Prudent Use of Blood Cultures for Hospitalized Patients With Cirrhosis

TL;DR

The study identifies risk factors for bacteremia in hospitalized cirrhosis patients to guide when blood cultures are needed.

Contribution

A risk stratification method is proposed to reduce unnecessary blood cultures in cirrhosis patients without concurrent infections.

Findings

Cirrhosis patients with concomitant bacterial infection have a 3.3-fold higher risk of bacteremia.

Bacteremia incidence is 0.76% in cirrhosis patients without concomitant bacterial infection.

Primary sclerosing cholangitis is strongly associated with bacteremia in cirrhosis patients.

Abstract

Background

No reliable risk stratification method is available to guide the extent of infectious work-up among hospitalized patients with cirrhosis. Therefore, we aimed to create a risk stratification method for obtaining blood cultures from hospitalized patients with cirrhosis.

Methods

This was a retrospective cohort study using the Healthcare Cost and Utilization Project - National Readmission Database 2019. Adult patients who were not immunocompromised comprised the final cohort. The primary outcome was the incidence of bacteremia among hospitalized patients with cirrhosis. Secondary outcomes included length of hospital stay, inpatient mortality, and 30-day readmission rate among cirrhosis patients with and without bacteremia. After propensity score matching, the χ2 test was used to assess the primary outcome and inpatient mortality. The Wilcoxon signed-rank test was used to compare the length of hospital stay. Readmission rates were compared via survival analysis. Concomitant bacterial infection, cirrhosis causes, and complications were assessed as potential risk factors for bacteremia using binomial regression.

Results

The risk ratio (RR) of bacteremia was 1.66 (95% confidence interval (CI): 1.55-1.78) among patients with cirrhosis compared to those without cirrhosis. A concomitant bacterial infection was found to have a strong association with bacteremia in patients with cirrhosis (RR: 3.3, 95% CI: 3.03-3.59). Among cirrhosis patients without concomitant bacterial infection, the incidence of bacteremia was 0.76% (<1%). Among the causes of cirrhosis, primary sclerosing cholangitis was found to have a strong association with bacteremia (RR: 3.88, 95% CI: 2.3-6.04, P < 0.001). Patients with cirrhosis who had bacteremia were hospitalized three days longer than those without bacteremia. There was no difference in inpatient mortality or 30-day readmission rates between cirrhotic patients with and without bacteremia.

Conclusion

This study suggests that, in the absence of another concomitant bacterial infection and primary sclerosing cholangitis, we can avoid unnecessary blood cultures among immunocompetent patients with cirrhosis. However, given some inherent limitations associated with the database (such as the unavailability of vitals or laboratory values), additional studies are needed to validate its findings.

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