Clinical impact of multidrug-resistant organisms in liver cirrhosis: A retrospective cohort study in the intensive care setting

BACKGROUND Colonization with multidrug-resistant organisms (MDROs) is frequently observed in critically ill patients with liver cirrhosis admitted to intensive care units (ICUs). However, whether colonization directly leads to infections or adversely impacts clinical outcomes remains unclear. Clarifying this relationship may help determine the prognostic significance of colonization in these patients. AIM To evaluate the clinical relevance of MDRO colonization and infection at ICU admission in patients with cirrhosis. METHODS This retrospective single-center cohort study included 107 ICU admissions of patients with liver cirrhosis at a tertiary care center (2018-2024). Colonization was assessed by rectal and nasal/pharyngeal swabs within 48 hours of ICU admission. Outcomes analyzed included MDRO infection during ICU stay, concordance between colonizing and infecting strains, organ support requirements, and 28-day transplant free survival. Multivariable logistic regression and Kaplan-Meier analyses were used to evaluate predictors of infection and mortality. RESULTS Nearly one-third (29.9%) of patients were colonized with MDROs on admission, more commonly in the acute-on-chronic liver failure phenotype than those with acute decompensation (34.5 vs 10.0%, P = 0.033). Although infections were established in the majority (85%) of cases, of which 17.6% due to MDROs, colonization alone did not independently predict these infections [odds ratio (OR) = 2.18, P = 0.383] nor influenced short-term mortality (OR = 1.14, P = 0.813). However, once MDRO infection occurred, an 82% concordance was observed between colonizing and infecting strains. MDRO infections, unlike colonization, significantly increased the need for organ-support interventions, including mechanical ventilation and vasopressor therapy and prolonged ICU stays. Only severity of organ dysfunction, quantified by the Sequential Organ Failure Assessment score, independently predicted 28-day mortality (OR = 1.38, P = 0.024). CONCLUSION MDRO colonization at ICU admission is frequent among critically ill patients with cirrhosis, particularly those with acute-on-chronic liver failure. While colonization alone does not predict infection or early mortality, its clinical value emerges in guiding empirical antibiotic treatment once infection is suspected. Ultimately, short-term survival appears to be more strongly influenced by the severity of organ failure than by either MDRO colonization or infection.