Prevalence and Predictors of Bacterial Infection in Hospitalized Patients with Liver Cirrhosis

Abstract

Background

Infections adversely affect the prognosis of patients with liver cirrhosis. The study aimed to analyze the prevalence and the predictors of infections in patients admitted with cirrhosis.

Methods

After obtaining ethical approval, this retrospective study was conducted at a tertiary care center between April 2021 and January 2024. All the patients admitted with cirrhosis were included. Infections were identified according to the standard definitions.

Results

Of the 417 patients (mean age: 54.28 ± 12.61 years; male: 299 [71.70%]), 375 (89.92%) had alcohol-related cirrhosis. The mean Child–Turcotte–Pugh (CTP), Model for End-Stage Liver Disease (MELD), and Model for End-Stage Liver Disease with sodium (MELD-Na) scores were 9.6 ± 2.2, 18.3 ± 8.3, and 20.1 ± 8.3, respectively. Infections were seen in 62 (14.86%) patients. The most prevalent infections were urinary tract infection (26 [6.23%]), spontaneous bacterial peritonitis (18 [4.31%]), bloodstream infection (7 [1.67%]), pneumonia (5 [1.19%]), cellulitis (4 [0.95%]), tuberculosis (3 [0.71%]), and upper respiratory tract infection (2 [0.47%]). Patients with infection had significantly high MELD (p = 0.01) and MELD-Na (p = 0.00) scores, and low albumin (p = 0.04) and sodium (p < 0.001) levels. On univariate analysis, ascites (odds ratio [OR]: 1.85; 95% confidence interval [CI]: 1.07–3.19; p = 0.02), gastrointestinal bleeding (OR: 0.50; 95% CI: 0.26–0.98; p = 0.04), MELD (OR: 1.04; 95% CI: 1.00–1.07; p = 0.01), MELD-Na (OR: 1.05; 95% CI: 1.01–1.08; p < 0.001), albumin (OR: 0.59; 95% CI: 0.36–0.98; p = 0.04), and sodium (OR: 0.93; 95% CI: 0.89–0.98; p < 0.001) predicted the presence of infection. On multivariate analysis, ascites (OR: 2.95; 95% CI: 1.06–8.17; p = 0.03) and the presence of comorbidity (OR: 2.74; 95% CI: 1.02–7.31; p = 0.04) were the only predictors of infection.

Conclusion

Infections were present in approximately 15% of the patients with cirrhosis. The presence of ascites and comorbidities predicted infection in admitted cirrhotic patients.

Keywords

infections - liver cirrhosis - peritonitis - predictor - prevalence

Introduction

Cirrhosis is a late stage of any chronic liver disease. It is characterized by the replacement of healthy liver tissue with fibrous tissue. The liver is a major organ of the immune system.[1] This is why the development of cirrhosis results in a state of acquired immune deficiency with a heightened risk of infection.[2] [3] The commonest infections associated with cirrhosis are bacterial. The prevalence and types of infections vary across the continents.[4] The development of infection marks a remarkable event in the natural course of patients with cirrhosis, as it portends a poor prognosis. Infection results in multiorgan failure and a high mortality.[5] The scenario is complicated further by the emergence of multidrug-resistant infections, with the highest prevalence being in Asian countries.[4] Although patients with cirrhosis form the majority of those hospitalized in gastroenterology wards, the data on infection among these patients are practically lacking in this part of the world.

Methods

This retrospective study was conducted at Chitwan Medical College, Bharatpur, Nepal. We collected data for the period between April 2021 and January 2024, after obtaining clearance from the institute's ethics committee with approval number CMC-IRC/080/081–089. All the consecutive patients admitted with cirrhosis were included. Those patients with incomplete details in the record sheets were excluded. Being a retrospective study, the consent of the patient was waived. Data were retrieved from the database of the hospital. Details of patients' demographic features, reason for admission, etiology, severity scores, complications of cirrhosis, infections, laboratory parameters, hospital stay, and outcome in the form of either recovery and discharge or death were noted in a predefined proforma. The current study aimed to evaluate the prevalence and predictors of infection in patients with liver cirrhosis.

Infections were diagnosed based on the following definitions:

• Spontaneous bacterial peritonitis (SBP): An absolute neutrophil count in ascitic fluid greater than 250 cells/mm³ with or without a positive culture report.[6]

• Urinary tract infection (UTI): Presence of one of the following signs or symptoms (fever 38°C, urgency, frequency, dysuria, or suprapubic tenderness) in addition to a positive urine culture or two of the following signs or symptoms (fever 38°C, dysuria, urgency, frequency, or suprapubic tenderness) with greater than 10 leukocytes/mL in urine.[7]

• Pneumonia: Chest imaging with a new or progression of a previous pulmonary infiltrate, consolidation, or cavitation and one of the following criteria (fever 38°C, leucocyte count >12,000/mm³ or <4,000/mm³) plus one of the following symptoms (new onset of purulent sputum or change in the character of sputum, new onset of cough, dyspnea, or tachypnea >20 breaths per minute, crepitations or bronchial breath sounds) and/or organisms isolated from blood, pleural fluid, or a specimen obtained by transtracheal aspirate and bronchoalveolar lavage.[7]

• Fever: A rectal temperature of 37.5°C to 38.3°C, an axillary temperature greater than 37.2°C, an oral temperature greater than 37.2°C in the morning, or an oral temperature greater than 37.7°C in the late afternoon.[8]

• Bacteremia: The presence of at least one blood culture for bacteria in addition to clinical signs and symptoms of infection.[9]

• Cellulitis: Cellulitis was diagnosed as an erythematous, warm, and edematous tender area of skin without underlying deep vein thrombosis and abscess on color Doppler imaging.[10]

Sample size: Being a retrospective study, we included all the patients within the defined study period.

Statistical Analysis

Data were analyzed using STATA. We expressed categorical variables as numbers (%). Continuous variables with normal and skewed distributions were expressed as mean ± standard deviation (SD) and median (interquartile range [IQR]), respectively. The significance of the difference for categorical variables was calculated using the chi-square test, and that for continuous variables was calculated using Student's t-test. Univariate and multivariate regression analyses were utilized to assess the predictors of infection, where infection was considered the dependent variable. Parameters that had a p-value of less than 0.1 on univariate analysis were considered for multivariate analysis. A p-value of less than 0.05 was considered significant.

Results

Baseline Characteristics

A total of 417 cirrhotic patients were included in this study. The mean age of the study population was 54.28 ± 12.61 years and comprised 299 (71.70%) male patients. The commonest etiology of cirrhosis was alcohol in 375 (89.92%) patients followed by nonalcoholic steatohepatitis (NASH) in 32 (7.67%), hepatitis B virus infection in 3 (0.71%), hepatic venous outflow tract obstruction in 3 (0.71%), cryptogenic in 2 (0.47%), autoimmune hepatitis and hepatitis C virus infection in 1 (0.24%) patient each. The mean Child–Turcotte–Pugh (CTP) score was 9.6 ± 2.2, with 25 (5.99%), 177 (42.44%), and 215 (51.55%) patients classified as CTP-A, CTP-B, and CTP-C, respectively. The Model for End-Stage Liver Disease (MELD) and Model for End-Stage Liver Disease with sodium (MELD-Na) scores were 18.3 ± 8.3 and 20.1 ± 8.3, respectively. The remaining baseline features are shown in [Table 1].

Table 1 Baseline characteristics

Characteristics	Total cohort (n = 417)
Age, mean ± SD (y)	54.28 ± 12.61
Male, n (%)	299 (71.70)
Comorbidities, n (%)	170 (40.76)
Hypertension	91 (21.82)
Diabetes	78 (18.70)
Hypothyroidism	23 (5.51)
Chronic obstructive pulmonary disease	10 (2.39)
Coronary artery disease	10 (2.39)
Chronic kidney disease	11 (2.63)
Etiology of CLD, n (%)
Alcohol	375 (89.92)
Nonalcoholic steatohepatitis	32 (7.67)
Hepatitis B virus	3 (0.71)
Hepatic veinous outflow tract obstruction	3 (0.71)
Cryptogenic	2 (0.47)
Hepatitis C virus	1 (0.24)
Autoimmune hepatitis	1 (0.24)
Presentation, n (%)
Ascites	181 (43.40)
Gastrointestinal bleed	127 (30.45)
Jaundice	103 (24.70)
Hepatic encephalopathy	45 (10.79)
Hepatocellular carcinoma	17 (4.07)
Other presentations	17 (4.07)
CTP, mean ± SD	9.6 ± 2.2
CTP-A, n (%)	25 (5.99)
CTP-B, n (%)	177 (42.44)
CTP-C, n (%)	215 (51.55)
Acute on chronic liver failure (ACLF), n (%)	79 (18.94)
MELD, mean ± SD	18.3 ± 8.3
MELD-Na, mean ± SD	20.1 ± 8.3
Duration of disease (mo), median (IQR)	5 (1–24)
Duration of hospital stay (d), median (IQR)	4 (2–6)
Outcome
Discharge, n (%)	281 (67.38)
Discharge on request, n (%)	73 (17.50)
Leave against medical advice, n (%)	41 (9.83)
Death, n (%)	22 (5.27)

Abbreviations: CLD, chronic liver disease; CTP, Child–Turcotte–Pugh; IQR, interquartile range; MELD, Model for End-Stage Liver Disease; MELD-Na, MELD with sodium; SD, standard deviation.

Prevalence of Infection

Infection of any kind was seen in 62 (14.86%) patients admitted with liver cirrhosis. The most prevalent infection was UTI, seen in 26 (6.23%) patients. SBP was seen in 18 (4.31%) patients. Other infections were bloodstream infection (bacteremia) in 7 (1.67%), pneumonia in 5 (1.19%), cellulitis in 4 (0.95%), tuberculosis in 3 (0.71%), and upper respiratory tract infections in 2 (0.47%) patients ([Table 2]). Among the patients with infection, three (4.83%) patients had two types of infections.

Table 2 Infections in the entire cohort

Infections of any kind, n (%)	62 (14.86)
Urinary tract infections	26 (6.23)
Spontaneous bacterial peritonitis	18 (4.31)
Bloodstream infection	7 (1.67)
Community-acquired pneumonia	5 (1.19)
Cellulitis	4 (0.95)
Tuberculosis	3 (0.71)
Upper respiratory tract infection	2 (0.47)

Note: Three patients had two types of infections.

Higher scores of MELD (21.1 ± 9.1 vs. 17.8 ± 8.1, p = 0.01) and MELD-Na (23.3 ± 9.2 vs. 19.5 ± 7.9, p < 0.001), and lower levels of serum albumin (2.50 ± 0.56 vs. 2.68 ± 0.61, p = 0.04) and serum sodium (134 ± 5.89 vs 136.7 ± 6.09, p < 0.001) were significantly associated with infection ([Table 3]). The total hospital stay (4.74 ± 3.86 vs. 4.0 ± 3.64 days; p = 0.63) and mortality (5 [8.06%] vs. 17 [4.78%], p = 0.28) were comparable in patients with and without infection.

Table 3 Associated factors in patients with and without infections

	Patients with infection (n = 62)	Patients without infection (n = 355)	p-value
Male, n (%)	43 (69.35)	256 (72.11)	0.65
Age, mean ± SD	54.2 ± 14.0	54.2 ± 12.36	0.96
Duration of hospital stay (d)	4.74 ± 3.86	4.0 ± 3.64	0.63
Type of discharge, n (%)
Discharge	34 (54.83)	247 (69.57)	0.13
Discharge on request	12 (19.35)	61 (17.18)
Leave against medical advice	9 (14.51)	32 (9.01)
Death	5 (8.06)	17 (4.78)	0.28
Any comorbidities, n (%)	32 (51.61)	138 (38.87)	0.06
Hepatocellular carcinoma, n (%)	2 (3.22)	15 (4.22)	0.71
ACLF, n (%)	16 (25.80)	63 (17.74)	0.13
Overall CTP, mean ± SD	10.1 ± 2.4	9.5 ± 2.1	0.05
CTP-A, n (%)	1 (1.61)	24 (6.76)	0.21
CTP-B, n (%)	25 (40.32)	152 (42.81)
CTP-C, n (%)	36 (58.06)	179 (50.42)
MELD, mean ± SD	21.1 ± 9.1	17.8 ± 8.1	0.01
MELD-Na, mean ± SD	23.3 ± 9.2	19.5 ± 7.9	< 0.001
INR, mean ± SD	1.76 ± 0.59	1.54 ± 0.52	0.05
Hemoglobin (g/dL), mean ± SD	9.4 ± 2.2	9.2 ± 2.3	0.57
Total leucocyte count, mean ± SD	9494.3 ± 6532.2	8400.3 ± 10930	0.46
Serum creatinine (mg/dL), mean ± SD	1.62 ± 1.78	1.34 ± 1.09	0.11
Total bilirubin (mg/dL), mean ± SD	5.07 ± 5.62	5.30 ± 6.8	0.80
Total protein (mg/dL), mean ± SD	6.60 ± 1.12	6.83 ± 3.47	0.63
Serum albumin (mg/dL), mean ± SD	2.50 ± 0.56	2.68 ± 0.61	0.04
Serum sodium (mEq/L), mean ± SD	134 ± 5.89	136.7 ± 6.09	< 0.001

Abbreviations: ACLF, acute on chronic liver failure; CTP, Child–Turcotte–Pugh; INR, international normalized ratio; MELD, Model for End-Stage Liver Disease; MELD-Na, MELD with sodium; SD, standard deviation.

Predictors of Infections

Different parameters, which included patients' demographic features, presentations, disease severity scores, and laboratory parameters, were assessed for predictive potential for infection. On univariate analysis, presence of ascites (OR: 1.85; 95% CI: 1.07–3.19; p = 0.02), gastrointestinal bleeding (OR: 0.50; 95% CI: 0.26–0.98; p = 0.04), MELD score (OR: 1.04; 95% CI: 1.00–1.07; p = 0.01), MELD-Na score (OR: 1.05; 95% CI: 1.01–1.08; p < 0.001), serum albumin (OR: 0.59; 95% CI: 0.36–0.98; p = 0.04), and serum sodium level (OR: 0.93; 95% CI: 0.89–0.98; p < 0.001) were the predictors of infection ([Table 4]). On multivariate analysis, however, ascites (OR: 2.95; 95% CI: 1.06–8.17; p = 0.03) and the presence of comorbidity (OR: 2.74; 95% CI: 1.02–7.31; p = 0.04) were the only predictors of infection ([Table 4]).

Table 4 Predictors of infection (univariate and multivariate analysis)

Predictors	Univariate analysis			Multivariate analysis
	Odds ratio	95% CI	p-value	Odds ratio	95% CI	p-value
Male sex	1.14	0.63–2.05	0.65
Age	0.99	0.97–1.02	0.96
Disease duration	1.00	0.99–1.01	0.37
Ascites	1.85	1.07–3.19	0.02	2.95	1.06–8.17	0.03
GI bleeding	0.50	0.26–0.98	0.04	0.16	0.01–1.44	0.10
HE	1.04	0.41–2.61	0.92
AKI	1.09	0.61–1.94	0.75
Any Comorbidities	1.67	0.97–2.88	0.06	2.74	1.02–7.31	0.04
HCC	1.32	0.29–5.93	0.71
ACLF	1.61	0.85–3.02	0.13
CTP	1.12	0.99–1.27	0.05	1.05	0.71–1.55	0.79
MELD	1.04	1.00–1.07	0.01	0.96	0.83–1.10	0.59
MELD-Na	1.05	1.01–1.08	<0.001	1.05	0.90–1.23	0.47
Albumin	0.59	0.36–0.98	0.04	0.95	0.37–2.43	0.91
INR	1.8	0.96–3.35	0.06	1.27	0.40–3.96	0.68
Total bilirubin	0.99	0.95–1.03	0.80
Serum sodium	0.93	0.89–0.98	<0.001	0.93	0.84–1.02	0.15
Serum creatinine	1.16	0.95–1.40	0.12
Hemoglobin	1.03	0.91–1.16	0.57
TLC	1.00	0.99–1.00	0.48

Abbreviations: ACLF, acute on chronic liver failure; AKI, acute kidney injury; CI, confidence interval; CTP, Child–Turcotte–Pugh; GI, gastrointestinal; HCC, hepatocellular carcinoma; HE, hepatic encephalopathy; INR, international normalized ratio; MELD, Model for End-Stage Liver Disease; MELD-Na, MELD with sodium; TLC, total leukocyte count.

Discussion

In this single-center retrospective study, we found that infection was prevalent in 62 (14.86%) admitted cirrhotic patients. The commonest infection was found to be UTI in 6.23%, followed by SBP in 4.31%, bloodstream infection in 1.67%, and pneumonia in 1.19% of patients. Cellulitis, tuberculosis, and upper respiratory tract infections each were present in less than 1% of the patients. Higher MELD and MELD-Na scores and lower serum albumin and serum sodium levels were significantly associated with the presence of infection. Among the different parameters analyzed, only the presence of ascites and comorbidities were found to predict the occurrence of infection. This is by far the first study from Nepal that deals with this important aspect of patients with cirrhosis.

Bacterial infection is a common phenomenon in cirrhotic patients.[11] Although death due to various complications of cirrhosis is on the decline, sepsis as a cause of death has been rising.[12] It is of note that bacterial infection is found to precipitate multiorgan failure and increase hospital stay and mortality by fourfold.[13] The prevalence of infection in cirrhotic patients is found to be 25 to 37.5% in studies across the world.[14] [15] [16] The prevalence of infection in the reported literature is higher compared to the current study. This finding could be because of differences in patient profiles. The commonest etiology of cirrhosis in the current study was alcohol (89.92%). The mean CTP, MELD, and MELD-Na scores in the current study were lower compared with the other studies. It is seen that a more severe disease portends a heightened odds of infection.[17] [18] [19] Moreover, the shorter median hospital stay in the current study (4 [2–6] days) could also explain a lower prevalence of infection. In addition, most of the patients receive many over-the-counter antibacterials before finally getting admitted. This antibiotic exposure could have lead to a lower rate of diagnosis of bacterial infection in the current cohort. However, in the study by Yoshida et al, bacterial infection was found to be present in 15.3% of patients, which is similar to the prevalence in our study (14.86%).[17]

The commonest bacterial infections in the current study were UTI and SBP. The other common infections were bloodstream infections, pneumonia, cellulitis, tuberculosis, and upper respiratory tract infections. A similar trend is also seen in studies from different parts of the world.[14] [16] [20] [21] In a recent multicenter global study, UTI, SBP, and pneumonia were the commonest infections in Asia, America, and Europe. Soft tissue infections/cellulitis and bloodstream infections were less common.[4] Hence, the pattern of bacterial infection in the current study is similar to other studies across the world.

A higher MELD and MELD-Na scores, and lower serum sodium and albumin levels showed a significant association with infection in the current study. Prior studies have also depicted an association of higher MELD scores with infection.[22] In the study by Yoshida et al, where they graded the liver disease severity as per CTP score, they found that severe disease, as indicated by higher CTP scores, had a higher prevalence of infection compared with low CTP scores.[17] A low serum albumin being a part of the CTP score, and a low serum sodium being a part of the MELD-Na score, might be associated with a higher prevalence of infection, as shown in our study. Similarly, a prospective hospital-based study showed that CTP score, MELD-Na score, sodium level, international normalized ratio (INR), and albumin level were predictors of infection on univariate analysis. However, these parameters did not predict infection on multivariate analysis.[23] It is seen that ascites and bleeding predict infection in patients with cirrhosis.[11] In the present study, ascites was found to predict infection. This could be because SBP, which was the second most common infection in the current study, occurs only in the presence of ascites. The presence of comorbidities was found to be another predictor of infection in the present study. This is a new finding in this study. There are sparse data on comorbidities in patients with liver cirrhosis and their effect on outcome.[24] This finding is likely because comorbidities like diabetes and chronic kidney disease are known states of immune dysfunction that predispose to infection.[25] [26]

No association was found between infection and mortality in the current study. A major reason for this could be a short median hospital stay of 4 days, as a short hospital stay would lead to less in-hospital mortality. It is important to acknowledge that terminal patients with grave outcomes, like those with end-stage liver disease, tend to be taken LAMA (leave against medical advice) by relatives, given the financial constraints in our setting. There were 41 critically ill patients in this study cohort who were taken home against medical advice. This could be a possible reason for the reported low mortality and hence the above finding.

To the best of our understanding, the current study is the first one from this part of the world that looked at infections in patients admitted with liver cirrhosis. The study is backed up by a large sample size. However, certain limitations need discussion. Being a retrospective design, the current study is prone to the disadvantages that are inherent to any retrospective study. This is a single-center study and might not be representative of the entire country, especially regarding the prevalence of infection. The pattern of the organism and hence the infection vary according to the health care settings. We did not assess the isolated organisms and multidrug resistance. In the current study, infections were not categorized into community-acquired, health care–associated, and nosocomial infections. The study does not discuss the biomarkers of infection, like procalcitonin, β-D-glucan, and galactomannan. These tests are expensive and have been assessed only in very few patients. We order procalcitonin only when a bacterial infection is suspected, but the diagnosis is in doubt. The biomarkers for fungal infections, galactomannan and β-D-glucan, are ordered only in patients with risk factors for fungal infection who are not responding to antibiotics. Moreover, biomarker assessment is not done routinely as these tests are not available at our center, and samples have to be sent outside, which takes a week for results to be available. The findings of this study imply that cirrhotic patients with ascites and other comorbid conditions are likely to develop bacterial infections. In case of deterioration in general conditions, these patients should be tested and treated for bacterial infection.

Conclusion

Patients admitted with liver cirrhosis are at heightened risk of infection. The most prevalent infections in these patients are UTI and SBP. Other less common infections are pneumonia, bloodstream infection, cellulitis, and tuberculosis. Although the pattern of infections in the current study is similar to that seen in the data available from the rest of the world, the prevalence of infection is relatively lower. A prospective study can provide further insight into this aspect.

Conflict of Interest

None declared.

Acknowledgments

None.

Ethical Approval

The institute review committee (IRC) approved this study (approval number: CMC-IRC/080/081–089).

Consent to Participate

Since this was a retrospective study, consent was not required.

Authors' Contributions

M.K.R. was involved in conceptualization, data collection, supervision, data analysis, manuscript writing, revision, and editing. P.N., B.M., and R.K.Y. contributed to data collection, literature review, data analysis, manuscript writing, and editing. A.S., H.S., N.P., and A.T. were responsible for data collection, literature review, data analysis, and manuscript writing.

Data Availability Statement

The data can be obtained from the corresponding author, provided there is a genuine request.

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Publication History

Received: 28 December 2024

Accepted: 23 February 2025

Article published online:
22 May 2025