Sustained impact of nosocomial-acquired spontaneous bacterial peritonitis in different stages of decompensated liver cirrhosis

Markus Kimmann; Tammo Lambert Tergast; Marie Schultalbers; Hans Laser; Svetlana Gerbel; Michael Peter Manns; Markus Cornberg; Benjamin Maasoumy

doi:10.1371/journal.pone.0220666

Sustained impact of nosocomial-acquired spontaneous bacterial peritonitis in different stages of decompensated liver cirrhosis

PLoS One. 2019 Aug 2;14(8):e0220666. doi: 10.1371/journal.pone.0220666. eCollection 2019.

Authors

Markus Kimmann¹, Tammo Lambert Tergast¹, Marie Schultalbers¹, Hans Laser², Svetlana Gerbel², Michael Peter Manns^{1

3

4}, Markus Cornberg^{1

3

4}, Benjamin Maasoumy^{1

3}

Affiliations

¹ Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany.
² Centre for Information Management (ZIMT), Hannover Medical School, Hannover, Germany.
³ German Centre for Infection Research (Deutsches Zentrum für Infektionsforschung DZIF), Partner-site Hannover-Braunschweig, Hannover, Germany.
⁴ Centre for Individualised Infection Medicine (CIIM), Hannover, Germany.

Abstract

Background & aims: Bacterial infections, in particular a spontaneous bacterial peritonitis (SBP), are a major threat in patients with liver cirrhosis. Recently, it has been shown that the impact on mortality might be underestimated by established risk-scores. Onset of infection was suggested to define a distinct stage of cirrhosis. However, it remains unclear whether all stages of decompensated cirrhosis are equally affected. Moreover, if there is such a distinct stage, it must be determined whether it is reversible after the infection has resolved. In this study we aimed to further analyze the impact of a current as well as a resolved SBP in different stages of decompensated liver cirrhosis.

Methods: A number of 579 patients with liver cirrhosis and ascites were included. MELD-score was used to determine the stage of liver disease. Low (<15), intermediate (15-25) and high (>25) MELD-groups were compared. Patients were followed up for 90 days. Primary endpoint was overall mortality. Statistical analyses were performed using the log-rank test, Cox regression and competing risk analysis.

Results: Mortality was significantly higher in patients with nosocomial-acquired SBP (nSBP) compared to patients without SBP (p<0.001;HR = 2.05). However, the most prominent difference in mortality was documented in the intermediate MELD-group (nSBP: p = 0.02;HR = 2.10). Importantly, mortality in nSBP patients remained increased even after the initial nSBP episode had resolved (p<0.01;HR = 1.90). Again, this was only significant in those with intermediate MELD-scores (p = 0.02;HR = 2.28). While a current as well as a resolved nSBP were significantly linked to a higher mortality, neither of them did increase the likelihood for liver transplantation.

Conclusions: Development of nSBP is independently associated with increased mortality supporting the concept of a distinct status of cirrhosis. Importantly, the prognosis remains unfavorable even after resolution of nSBP. This could be particularly relevant for patients with intermediate MELD-scores, who have limited chances for a donor liver.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Aged
Cross Infection / complications*
Cross Infection / mortality
End Stage Liver Disease / complications*
End Stage Liver Disease / mortality
Female
Humans
Liver Cirrhosis / complications*
Liver Cirrhosis / mortality
Male
Middle Aged
Peritonitis / complications*
Peritonitis / microbiology
Peritonitis / mortality
Prognosis
Survival Rate

Grants and funding

T.L.T. and this study were supported by the ‘KlinStrucMed’ Programme funded by the Else Kröner-Fresenius Foundation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.