Gastroenterology

Gastroenterology

Volume 137, Issue 2, August 2009, Pages 541-548
Gastroenterology

Clinical Advances in Liver, Pancreas, and Biliary Tract
Infection in Patients With Severe Alcoholic Hepatitis Treated With Steroids: Early Response to Therapy Is the Key Factor

https://doi.org/10.1053/j.gastro.2009.04.062Get rights and content

Background & Aims

In severe (Maddrey score ≥32) alcoholic hepatitis (AH), infection is classically viewed as a contraindication for corticosteroids, although specific data are lacking. This study's aims were (1) to evaluate the incidence of infection in patients with severe AH before and after corticosteroid treatment; (2) to determine whether infection contraindicates corticosteroids; and (3) to focus on predictive factors of development of infection.

Methods

At admission, systematic screening of infection consisted of chest x-ray and blood, ascites, and urinary cultures. All patients were treated with prednisolone. Response to steroids was defined using the Lille model.

Results

Two hundred forty-six patients with severe AH were prospectively included. Infections at admission were as follows: 63 infections (25.6%) were diagnosed: 28 (44.4%) spontaneous bacterial peritonitis or bacteremia, 8 (12.7%) pulmonary infections, 20 (31.7%) urinary tract infections, and 7 (11.2%) other infections. Patients infected before using corticosteroids had 2-month survival similar to that of others: 70.9% ± 6.1% vs 71.6% ± 3.4%, respectively, P = .99. Development of infection after steroids: 57 patients (23.7%) developed infection: 16 (28.1%) spontaneous bacterial peritonitis or bacteremia, 23 (40.3%) pulmonary, 10 (17.5%) urinary tract, and 8 (14.1%) other infections. Infection occurred more frequently in nonresponders than in responders: 42.5% vs 11.1%, respectively, P < .000001. In multivariate analysis, only the Lille model (P = .0002) independently predicted infection upon steroids use. The Lille model (P = .000001) and Model for End-Stage Liver Disease score (P = .006) were independently associated with survival, whereas infection was not (P = .52).

Conclusions

Severe AH is associated with high risk of infection. Infection screening is warranted but should not contraindicate steroids. In terms of mechanisms, nonresponse to steroids is the key factor in development of infection and prediction of survival.

Section snippets

Infection Screening and Treatment Protocol

From April 2002 to August 2008, all patients admitted to the Hepatology Unit of Hôpital Huriez, Lille, were systematically evaluated for infection at the time of admission. Criteria for treatment with corticosteroids were the following: (1) severity of AH defined by Maddrey score ≥32; (2) recent onset of jaundice (less than 3 months); (3) history of long-standing alcoholism; (4) liver chemistry suggestive of severe AH; (5) absence of recent gastrointestinal hemorrhage (ie, <15 days); and (6)

Characteristics of the Study Population

Two hundred forty-six patients with severe AH were prospectively included. Clinical and biologic characteristics are given in Table 1. One- and 2-month survival were 85.5% ± 3% and 72.2% ± 3%, respectively. Among the 246 patients, corticosteroids were given to 240 patients, and 6 early deaths (5 related to infection) precluded initiation of corticosteroids. In the 240 patients receiving corticosteroids, Maddrey scores calculated at admission and at start of corticosteroids were not

Discussion

The comprehensiveness of pathogenesis of infection in patients with severe AH treated with corticosteroids appears more complex than classically believed. In the present study, we observed that (1) infection is frequent in severe AH; (2) corticosteroid treatment is not associated with a higher risk of infection, and its use should not be precluded in already infected patients after appropriate and effective antibiotherapy; (3) nonresponse to corticosteroids is the main factor contributing to

References (33)

  • E. Bouza et al.

    A European perspective on nosocomial urinary tract infections IReport on the microbiology workload, etiology and antimicrobial susceptibility (ESGNI-003 study)

    European Study Group on Nosocomial InfectionsClin Microbiol Infect

    (2001)
  • E. Cabre et al.

    Short- and long-term outcome of severe alcohol-induced hepatitis treated with steroids or enteral nutrition: a multicenter randomized trial

    Hepatology

    (2000)
  • Y. Adachi et al.

    Antibiotics prevent liver injury in rats following long-term exposure to ethanol

    Gastroenterology

    (1995)
  • P. Mathurin et al.

    Exacerbation of alcoholic liver injury by enteral endotoxin in rats

    Hepatology

    (2000)
  • S. Mandayam et al.

    Epidemiology of alcoholic liver disease

    Semin Liver Dis

    (2004)
  • R.L. Carithers et al.

    Methylprednisolone therapy in patients with severe alcoholic hepatitisA randomized multicenter trial

    Ann Intern Med

    (1989)
  • Cited by (293)

    • Alcoholic Hepatitis: The Rising Epidemic

      2023, Medical Clinics of North America
    View all citing articles on Scopus

    Conflicts of interest The authors disclose no conflicts.

    View full text