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
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.
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.
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.
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.
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.
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.
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.