Copyright
©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
Comparison of fungal vs bacterial infections in the medical intensive liver unit: Cause or corollary for high mortality?
Sarah Khan, Hanna Hong, Stephanie Bass, Yifan Wang, Xiao-Feng Wang, Omar T Sims, Christine E Koval, Aanchal Kapoor, Christina C Lindenmeyer
Sarah Khan, Department of Internal Medicine, Cleveland Clinic, Cleveland, OH 44195, United States
Hanna Hong, Cleveland Clinic Lerner College of Medicine, Cleveland Clinic, Cleveland, OH 44195, United States
Stephanie Bass, Department of Pharmacy, Cleveland Clinic, Cleveland, OH 44195, United States
Yifan Wang, Xiao-Feng Wang, Department of Quantitative Health Sciences/Biostatistics Section, Cleveland Clinic, Cleveland, OH 44195, United States
Omar T Sims, Christina C Lindenmeyer, Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH 44195, United States
Christine E Koval, Department of Infectious Disease, Cleveland Clinic, Cleveland, OH 44195, United States
Aanchal Kapoor, Department of Critical Care Medicine, Cleveland Clinic, Cleveland, OH 44195, United States
Author contributions: All authors were involved in study design; Khan S and Hong H collected data and designed the data collection tool; Khan S, Wang X, Wang Y, Sims O and Lindenmeyer CC were responsible for statistical analysis; Khan S, Bass S, Sims O, Koval C, Kapoor A and Lindenmeyer CC were involved in analysis and interpretation of results of statistical testing; Khan S, Sims O and Lindenmeyer CC were involved in writing the manuscript; all authors were involved in manuscript appraisal and approval.
Institutional review board statement: The study was reviewed and approved by the Cleveland Clinic Foundation Institutional Review Board [IRB# 22-721].
Informed consent statement: Our Institutional Review Board allowed our study to proceed without the need for informed consent.
Conflict-of-interest statement: None of the study authors have any conflicts of interest to disclose.
Data sharing statement: Our statistical code and de-identified data may be made available upon reasonable request.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
https://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: Sarah Khan, MD, Doctor, Department of Internal Medicine, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States. khans21@ccf.org
Received: October 19, 2023
Peer-review started: October 19, 2023
First decision: December 26, 2023
Revised: January 17, 2024
Accepted: February 26, 2024
Article in press: February 26, 2024
Published online: March 27, 2024
ARTICLE HIGHLIGHTS
Research background
Advanced liver disease predisposes critically ill patients to the development of fungal infections. While bacterial infections have been well-studied as the most common cause of acute-on-chronic liver failure and associated mortality, fungal infections have been relatively under-studied in the intensive care setting.
Research motivation
Infections increase mortality four-fold among critically ill liver patients, but few studies have compared predictors and outcomes of fungal infections to bacterial infections in this population.
Research objectives
We compared outcomes of fungal and bacterial infections among critically ill patients who were admitted to our unique medical intensive liver unit (MILU) from 2018-2022. We also conducted a comprehensive comparison of predictors and illness severity scores between these cohorts. Finally, we characterized microbiologic epidemiology of infections within our unit.
Research methods
Patients were identified for inclusion from a prospectively-curated database of all admissions to our MILU during the study period. Infections were defined based on culture positivity and clinical presentation. Data on outcomes and predictors of interest were collected manually through chart review.
Research results
We found that fungal infections among our patients were all caused by Candida species and were most frequently blood isolates. Mortality was significantly worse among the fungal cohort relative to patients with bacterial infections, as the majority of these patients died or transitioned to hospice during the intensive care unit (ICU) stay. The majority of patients in the fungal cohort developed severe acute on chronic liver failure, and they had higher need for vasopressors, mechanical ventilation and acute kidney injury. Further, patients who developed fungal infections were sicker on admission to the unit. Patients with fungal infection had higher rate of transplant hold placement, and lower rates of transplant; however, differences did not achieve statistical significance.
Research conclusions
Fungal infection is a poor prognostic marker for patients with advanced liver disease in the critical care setting, and it is associated with significantly worse mortality than bacterial infection. This may be in large part due to development of severe acute on chronic liver failure. Patients who developed fungal infections had higher Model for End-Stage Liver Disease-Sodium, Acute Physiology and Chronic Health Evaluation, and Acute Physiology Score scores on admission to the ICU.
Research perspectives
We believe our work highlights the importance of a need for future studies to investigate associations between fungal infections and acute on chronic liver failure. Furthermore, research efforts examining prognostic markers, potential indications for prophylactic/empiric antifungal use, and transplant outcomes would be equally important and informative for clinical practice.
