Introduction Patients with cirrhosis have a high risk of sepsis, which confers a poor prognosis. The systemic inflammatory response syndrome (SIRS) criteria have several limitations in cirrhosis. Recently, new criteria for sepsis (Sepsis-3) have been suggested in the general population (increase of Sequential Organ Failure Assessment (SOFA) ≥2 points from baseline). Outside the intensive care unit (ICU), the quick SOFA (qSOFA (at least two among alteration in mental status, systolic blood pressure ≤100 mm Hg or respiratory rate ≥22/min)) was suggested to screen for sepsis. These criteria have never been evaluated in patients with cirrhosis. The aim of the study was to assess the ability of Sepsis-3 criteria in predicting in-hospital mortality in patients with cirrhosis and bacterial/fungal infections.
Methods 259 consecutive patients with cirrhosis and bacterial/fungal infections were prospectively included. Demographic, laboratory and microbiological data were collected at diagnosis of infection. Baseline SOFA was assessed using preadmission data. Patients were followed up until death, liver transplantation or discharge. Findings were externally validated (197 patients).
Results Sepsis-3 and qSOFA had significantly greater discrimination for in-hospital mortality (area under the receiver operating characteristic (AUROC)=0.784 and 0.732, respectively) than SIRS (AUROC=0.606) (p<0.01 for both). Similar results were observed in the validation cohort. Sepsis-3 (subdistribution HR (sHR)=5.47; p=0.006), qSOFA (sHR=1.99; p=0.020), Chronic Liver Failure Consortium Acute Decompensation score (sHR=1.05; p=0.001) and C reactive protein (sHR=1.01;p=0.034) were found to be independent predictors of in-hospital mortality. Patients with Sepsis-3 had higher incidence of acute-on-chronic liver failure, septic shock and transfer to ICU than those without Sepsis-3.
Conclusions Sepsis-3 criteria are more accurate than SIRS criteria in predicting the severity of infections in patients with cirrhosis. qSOFA is a useful bedside tool to assess risk for worse outcomes in these patients. Patients with Sepsis-3 and positive qSOFA deserve more intensive management and strict surveillance.
- acute on chronic liver failure
- septic shock
- liver transplantation
- liver cirrhosis
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SP and MB contributed equally.
Contributors SP: Study concept and design, collection of data, analysis and interpretation of data, drafting of the manuscript. MiB: Study design, collection of data, interpretation of data, drafting of the manuscript, critical revision for important intellectual content. MT, MaBa, GC, AR, EV, CP, MS: Collection of data. AB: technical support. MD, PV, MaBe: Study supervision, critical revision for important intellectual content. ACF: Statistical analysis. PC: Study concept and design, study supervision, drafting of the manuscript, critical revision for important intellectual content. PA: Study concept and design, study supervision, interpretation of data, drafting of the manuscript, critical revision for important intellectual content.
Funding The study was supported by a grant from the Italian Ministry of Education, University and Research (DOR1678487/16), a grant from the Italian Ministry of Health (rf-2010-2310623) and a grant from the Emilia-Romagna Region (PRUa1GR-2012-002).
Competing interests None declared.
Patient consent Obtained.
Ethics approval Ethics committee of the University Hospital of Padova; ethics committee of the University Hospital of Bologna.
Provenance and peer review Not commissioned; externally peer reviewed.