Published online Mar 27, 2024. doi: 10.4254/wjh.v16.i3.379
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
Processing time: 153 Days and 23.6 Hours
Due to development of an immune-dysregulated phenotype, advanced liver disease in all forms predisposes patients to sepsis acquisition, including by opportunistic pathogens such as fungi. Little data exists on fungal infection within a medical intensive liver unit (MILU), particularly in relation to acute on chronic liver failure.
To investigate the impact of fungal infections among critically ill patients with advanced liver disease, and compare outcomes to those of patients with bacterial infections.
From our prospective registry of MILU patients from 2018-2022, we included 27 patients with culture-positive fungal infections and 183 with bacterial infections. We compared outcomes between patients admitted to the MILU with fungal infections to bacterial counterparts. Data was extracted through chart review.
All fungal infections were due to Candida species, and were most frequently blood isolates. Mortality among patients with fungal infections was significantly worse relative to the bacterial cohort (93% vs 52%, P < 0.001). The majority of the fungal cohort developed grade 2 or 3 acute on chronic liver failure (ACLF) (90% vs 64%, P = 0.02). Patients in the fungal cohort had increased use of vasopressors (96% vs 70%, P = 0.04), mechanical ventilation (96% vs 65%, P < 0.001), and dialysis due to acute kidney injury (78% vs 52%, P = 0.014). On MILU admission, the fungal cohort had significantly higher Acute Physiology and Chronic Health Evaluation (108 vs 91, P = 0.003), Acute Physiology Score (86 vs 65, P = 0.003), and Model for End-Stage Liver Disease-Sodium scores (86 vs 65, P = 0.041). There was no significant difference in the rate of central line use preceding culture (52% vs 40%, P = 0.2). Patients with fungal infection had higher rate of transplant hold placement, and lower rates of transplant; however, differences did not achieve statistical significance.
Mortality was worse among patients with fungal infections, likely attributable to severe ACLF development. Prospective studies examining empiric antifungals in severe ACLF and associations between fungal infections and transplant outcomes are critical.
Core Tip: In the critical care setting, patients with advanced liver disease who develop fungal infections have significantly higher mortality than those who develop bacterial infections. These patients require greater support with vasopressors, mechanical ventilation, and dialysis than their counterparts with bacterial infections. Patients who developed fungal infections appeared more acutely ill on admission to the intensive care unit, with higher Acute Physiology and Chronic Health Evaluation, Acute Physiology Score, and Model for End-Stage Liver Disease scores. In such patients, fungal infection development is closely associated with development of severe acute-on-chronic liver failure. Further work elucidating this relationship will allow for better prognostication and development of predictors for acute on chronic liver failure in this population.