Isolated bacterial infection without decompensation has no impact on survival of compensated patients

Background:Patients with cirrhosis can be separated in the compensated and decompensated stage, which has major prognostic relevance. The development of bacterial infections (BI) is common in the natural course of the disease and frequently triggers decompensation. Indeed, BI have been considered as critical events that mark the transition to the decompensated stage. Our aim was to evaluate the impact of BI on the natural history of compensated cirrhosis.

Patients and methods:

We performed a secondary analysis of a prospectively recruited cohort (n = 858) of consecutive patients with liver cirrhosis, who were screened for the randomized controlled INCA trial (EudraCT 2013 – 001626 – 26) in two academic medical centers between 02/2014 – 05/2019. In- and outpatient medical records were reviewed for present and past decompensation, BI, type 2 diabetes, and inflammatory markers. Only patients with previously compensated disease were included. Applying consensus criteria, BI were defined as infections that required antibiotic therapy and had to be treated in the hospital. The patients were divided into four groups according to their status at baseline: compensated without BI, compensated with BI, 1st decompensation without BI, 1st decompensation with BI. Kaplan-Meier curves were calculated and compared with log rank tests.

Results:

Overall, 425 patients [median 61 (53 – 69) years old] were included in the analysis, and median follow-up was 372 days (105 – 622). At baseline, 257 patients were compensated (12 [4.9%] with BI), whereas 168 previously compensated patients presented with their 1st decompensation at baseline (42 [25.0%] with BI). MELD score at inclusion did neither differ among compensated patients (no BI 8 [7 – 10], with BI 8 (7 – 11); p = 0.60] nor among patients with first decompensation (no BI 13 [10 – 16], with BI 14 [11 – 21]; p = 0.15). Among patients who remained compensated, BI had no influence on transplant-free survival, but patients with first decompensation plus concomitant BI had significantly (p < 0.001) worse transplant-free survival than those without BI at inclusion.

Conclusions:

BI without accompanying decompensation has no negative impact on survival of patients with compensated cirrhosis. In contrast, and as previously demonstrated, the first decompensation episode triggered by BI is associated with worst survival. This observation underscores the clinical need for prophylactic strategies to avoid common BI in at-risk patients with cirrhosis.