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

Abstract

<h3>Background</h3> Fungal 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. <h3>Methods</h3> PubMed, 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) <h3>Results</h3> We 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&gt;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&lt;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. <h3>Conclusions</h3> FIs 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.