Impact of liver cirrhosis on the clinical profile and outcomes in community-acquired pneumonia: A systematic review
Abstract
Objective
Community-acquired pneumonia (CAP) is a serious infection in patients with cirrhosis. This study aimed to describe clinical features of patients with cirrhosis and CAP, and to determinate whether cirrhosis is consistently associated with poor outcomes.
Methods
Databases were systematically searched for full-text articles comparing patients with and without cirrhosis with CAP and evaluating the impact of cirrhosis on clinical profile and outcomes, from inception to February 2021.
Results
Totals of 1485 and 114740 patients with cirrhosis and without cirrhosis with CAP were included, respectively. Patients with cirrhosis had different characteristics and more severe disease at admission compared to patients without cirrhosis (hypotension, altered mental status, hyponatremia, hypoalbuminemia were more frequent in patients with cirrhosis). Streptococcus pneumoniae was more frequently identified as the causative pathogen of CAP in patients with cirrhosis, and bloodstream infections were also more common. Likewise, risk of intensive care unit admission and mortality was higher in patients with cirrhosis than in patients without cirrhosis (range 11.1%-23.3% versus 8.8%-17.2% and 2.7%-23% compared with 14.4%-34.5%, respectively).
Discussion
Patients with cirrhosis and CAP have a poorer prognosis than patients without cirrhosis. Information on the clinical features of CAP in patients with cirrhosis and on risk factors for poor outcomes remains limited.
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References
1. GBD 2017 Cirrhosis Collaborators. The global, regional, and national burden of cirrhosis by cause in 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet Gastroenterol Hepatol 2020; 5: 245–266.
2. Fernández J, Piano S, Bartoletti M, et al. Management of bacterial and fungal infections in cirrhosis: the MDRO challenge. J Hepatol 2021; 75: S101–S117.
3. Miranda-Zazueta G, León-Garduño LAP, Aguirre-Valadez J, et al. Bacterial infections in cirrhosis: current treatment. Ann Hepatol 2020; 19: 238–244.
4. Bellinghausen C, Pletz MW, Rupp J, et al. Members of the CAPNETZ study group. Chronic liver disease negatively affects outcome in hospitalised patients with community-acquired pneumonia. Gut 2021; 70: 221–222.
5. Xu L, Ying S, Hu J, et al. Pneumonia in patients with cirrhosis: risk factors associated with mortality and predictive value of prognostic models. Respir Res 2018; 19: 42.
6. Mortensen EM, Coley CM, Singer DE, et al.Causes of death for patients with community-acquired pneumonia: results from the Pneumonia Patient Outcomes Research Team cohort study. Arch Intern Med 2002; 162: 1059–1064.
7. Karki BJ, Ponnekanti SK, Salunkhe V, et al. Outcomes of adult patients hospitalized with community-acquired pneumonia with liver disease or cirrhosis. Univ Louisville J Respir Infect 2020; 4: Article 3.
8. Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000; 283: 2008–2012.
9. Viasus D, Garcia-Vidal C, Castellote J, et al. Community-acquired pneumonia in patients with liver cirrhosis: clinical features, outcomes, and usefulness of severity scores. Medicine (Baltimore) 2011; 90: 110–118.
10. Boivin Z, Perez MF, Atuegwu NC, et al. Impact of cirrhosis on pneumonia-related outcomes in hospitalized older veterans. Am J Med Sci 2019; 357: 296–301.
11. Manno D, Puoti M, Signorini L, et al. Risk factors and clinical characteristics associated with hospitalization for community-acquired bacterial pneumonia in HIV-positive patients according to the presence of liver cirrhosis. Infection 2009; 37: 334–339.
12. Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997; 336: 243–250.
13. Mortensen EM, Pugh MJ, Copeland LA, et al. Impact of statins and angiotensin-converting enzyme inhibitors on mortality of subjects hospitalised with pneumonia. Eur Respir J 2008; 31: 611Y–6617.
14. Charlson ME, Pompei P, Ales KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40: 373–383.
15. Falguera M, Martín M, Ruiz-González A, et al. Community-acquired pneumonia as the initial manifestation of serious underlying diseases. Am J Med 2005; 118: 378–383.
16. Han X, Zhou F, Li H, et al.; CAP-China network. Effects of age, comorbidity and adherence to current antimicrobial guidelines on mortality in hospitalized elderly patients with community-acquired pneumonia. BMC Infect Dis 2018; 18: 92.
17. Liu JL, Xu F, Zhou H, et al. Expanded CURB-65: a new score system predicts severity of community-acquired pneumonia with superior efficiency. Sci Rep 2016; 6: 22911.
18. Nseir WB, Mograbi JM, Amara AE, et al. Non-alcoholic fatty liver disease and 30-day all-cause mortality in adult patients with community-acquired pneumonia. QJM 2019; 112: 95–99.
19. Albillos A, Martin-Mateos R, Van der Merwe S, et al. Cirrhosis-associated immune dysfunction. Nat Rev Gastroenterol Hepatol 2022; 19: 112–134.
20. Mellencamp MA, Preheim LC. Pneumococcal pneumonia in a rat model of cirrhosis: effects of cirrhosis on pulmonary defense mechanisms against Streptococcus pneumoniae. J Infect Dis 1991; 163: 102–108.
21. Propst-Graham KL, Preheim LC, Vander Top EA, et al. Cirrhosis-induced defects in innate pulmonary defenses against Streptococcus pneumoniae. BMC Microbiol 2007; 7: 94.
22. Noor MT, Manoria P. Immune dysfunction in cirrhosis. J Clin Transl Hepatol 2017; 5: 50–58.
23. Liaskou E, Hirschfield GM. Cirrhosis-associated immune dysfunction: Novel insights in impaired adaptive immunity. EBioMedicine 2019; 50: –4.
24. Centers for Disease Control and Prevention. Pneumococcal vaccination: Summary of who and when to vaccinate. Available at: https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html.
25. Ewald H, Briel M, Vuichard D, et al. The clinical effectiveness of pneumococcal conjugate vaccines: a systematic review and meta-analysis of randomized controlled trials. Dtsch Arztebl Int 2016; 113: 139–146.
26. Falkenhorst G, Remschmidt C, Harder T, et al. Effectiveness of the 23-valent pneumococcal polysaccharide vaccine (PPV23) against pneumococcal disease in the elderly: systematic review and meta-analysis. PLoS One 2017; 12: e0169368.
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Published In
Article first published online: April 7, 2026
Keywords
PubMed: 41944478
Authors
Author contribution
Conception and design: DS, AE, DV and JC. Investigation: DS, AE, FF, EB, NA, and LM. Analysis and interpretation of the data: DS, FF and DV. Original draft preparation: DS, FF and DV. Review and editing: EB, NA, LM and JC. All authors have read and agreed to the final version of the manuscript. All authors agree to be accountable for all aspects of the work.
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