Medical Mycology, 2022, 60, myab069 https://doi.org/10.1093/mmy/myab069 Advance Access Publication Date: 3 November 2021 Original Article Original Article Factors determining the mortality in cirrhosis patients with invasive candidiasis: A systematic review and meta-analysis Nipun Verma 1, *,† , Akash Roy 2,† , Shreya Singh 3 , Pranita Pradhan 4 , Pratibha Garg 1 and Meenu Singh 4 1 Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India, 2 Department of Hepatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India, 3 Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India, 4 Department of Internal Medicine, Government Medical College and Hospital, Chandi- garh, 160012, India and 5 Indian Council of Medical Research Center for Evidence-Based Child Health, Postgraduate Institute of Medical Education and Research, Chandigarh, 160012, India ∗ To whom correspondence should be addressed. Nipun Verma, MBBS, MD, DM, Assistant Professor, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. Tel: +911722754777; E-mail: nipun29j@gmail.com † Joint First Authors Received 3 August 2021; Revised 11 October 2021; Accepted 1 November 2021; Editorial Decision 27 October 2021 Abstract The impact of invasive candidiasis (IC) on the outcomes in the non-conventional high-risk cirrhosis popula- tion is poorly characterized. Therefore, we reviewed the outcomes and their infuencing factors in cirrhosis patients with IC. PubMed, Embase, Ovid, CINHAL, and Web of Science were searched for full-text observa- tional studies describing mortality due to IC in cirrhosis. We did a systematic review and random-effects meta-analysis to pool the point-estimate and comparative-odds of mortality. The estimate’s heterogeneity was explored on sub-groups, outliers-test, and meta-regression. We evaluated the asymmetry in estimates on funnel plot and Eggers regression. Quality of studies was assessed on the New-Castle Ottawa scale. Of 3143 articles, 13 studies (611 patients) were included (good/fair quality: 6/7). IC patients were sick with a high model for end-stage liver disease (MELD: 27.0) and long hospital stay (33.2 days). The pooled-mortality was 54.7% (95% CI: 41.3–67.5), I2: 80%, P < 0.01. Intensive care unit (ICU) admission (P < 0.001), site of in- fection; viz. peritonitis and candidemia (P = 0.014) and high MELD of cases (P = 0.029) were predictors of high mortality. The odds of mortality due to IC was 4.4 times higher than controls and was 8.5 and 3.3 times higher than non-infected, and bacterially-infected controls. Studies in ICU-admitted (OR: 5.0) or acute-on- chronic liver failure (ACLF, OR: 6.3) patients had numerically higher odds of mortality than all-hospitalized cirrhosis patients (OR: 4.0). In conclusion, substantially high mortality is reported in cirrhosis patients with IC. ICU admission, ACLF, high MELD, peritonitis, and candidemia are key factors determining high mortality in cirrhosis patients with IC. Lay Summary We report a high mortality rate of 55% in patients with liver cirrhosis and invasive candidiasis. Higher odds (4.4 times) of death, especially in patients with ACLF (6.3 times) or ICU admission (5.0 times) were seen. Candida peritonitis and candidemia are associated with high mortality in cirrhosis. Highlights 1. Mortality associated with invasive candidiasis (IC) in patients with cirrhosis is 54.7% (95% CI: 41.3–67.5). 2. A signifcantly higher mortality in cirrhosis patients with IC is noted among intensive care unit admitted patients (79.9%) than all-hospitalized patients (42.5%). 3. Mortality increases linearly with increase in severity (MELD) of cirrhosis patients with IC. © The Author(s) 2021. Published by Oxford University Press on behalf of The International Society for Human and Animal Mycology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com 1 Downloaded from https://academic.oup.com/mmy/article/60/1/myab069/6420248 by guest on 02 July 2022