IDDF2021-ABS-0143 Global epidemiological trends of fungal infections in cirrhosis patients: a systematic review with meta-analysis (FUNGDEMIC)

BackgroundFungal infections (FIs) have serious implications, yet are poorly reported in cirrhosis patients. Therefore, we reviewed the global burden and trends of FIs among cirrhosis patients.MethodsPubMed, Ovid, Web of Science, and EMBASE were searched and full-text articles describing FIs and their prevalence among cirrhosis patients were reviewed. Studies from post-transplant, malignancy, and classical-immuno-deficiency patients were excluded. A random-effects meta-analysis was done to pool estimates of FIs (overall, and by mycological type and infection-site) and their variation (I2) was explored on moderator-analysis, meta-regression, and outlier-influential diagnostics. The risk of bias and asymmetry in estimates was assessed by a checklist and Eggers regression, respectively. (PROSPERO ID: CRD42019142782)ResultsWe included 38 studies in the review (34 with low-risk of bias and 4 with moderate-risk of bias, 31984 patients). Pooled-estimates of overall-FIs (17 studies), invasive fungal infections (IFIs; 17 studies), invasive-candidiasis (IC, 23 studies), and invasive-aspergillosis (IA, 16 studies) in cirrhosis were 10.2% (6.0-16.9), 9.5% (5.4-16.2), 4.0% (2.0-8.0) and 2.8% (1.5-5.3); respectively (I2>90%; each) (IDDF2021-ABS-0143 Figure 1A. Pooled estimates with 95 CI of fungal infections FIS in cirrhosis by mycological type of FI A and site Of FI B). Site of FIs in decreasing order of pooled-prevalence was pulmonary (3.4%), urinary tract (2.6%), bloodstream (1.9%), peritoneal (1.7%), esophageal (1.3%), and cerebral (0.9%) (IDDF2021-ABS-0143 Figure 1B. Pooled estimates with 95 CI of fungal infections FIS in cirrhosis by mycological type of FI A and site Of FI B). Geographic differences in these estimates were remarkable, with the highest burden of overall-FIs from Belgium, the USA, and India (IDDF2021-ABS-0143 Figure 2). Non-Albicans-Candida and Aspergillus infections have increased in cirrhosis patients over the last decade (p<0.05). Intensive-care-unit (ICU)-admitted (10.8%) and acute-on-chronic liver failure (ACLF) patients (14.4%) had the highest prevalence of IFIs. Model for Endstage Liver Disease of cases, risk of bias score, and sample size across studies were the other predictors of variance in overall-FI-estimates. Diabetes, steroid and antibiotic exposure, and multiple organ failures were the common risk factors reported in patients with FIs.ConclusionsFIs impose a considerable burden and should not be neglected in cirrhosis patients. ACLF and critically ill cirrhosis patients in ICU should be considered as a host factor for defining IFIs.