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

Hannah Wozniak; Alexis Tabah; François Barbier; Stéphane Ruckly; Ambre Loiodice; Murat Akova; Marc Leone; Andrew Conway Morris; Matteo Bassetti; Kostoula Arvaniti; Ricard Ferrer; Liesbet de Bus; Jose Artur Paiva; Hendrik Bracht; Adam Mikstacki; Adel Alsisi; Liana Valeanu; Josef Prazak; Jean-François Timsit; Niccolò Buetti; EUROBACT-2 Study Group, ESICM, ESCMID ESGCIP and the OUTCOMEREA Network

doi:10.1186/s13613-024-01299-x

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

Ann Intensive Care. 2024 May 2;14(1):70. doi: 10.1186/s13613-024-01299-x.

Authors

Hannah Wozniak^{1

2}, Alexis Tabah^{3

4

5

6}, François Barbier⁷, Stéphane Ruckly^{8

9}, Ambre Loiodice⁹, Murat Akova¹⁰, Marc Leone¹¹, Andrew Conway Morris^{12

13

14}, Matteo Bassetti¹⁵, Kostoula Arvaniti¹⁶, Ricard Ferrer¹⁷, Liesbet de Bus^{18

19}, Jose Artur Paiva^{20

21}, Hendrik Bracht²², Adam Mikstacki^{23

24}, Adel Alsisi^{25

26}, Liana Valeanu²⁷, Josef Prazak²⁸, Jean-François Timsit^{29

30}, Niccolò Buetti^{29

31}; EUROBACT-2 Study Group, ESICM, ESCMID ESGCIP and the OUTCOMEREA Network

Affiliations

¹ Division of Critical Care, Department of Acute Medicine, University Hospital of Geneva, University of Geneva, Geneva, Switzerland. Hannah.wozniak@hcuge.ch.
² Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada. Hannah.wozniak@hcuge.ch.
³ Intensive Care Unit, Redcliffe Hospital, Brisbane, Australia.
⁴ Queensland Critical Care Research Network (QCCRN), Brisbane, QLD, Australia.
⁵ Queensland University of Technology, Brisbane, QLD, Australia.
⁶ Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.
⁷ Service de Médecine Intensive-Réanimation, Centre Hospitalier Régional d'Orléans, Orléans, France.
⁸ Université de Paris, INSERM, IAME UMR 1137, Paris, 75018, France.
⁹ ICUREsearch, Biometry, Fontaine, 38600, France.
¹⁰ Department of Infectious Diseases, Hacettepe University School of Medicine, Ankara, Turkey.
¹¹ Department of Anesthesiology and Intensive Care Unit, Hospital Nord, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Marseille, France.
¹² Division of Anaesthesia, Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK.
¹³ Division of Immunology, Department of Pathology, University of Cambridge, Tennis Court Road, Cambridge, Cb2 1QP, UK.
¹⁴ JVF Intensive Care Unit, Addenbrooke's Hospital, Cambridge, Hills Road, Cambridge, CB2 0QQ, UK.
¹⁵ Infectious Diseases Clinic, Department of Health Sciences, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy.
¹⁶ Intensive Care Unit, Papageorgiou University Affiliated Hospital, Thessaloníki, Greece.
¹⁷ Intensive Care Department, SODIR-VHIR Research Group, Vall d'Hebron University Hospital, Barcelona, Spain.
¹⁸ Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium.
¹⁹ Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.
²⁰ Intensive Care Medicine Department, Centro Hospitalar Universitário São João (CHUSJ), Porto, Portugal.
²¹ Department of Medicine, Faculty of Medicine, University of Porto (FMUP), Porto, Portugal.
²² Central Interdisciplinary Emergency Medicine, University Hospital Ulm, Ulm, Germany.
²³ Faculty of Health Sciences, Poznan University of Medical Sciences, Poznan, Poland.
²⁴ Department of Anaesthesiology and Intensive Therapy, Regional Hospital in Poznan, Poznan, Poland.
²⁵ ICU Department, Prime Hospital, Dubai, United Arab Emirates.
²⁶ Critical Care Department, Faculty of Medicine, Cairo University, Cairo, Egypt.
²⁷ Cardiac Anesthesiology and Intensive Care Department I, Emergency Institute for Cardiovascular Diseases Prof. Dr. C. C. Iliescu, Bucharest, Romania.
²⁸ Department of Intensive Care Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland.
²⁹ Université Paris- Cité, INSERM, IAME UMR 1137, Paris, 75018, France.
³⁰ Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, Paris, France.
³¹ Infection Control Program and World Health Organization Collaborating Centre on Patient Safety, Faculty of Medicine, University Hospitals, University of Geneva, Geneva, Switzerland.

Abstract

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: 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: 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: Critically ill cirrhotic patients with hospital-acquired bloodstream infections exhibit distinct epidemiology, with more Gram-positive infections and particularly Enterococcus faecium.