Burroughs AK, et al. Early invasive fungal infections and colonization in patients with cirrhosis admitted to the intensive care unit. Clin Microbiol Infect. 2016;22. https://doi.org/10.1016/j.cmi.2015.10.020 . :189.e1-189.e7.
Rasool S, Babar AN, Shafquat U, Azhar S, Khan RR. Fungal infections in patients with chronic liver disease: mortality and associated risk factors. Int J Res Med Sci. 2019;7:3882. https://doi.org/10.18203/2320-6012.ijrms20194326
doi: 10.18203/2320-6012.ijrms20194326
Bajaj JS, Leary JGO, Tandon P, Wong F, Garcia-tsao G, Kamath PS, et al. Outcomes in hospitalized patients with cirrhosis. Am J Infect Dis. 2020;3:1091–100. https://doi.org/10.14309/ajg.0000000000000280.Nosocomial
doi: 10.14309/ajg.0000000000000280.Nosocomial
Vincent JL. Nosocomial infections in adult intensive-care units. Lancet. 2003;361:2068–77. https://doi.org/10.1016/S0140-6736(03)13644-6
doi: 10.1016/S0140-6736(03)13644-6 pubmed: 12814731

Auteurs

Hannah Wozniak (H)

Division of Critical Care, Department of Acute Medicine, University Hospital of Geneva, University of Geneva, Geneva, Switzerland. Hannah.wozniak@hcuge.ch.
Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada. Hannah.wozniak@hcuge.ch.
ORCID: 0000-0001-5404-4621

Alexis Tabah (A)

Intensive Care Unit, Redcliffe Hospital, Brisbane, Australia.
Queensland Critical Care Research Network (QCCRN), Brisbane, QLD, Australia.
Queensland University of Technology, Brisbane, QLD, Australia.
Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.

François Barbier (F)

Service de Médecine Intensive-Réanimation, Centre Hospitalier Régional d'Orléans, Orléans, France.

Stéphane Ruckly (S)

Université de Paris, INSERM, IAME UMR 1137, Paris, 75018, France.
ICUREsearch, Biometry, Fontaine, 38600, France.

Ambre Loiodice (A)

ICUREsearch, Biometry, Fontaine, 38600, France.

Murat Akova (M)

Department of Infectious Diseases, Hacettepe University School of Medicine, Ankara, Turkey.

Marc Leone (M)

Department of Anesthesiology and Intensive Care Unit, Hospital Nord, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Marseille, France.

Andrew Conway Morris (A)

Division of Anaesthesia, Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK.
Division of Immunology, Department of Pathology, University of Cambridge, Tennis Court Road, Cambridge, Cb2 1QP, UK.
JVF Intensive Care Unit, Addenbrooke's Hospital, Cambridge, Hills Road, Cambridge, CB2 0QQ, UK.

Matteo Bassetti (M)

Infectious Diseases Clinic, Department of Health Sciences, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy.

Kostoula Arvaniti (K)

Intensive Care Unit, Papageorgiou University Affiliated Hospital, Thessaloníki, Greece.

Ricard Ferrer (R)

Intensive Care Department, SODIR-VHIR Research Group, Vall d'Hebron University Hospital, Barcelona, Spain.

Liesbet de Bus (L)

Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium.
Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.

Jose Artur Paiva (JA)

Intensive Care Medicine Department, Centro Hospitalar Universitário São João (CHUSJ), Porto, Portugal.
Department of Medicine, Faculty of Medicine, University of Porto (FMUP), Porto, Portugal.

Hendrik Bracht (H)

Central Interdisciplinary Emergency Medicine, University Hospital Ulm, Ulm, Germany.

Adam Mikstacki (A)

Faculty of Health Sciences, Poznan University of Medical Sciences, Poznan, Poland.
Department of Anaesthesiology and Intensive Therapy, Regional Hospital in Poznan, Poznan, Poland.

Adel Alsisi (A)

ICU Department, Prime Hospital, Dubai, United Arab Emirates.
Critical Care Department, Faculty of Medicine, Cairo University, Cairo, Egypt.

Liana Valeanu (L)

Cardiac Anesthesiology and Intensive Care Department I, Emergency Institute for Cardiovascular Diseases Prof. Dr. C. C. Iliescu, Bucharest, Romania.

Josef Prazak (J)

Department of Intensive Care Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland.

Jean-François Timsit (JF)

Université Paris- Cité, INSERM, IAME UMR 1137, Paris, 75018, France.
Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, Paris, France.

Niccolò Buetti (N)

Université Paris- Cité, INSERM, IAME UMR 1137, Paris, 75018, France.
Infection Control Program and World Health Organization Collaborating Centre on Patient Safety, Faculty of Medicine, University Hospitals, University of Geneva, Geneva, Switzerland.

Classifications MeSH