Prognosis of compensated cirrhosis is good until decompensation. In decompensated cirrhosis, bacterial infections (BIs) are common and increase the risk of death. The incidence and prognostic implications of BIs in compensated cirrhosis are less characterized. This study aimed to assess whether BIs influence the risk of decompensation and survival in patients with compensated cirrhosis.This is a cohort study nested to the PREDESCI, a double-blind, multicenter RCT evaluating if β-blockers could prevent decompensation of cirrhosis. Patients with compensated cirrhosis and HVPG ≥10 mmHg were included. Development of BIs during follow-up was prospectively registered. Using a competing-risk time-dependent regression analysis, we investigated whether BIs affect the risk of decompensation and survival. Decompensation was defined as development of ascites, bleeding or overt encephalopathy.201 patients were randomized and followed for a median of 36 months (IQR: 24-47 months). 34 patients (17%) developed BIs, which in 33 cases occurred before decompensation, and 29 (14%) developed ascites. Respiratory and urinary tract infections were the most frequent BIs. Cirrhosis decompensation occurred in 26% patients with BIs vs 16% without BIs. Patients with BIs had higher risk of decompensation (HR=2.93, 95%CI=1.02-8.42; P= 0.047) and of developing ascites (HR=3.55, 95%CI=1.21-10.47; P=0.022) than those without BIs. Risk of death was also higher in patients with BIs (SHR=6.93, 95%CI=2.64-18.18; P< 0.001), although in 71% of such cases decompensation occurred before death.BIs have a marked impact on natural history of compensated cirrhosis, significantly increasing the risk of decompensation, mainly that of ascites, and increasing the risk of death, which usually occurs after decompensation. Our results suggest that BIs may constitute a target to prevent decompensation.In decompensated cirrhosis bacterial infections are common and increase the mortality risk. However, the relevance of bacterial infections in compensated cirrhosis has not been well studied so far. This study shows that in patients with compensated cirrhosis and clinically significant portal hypertension, bacterial infections occur as frequently as the development of ascites, which is the most frequent decompensating event. Most of these infections are from the respiratory or urinary tract. Their development increases the risk of progression to decompensation, mainly by a higher risk of ascites, and also increases the risk of death which in most cases occurs after decompensation. Bacterial infections have a deep impact on the natural history of compensated cirrhosis and may represent a target to prevent decompensation. CLINICALTRIALS.NCT01059396.
Càndid Villanueva, Agustín Albillos, Joan Genescà, Joan C Garcia-Pagan, Anna Brujats, José L Calleja, Carles Aracil, Rafael Bañares, Rosa M Morillas, María Poca, Beatriz Peñas, Salvador Augustin, Juan G Abraldes, Edilmar Alvarado, Ferran Torres, Jaume Bosch, PreDesCI Study Investigators