Chronic liver disease and cirrhosis result in an estimated 800,000 deaths each year worldwide.1 In the United States alone, it is the ninth leading cause of death, with about 30,000 deaths each year.2 An additional 30 million Americans have chronic liver impairment.3 Hospitalizations of these patients are frequent and substantial proportions of these admissions include stays in the intensive care unit (ICU).4-6 The estimated number of ICU admissions related to cirrhosis in the United States alone is in excess of 26,000 per year with an estimated cost of $3 billion.7
A major cause of ICU admission among patients with cirrhosis is sepsis.5, 8-10 The incidence of sepsis is estimated to be at least 30%-50% of hospital admissions in this group.11, 12 Cirrhosis-associated septic shock stands out in terms of presentation, outcome,13 and therapeutic options.14 One of the key questions is whether modifiable practice-related factors contribute to the poor outcome in this group of patients. Limited data are available about the appropriate application of the newer options that have emerged in the management of sepsis over the last decade15-17 in this high-risk group,18 as patients with cirrhosis-related septic shock are often excluded from clinical trials. In addition to this paucity of evidence-based information,19 the Surviving Sepsis Campaign guidelines do not provide a clear direction for this group of patients.20
In a heterogeneous patient population with septic shock, the early initiation of appropriate antimicrobials and combination antibiotics (for bacterial septic shock) is associated with higher survival rate.21-23 However, few data exist on the use of antibiotics and outcome from septic shock among patients with cirrhosis.11 Such lack of information may adversely affect decision-making about patient management and prognostication.
We conducted this study to examine the relationship between the aspects of early, initial empiric antimicrobial therapy and hospital mortality in patients with cirrhosis and septic shock.