Trends and outcomes of infective endocarditis in cirrhosis: a propensity-matched national study.

BACKGROUND: Cirrhosis is the most common cause of liver-related death and bacterial infection is a common comorbidity in cirrhosis. We aimed to study the trends and outcomes of infective endocarditis in cirrhosis. METHODS: A propensity-matched analysis of the National Inpatient Sample database was performed to assess outcomes of infective endocarditis in adult patients (>18 years) from 2004-2013 with and without cirrhosis. Various outcomes were assessed for outcomes of infective endocarditis in cirrhosis. Multivariate regression analysis was performed for predictors of mortality in infective endocarditis. RESULTS: There has been no significant change in incidence (3.3-3.6%, P = 0.27) and overall mortality (6.3-8.6%, P = 0.42) of infective endocarditis in cirrhosis. After propensity matching, patients with cirrhosis had significantly higher in-hospital mortality (15 vs. 10.6%, P < 0.001) and acute kidney injury (AKI) (31.8 vs. 28.5%, P < 0.001) as compared to no cirrhosis. Microbiological analysis revealed significantly higher rates of streptococci (35.3 vs. 31.9%, P < 0.001) and fungal infective endocarditis (0.03 vs. 0%, P < 0.001) and lower incidence of Gram-negative infective endocarditis (3.9 vs. 6.3%, P < 0.001) in cirrhosis. Cirrhosis patients had significantly less surgical intervention (10.2 vs. 30.3%, P < 0.001) along with overall total cost and length of stay as compared to no cirrhosis. On multivariate analysis, advanced age, AKI, shock and mechanical ventilation were positive predictors of mortality in infective endocarditis patients with cirrhosis patients. CONCLUSIONS: Cirrhosis is an independent predictor of mortality in infective endocarditis with worse outcomes and less surgical intervention. Gram-negative infective endocarditis is lower in cirrhosis, whereas streptococci and fungal infective endocarditis are higher than noncirrhotic patients.

Non-invasive testing for Helicobacter pylori in patients hospitalized with peptic ulcer hemorrhage: a cost-effectiveness analysis.

PURPOSE: Guidelines recommend routine invasive screening for Helicobacter pylori in patients with peptic ulcer hemorrhage (PUH). However, compliance with screening remains suboptimal. The aim of this study was to determine if a simplified approach based on noninvasive screening is cost effective in PUH. RESULTS: In the base case, post-endoscopy urea breath test (UBT) dominated the invasive testing with 34 fewer hemorrhages and cost savings of $406,600 in a cohort of 10,000 patients. When compliance with invasive testing decreases to 60%, post-endoscopy UBT leads to 109 fewer hemorrhages and cost savings of $1,089,600. The invasive strategy becomes the preferred choice if the sensitivity of UBT reduces to <75%, such as in patients taking proton-pump inhibitors (PPI) before hospitalization. CONCLUSIONS: Post-endoscopy UBT is cost effective in PPI-naïve patients presenting with PUH. This strategy, once prospectively validated, can prove to be a preferred approach in institutions where compliance with invasive testing is suboptimal.