Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study

Current and emerging pharmacotherapy for the treatment of bacterial peritonitis

INTRODUCTION

Spontaneous bacterial peritonitis (SBP) is the quintessential model of bacterial infection in cirrhotic patients. In these particularly frail subjects, infections clearly worsen prognosis increasing substantially mortality. Furthermore, treatment of SBP has become more challenging because of the growing impact of multidrug-resistant (MDR) bacteria.

AREAS COVERED

This review addresses the reasons behind the change in therapeutic recommendations for SBP that have occurred in the past few years, by focusing on the following aspects: the importance of an early appropriate empirical treatment, the difference between nosocomial and non-nosocomial forms and the overall microbiological shift (rise of Gram-positive bacteria and MDR strains) that have affected SBP.

EXPERT OPINION

Until recently, third-generation cephalosporins have represented the cornerstone of SBP treatment, a safe choice covering the most important causative agents, namely Enterobacteriaceae. Unfortunately, massive exposure to health systems makes cirrhotic patients prone to MDR infections, which poses significant challenges, all the while not forgetting to strike a balance between effective antimicrobial activity and the risk of toxicity in these fragile subjects. Moreover, there is sparse information about new antibiotics in cirrhotic patients and about drugs levels in ascitic fluid. Therefore, further research is needed to optimize the treatment of SBP.

Bacteremia in Patients With Liver Cirrhosis: Prevalence and Predictors of Multidrug Resistant Organisms

GOALS

The objective of this study was to assess the prevalence and predictors of multidrug resistant organisms (MDRO) in cirrhotic patients with bacteremia at a large tertiary center in the United States.

BACKGROUND

The epidemiology of bacteremia in patients with liver cirrhosis has not been well studied in the United States.

STUDY

This case-case control study included 180 adults with liver cirrhosis hospitalized from 2011 to 2015. Case group 1 were patients with bacteremia due to a MDRO (n=30). Case group 2 were patients with bacteremia due to a non-MDRO (n=60). Control group comprised patients without bacteremia (n=90). MDRO was defined as bacteria that was nonsusceptible to ≥1 agent in ≥3 antimicrobial categories.

RESULTS

Of the 90 bacteremia episodes, 44% were because of gram-positive bacteria, 50% were because of gram-negative bacteria, and 6% were polymicrobial. MDROs caused 30 of 90 (33%) bacteremia episodes, including methicillin-resistant Staphylococcus species [12% (11/90)], fluoroquinolone-resistant Enterobacteriaceae [10% (9/90)], and Enterococcus faecium [3% (3/90)]. Eight percent of Enterobacteriaceae produced extended-spectrum β-lactamases. Four independent predictors of MDROs were identified: nonwhite race [adjusted odds ratio (aOR), 3.35; 95% confidence interval (CI), 1.19-9.38], biliary cirrhosis (aOR, 11.75; 95% CI, 2.08-66.32), blood cultures obtained >48 hours after hospital admission (aOR, 6.02; 95% CI, 1.70-21.40), and recent health care exposure (aOR, 9.81; 95% CI, 2.15-44.88).

CONCLUSIONS

A significant proportion of bacteremia in cirrhotic patients was due to MDROs at a large US tertiary care center. Local epidemiology data and identification of risk factors associated with MDROs may help with optimal empiric antibiotic selection.

Management of Infectious Complications Associated with Acute-on-Chronic Liver Failure

Introduction

Acute-on-chronic liver failure (ACLF) is associated with a high susceptibility to infections leading to complications and poor prognosis. The sensitized immune system overwhelmingly responds to invading bacteria leading to organ damage. After resolution of infection or prolonged disease duration, the phagocytic system becomes irresponsive with a reduced bacterial clearance capacity promoting secondary infection.

Methods

This review focuses on the best management strategies for patients with ACLF and infections. Using the following terms, an extensive literature research on the Medline database was performed: 'acute-on-chronic liver failure', 'infection', 'ACLF', 'bacteria', 'multi-resistance'.

Results

Analysis of the literature confirmed that delayed diagnosis and treatment of infections in patients with ACLF results in a poor prognosis. Patients with ACLF should be considered as having a potential infection and should undergo a complete screening for sepsis. Once biochemical analysis indicates a potential infection, such as abnormal levels of C-reactive protein and procalcitonin, antibiotic treatment should be initiated immediately without microbiological culture results. For community-acquired infections third-generation cephalosporins are still the first choice, whereas in the nosocomial setting antibiotics with broader spectrum, such as piperacillin/combactam or carbapenems ± glycopeptides, are preferred. The patient should be re-assessed 48 h after treatment initiation in order to tailor the treatment. Non-response is suspicious, likely due to bacterial resistance or fungal infection, which should be considered when choosing further treatment strategies. Albumin substitution to prevent hepatorenal syndrome and to improve patients' outcome is mandatory in patients with spontaneous bacterial peritonitis. Prophylactic antibiotic therapy is suitable to prevent infections in high-risk patients.

Conclusion

The screening for infections and its treatment is an essential part of managing patients with ACLF. In order to improve patients' prognosis, antibiotic treatment should be initiated once an infection is suspected. However, preventive strategies are already established and should be applied according to the guidelines.

Comparison of the predictive value of scoring systems on the prognosis of cirrhotic patients with suspected infection

Cirrhotic patients with infection are prone to develop sepsis or even septic shock rendering poorer prognosis. However, few methods are available to predict the prognosis of cirrhotic patients with infection although there are some scoring systems can be used to predict general patients with cirrhosis. Therefore, we aimed to explore the predictive value of scoring systems in determining the outcome of critically ill cirrhotic patients with suspected infection.This was a retrospective cohort study based on a single-center database. The prognostic accuracy of the systemic inflammatory response syndrome (SIRS) criteria, quick Sequential Organ Failure Assessment (qSOFA), chronic liver failure (CLIF)-SOFA, quick CLIF-SOFA (qCLIF-SOFA), CLIF-consortium organ failure (CLIF-C OF), Model for End-Stage Liver Disease (MELD), and Simplified Acute Physiology Score (SAPS) II were compared by using area under the receiver operating characteristic (AUROC) curve and net benefit with decision curve analysis. The primary endpoint was in-hospital mortality while the secondary endpoints were duration of hospital and intensive care unit (ICU) stay and ICU mortality.A total of 1438 cirrhotic patients with suspected infection were included in the study. Nearly half the patients (50.2%) were admitted to the ICU due to hepatic encephalopathy and the overall in-hospital mortality was 32.0%. Hospital and ICU mortality increased as the score of each scoring system increased (P < .05 for all trends). The AUROC of CLIF-SOFA (AUROC, 0.742; 95% confidence interval, CI, 0.714-0.770), CLIF-C OF (AUROC, 0.741; 95% CI, 0.713-0.769), and SAPS II (AUROC, 0.759; 95% CI, 0.733-0.786) were significantly higher than SIRS criteria (AUROC, 0.618; 95% CI, 0.590-0.647), qSOFA (AUROC, 0.612; 95% CI, 0.584-0.640), MELD (AUROC, 0.632; 95% CI, 0.601-0.662), or qCLIF-SOFA (AUROC, 0.680; 95% CI, 0.650-0.710) (P < .05 for all). In the decision curve analysis, the net benefit of implementing CLIF-SOFA and CLIF-C OF to predict the prognosis of cirrhotic patients with suspected infection were higher compared with SIRS, qSOFA, MELD, or qCLIF-SOFA.CLIF-SOFA and CLIF-C OF scores, as well as SAPS II were better tools than SIRS, qSOFA, MELD, or qCLIF-SOFA to evaluate the prognosis of critically ill cirrhotic patients with suspected infection.

Predicting mortality in patients with spontaneous bacterial peritonitis using routine inflammatory and biochemical markers

OBJECTIVES

Spontaneous bacterial peritonitis (SBP) is a common and high-mortality infectious complication of patients with cirrhosis. New inflammatory markers are associated with morbidity/mortality in various diseases. The aim of our study was to find the 30-day mortality rate of SBP and their predictors.

PATIENTS AND METHODS

Seventy patients with cirrhosis complicated with SBP and 55 non-SBP controls were enrolled into the study, and patients were evaluated for mortality rate and its predictors.

RESULTS

The 30-day and 3-month mortality rates in the SBP group were 26.1 and 50.7%, respectively. Mortality rates were higher in the SBP group than in the controls. Symptoms at hospital admission and cell counts in ascitic fluid made no difference in predicting 30-day mortality. Patients with SBP with high serum neutrophil counts, high neutrophil-lymphocyte ratio, high C reactive protein (CRP)/albumin ratio, and high model for end-stage liver disease (MELD) score had higher 30-day mortality rates. We determined optimal cutoff values of MELD scores and serum neutrophil counts for predicting 30-day mortality as 20.5 and 6850/mm, respectively. The sensitivity and specificity for the MELD cutoff value were 83.3 and 80.4%, respectively. We also followed up patients for 60 months after SBP; the patients with high inflammatory markers and MELD scores at the time of SBP diagnosis had worse survival compared with the group with lower levels.

CONCLUSION

Our results suggest that SBP has high 30-day mortality. MELD scores and inflammatory markers (CRP, CRP albumin ratio, neutrophil-lymphocyte ratio) may be used to predict mortality in patients with SBP.

Respiratory Complications Before and After Liver Transplant

Respiratory complications before and after liver transplant are common, diverse, and potentially have a negative impact on patient outcomes. In this review, we discuss the most frequent respiratory conditions that patients may develop in the perioperative period. Their prevention and/or treatment may help to maximize the benefit these patients may derive from liver transplant. This review examines diagnostic and therapeutic approaches to these complications for hepatologists, surgeons, and critical care physicians.

Clinical and bacteriological features and prognosis of ascitic fluid infection in Chinese patients with cirrhosis

Background

Spontaneous bacterial peritonitis (SBP) and bacterascites (BA) represent frequent and serious complications in cirrhosis patients with ascites. However, few detailed data are available regarding the clinical and bacteriological feature of SBP or BA patients in China.

Methods

We retrospectively analyzed bacteriological and clinical characteristics of patients with SBP and BA at Beijing 302 Hospital in China from January 2012 to December 2015.

Results

A total of 600 patients with SBP (n = 408) or BA (n = 192) were enrolled. Patients with BA appeared to have a less severe clinical manifestation and lower mortality rate than patients with SBP. Gram-negative bacteria formed the majority of pathogens in SBP (73.9%) and BA (55.8%) cases. Higher ascitic fluid polymorphonuclear leucocytes (PMN) count and hepatocellular carcinoma were independent risk factors for BA episode progressing to SBP. The concentration of blood urea nitrogen (BUN) was independent risk factor for 30-day mortality of BA patients. For patients with SBP, the independent risk factors for 30-day mortality were age, Model for End-Stage Liver Disease (MELD) score, septic shock and hepatocellular carcinoma. Patients with third-generation cephalosporin or carbapenems resistant infection had a significantly lower survival probability. There were significant differences in clinical characteristics and outcome among the major bacteria. Multivariate analysis showed that patients infected with Klebsiella spp. had higher hazard ratio of 30-day mortality.

Conclusion

Our study reported the bacteriological and clinical characteristics of patients with SBP and BA. Higher ascitic fluid PMN count and hepatocellular carcinoma were found to be independent risk factors for BA episode progressed to SBP. Outcome of ascitic fluid infection in patients with cirrhosis was influenced by the type of bacteria and antimicrobial susceptibility.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3101-1) contains supplementary material, which is available to authorized users.

The impact of infections on delisting patients from the liver transplantation waiting list

Approximately 20% of the patients listed for liver transplantation die before transplantation can be accomplished. Understanding risk factors for waiting list mortality may help to improve survival and organ allocation. Infections are very common in patients with cirrhosis and are associated with significant morbidity and mortality. This study analysed the frequency and characteristics of infections in patients awaiting liver transplantation, identified risk factors for withdrawal from the waiting list and evaluated the impact of infections on the clinical outcome. A retrospective analysis of consecutive patients listed for liver transplantation in Rotterdam, the Netherlands from 2007 to 2014 was conducted. Infections occurred in 144 of 327 studied patients (44%). In this cohort, 23.4% of the patients on the liver transplantation waiting list were delisted or died before transplantation. Patients with an infection were 5.2 times more likely to become delisted than noninfected patients. In the 30 days after the first infection, patients were 33.8 times more likely to become delisted compared to noninfected patients. High age, high MELD score, refractory ascites and inappropriate antibiotic therapy were independent predictors for delisting due to infection. Infections occur frequently in patients on the liver transplantation waiting list. Emphasis on appropriate and timely antimicrobial therapy is required.

Clarifying the role of C-reactive protein as a bacterial infection predictor in decompensated cirrhosis

INTRODUCTION

Bacterial infections are frequent in cirrhosis and may induce other deleterious complications. Ultrasensitive C-reactive protein (US-CRP), like other acute-phase proteins, is often considered useful in predicting bacterial infection in decompensated cirrhosis. However, US-CRP's reliability remains inconclusive, as inflammation in cirrhosis causes US-CRP synthesis independently of infection. The aim of this study was to clarify US-CRP's role as an infection predictor in decompensated cirrhosis.

PATIENTS AND METHODS

This was a prospective single-center study with systematic inclusion of cirrhotic patients admitted because of decompensation.

RESULTS

A total of 118 patients were enrolled, of whom 47 (39.8%) had an overt infection, defined by clinical and laboratory/imaging criteria. Within those, 17 had infection confirmed by culture bacterial identification. Escherichia coli was the most frequent isolated bacteria. Seventeen patients had spontaneous bacterial peritonitis, but only four (23.5%) had positive ascitic fluid cultures. US-CRP levels were significantly higher in cases of overt infection and positive culture groups than the no infection group (median: 4.14 and 6.40 vs. 1.11 mg/dl, P<0.0001 for both). When considering both overt infection and positive culture groups, the US-CRP values of area under the curve as an infection predictor were, respectively, 0.824 and 0.870, P<0.0001 for both, with associated cutoff values of 2.40 and 3.92 mg/dl, and sensitivity and specificity of 78.7/74.6 and 82.4/79.2%, respectively.

CONCLUSION

The ideal US-CRP infection confirmatory cutoff is probably situated between 2.40 and 3.92 mg/dl. However, as infection is somewhat concealed and hazardous in cirrhotic patients, if not considered with lower US-CRP levels according to specific clinic scenarios, it should be carefully considered, at least, if US-CRP is greater than 2.40 mg/dl (0.5 mg/dl normal upper cutoff).

Prevalence and predictors of spontaneous bacterial peritonitis due to ceftriaxone-resistant organisms at a large tertiary centre in the USA

OBJECTIVES

The epidemiology of spontaneous bacterial peritonitis (SBP) due to ceftriaxone-resistant organisms has not been well studied in the USA. The primary objective of this study was to assess the prevalence and predictors of ceftriaxone-resistant SBP at a large US tertiary-care centre.

METHODS

This 1:1:4 case-case-control study included 141 adults with liver cirrhosis admitted from November 2011 to March 2016. Case group 1 were patients with SBP with a ceftriaxone-resistant organism (n=21). Case group 2 were patients with SBP with a ceftriaxone-susceptible organism (n=26). The control group were patients without SBP (n=94). Multiple logistic regression analysis was used to identify predictors of ceftriaxone-resistant SBP.

RESULTS

Fifty isolates were identified from 47 patients with culture-positive SBP (case groups 1 and 2). Of these 50 isolates, 32 (64%) were Gram-negatives [mostly Enterobacteriaceae (91%)], 15 (30%) were Gram-positives and 3 (6%) were Candida spp. The prevalence of ceftriaxone resistance in patients with culture-positive SBP was 45% (21/47). The most common ceftriaxone-resistant organisms were ESBL-producing Enterobacteriaceae (45%). Independent predictors of ceftriaxone-resistant SBP included duration of β-lactam therapy in the past 90days (aOR=1.07, 95% CI 1.01-1.13) and recent invasive gastrointestinal procedure (aOR=12.47, 95% CI 2.74-56.67).

CONCLUSIONS

The prevalence of ceftriaxone-resistant SBP was significant at a US tertiary centre. Local epidemiological data and identification of risk factors associated with ceftriaxone-resistant SBP, e.g. increased usage of previous β-lactam therapy and invasive gastrointestinal procedure, may help clinicians identify patients requiring alternative empirical antibiotics.

Rifaximin and Propranolol Combination Therapy Is More Effective than Propranolol Monotherapy for the Reduction of Portal Pressure: An Open Randomized Controlled Pilot Study

Background/Aims

Non-selective beta blockers (NSBBs) are currently the only accepted regimen for preventing portal hypertension (PHT)-related complications. However, the effect of NSBBs is insufficient in many cases. Bacterial translocation (BT) is one of the aggravating factors of PHT in cirrhosis; therefore, selective intestinal decontamination by rifaximin is a possible therapeutic option for improving PHT. We investigated whether the addition of rifaximin to propranolol therapy can improve hepatic venous pressure gradient (HVPG) response.

Methods

Sixty-four cirrhosis patients were randomly assigned to propranolol monotherapy (n=48) versus rifaximin and propranolol combination therapy (n=16). Baseline and post-treatment HVPG values, BT-related markers (lipopolysaccharide [LPS], LPS-binding protein [LBP], interleukin-6 [IL-6], and tumor necrosis factor α [TNF-α]), serological data, and adverse event data were collected. HVPG response rate was the primary endpoint.

Results

Combination therapy was associated with better HVPG response rates than monotherapy (56.2% vs 87.5%, p=0.034). In combination therapy, posttreatment BT-related markers were significantly decreased (LPS, p=0.005; LBP, p=0.005; IL-6, p=0.005; TNF-α, p=0.047).

Conclusions

Rifaximin combination therapy showed an additive effect in improving PHT compared to propranolol monotherapy. These pilot data suggest that the addition of rifaximin to NSBBs could be a good therapeutic option for overcoming the limited effectiveness of NSBBs.

Bacteremia in cirrhotic patients with upper gastrointestinal bleeding

BACKGROUND/AIMS

Increased risk of bacterial infection is common in cirrhotic patients with upper gastrointestinal bleeding (UGIB). Our study aimed to explore the association of the bacteremia with in-hospital mortality and risk factors of bacteremia in these patients.

MATERIALS AND METHODS

In our retrospective cohort study, we collected data for cirrhotic patients with UGIB admitted to our hospital between August 2010 and December 2010. The primary outcome was in-hospital mortality. The secondary outcome was bacteremia. A multivariate logistic regression analysis was performed to determine risk factors for mortality and bacteremia.

RESULTS

A total of 202 patients with cirrhosis presenting with UGIB at the emergency department (ED) were enrolled. Bacteremia was associated with a higher mortality rate (adjusted odds ratio [OR]: 9.7; 95% confidence interval [CI]: 1.9-50.6, p=0.007), whereas shock (systolic blood pressure <90 mmHg at ED triage) and bandemia (>0% immature neutrophils of band form) were associated with bacteremia in cirrhotic patients with UGIB (adjusted OR: 5.3; 95% CI: 2.3-12.7, p<0.0001 and adjusted OR: 4.0; 95% CI: 1.6-9.9, p=0.0003, respectively).

CONCLUSION

Bacteremia in cirrhotic patients with UGIB is one of the major risk factors leading to in-hospital mortality. On the basis of our findings, prevention of bacteremia in cirrhotic patients with UGIB, especially in those with shock and bandemia, is important; thus, adequate antibiotic treatment is suggested.

Administration of Albumin Solution Increases Serum Levels of Albumin in Patients With Chronic Liver Failure in a Single-Arm Feasibility Trial

BACKGROUND & AIMS

Infections are life-threatening to patients with acute decompensation and acute-on-chronic liver failure (AD/ACLF). Patients with AD/ACLF have prostaglandin E2-mediated immune suppression, which can be reversed by administration of albumin; infusion of 20% human albumin solution (HAS) might improve outcomes of infections. We performed a feasibility study to determine optimal trial design, assess safety, and validate laboratory assessments of immune function to inform design of a phase 3 trial.

METHODS

We performed a prospective multicenter, single-arm, open-label trial of 79 patients with AD/ACLF and levels of albumin lower than 30 g/L, seen at 10 hospitals in the United Kingdom from May through December 2015. Patients were given daily infusions of 20% HAS, based on serum levels, for 14 days or until discharge from the hospital. Rates of infection, organ dysfunction, and in-hospital mortality were recorded. The primary end point was daily serum albumin level during the treatment period. Success would be demonstrated if 60% achieved and maintained serum albumin levels at or above 30 g/L on at least one third of days with recorded levels.

RESULTS

The patients' mean model for end-stage disease score was 20.9 ± 6.6. The primary end point (albumin ≥30 g/L on at least one third of days recorded) was achieved by 68 of the 79 patients; 75% of administrations were in accordance with suggested dosing regimen. Mean treatment duration was 10.3 days (104 ± 678 mL administered). There were 8 deaths and 13 serious adverse events, considered by the independent data-monitoring committee to be consistent with those expected. Twelve of 13 patients that developed either respiratory or cardiovascular dysfunction (based on ward-based clinical definitions) as their only organ dysfunction were alive at 30 days compared with 1 of 3 that developed renal dysfunction. Only 1 case of brain dysfunction was recorded.

CONCLUSIONS

In a feasibility trial, we found that administration of HAS increased serum levels of albumin in patients with AD/ACLF. The dosing regimen was acceptable at multiple sites and deemed safe by an independent data-monitoring committee. We also developed a robust system to record infections. The poor prognosis for patients with renal dysfunction was confirmed. However, patients with cardiovascular or respiratory dysfunction had good outcomes, which is counterintuitive. Severe encephalopathy appeared substantially under-reported, indicating that ward-based assessment of these parameters cannot be recorded with sufficient accuracy for use as a primary outcome in phase 3 trials. Trial registration no: EudraCT 2014-002300-24 and ISRCTN14174793.

Mortality from Spontaneous Bacterial Peritonitis Among Hospitalized Patients in the USA

BACKGROUND AND AIM

Spontaneous bacterial peritonitis (SBP) is a serious complication of cirrhosis and is associated with significant morbidity and mortality. In this study, we examined the clinical characteristics and risk factors associated with mortality in hospitalized patients presenting with SBP.

METHODS

The Nationwide Inpatient Sample was queried for all hospitalizations involving SBP from 2006 to 2014 using the International Classification of Disease-9-CM Code. Logistic regression was performed to evaluate the association between SBP mortality and factors such as age, gender, race/ethnicity, and concomitant medical conditions at presentation (e.g., variceal hemorrhage, hepatic encephalopathy, acute renal failure, coagulopathy, and other infections including pneumonia). The lengths of stay (LOS) and total charges were also examined.

RESULTS

From 2006 to 2014, there were 88,167 SBP hospitalizations with 29,963 deaths (17.6% in-hospital mortality). The mean age of patients who died in the hospital was higher (58.2 years vs. 55.8, p < 0.01) than those who survived the admission. Acute alcoholic hepatitis was noted among a higher proportion of patients who died (7.0 vs. 5.9%, p < 0.01), who were also likely to have more medical comorbidities. In multivariable analysis, older age, female gender, hepatic encephalopathy, coagulopathy, variceal hemorrhage, sepsis, pneumonia, and acute kidney injury were associated with increased in-hospital mortality. This group also had longer LOS (11.6 days vs. 9.1, p < 0.01) and higher total charges ($138,273 vs. $73,533, p < 0.01).

CONCLUSION

SBP is associated with significant in-hospital mortality, especially in patients with concurrent risk factors. SBP remains a significant burden to the healthcare system.

Opportunistic infections in end stage liver disease

Liver cirrhosis is the 10th most common cause of death in Western world and infection is associated with a high morbidity and mortality, and represents the leading cause of acute liver decompensation. Patients with end-stage liver disease exhibit an important impairment of immune system. This condition, called cirrhosis-associated immune dysfunction, summarizes both local and systemic immune system alterations in liver cirrhosis that play a pivotal role in determining both the high incidence of infections and the ominous infections related mortality in this population. Another concerning feature of infections in cirrhotic patients is the growing prevalence of multidrug- resistant or extensively drug-resistant pathogens, which are associated with higher mortality, increased length of in-hospital stay and higher healthcare related costs if compared with infection caused by susceptible strains. Finally, patient with liver cirrhosis have several unique pathophysiological characteristics including hypoalbuminemia and reduction binding to proteins; altered distribution; altered clearance of the antimicrobials that can affect the pharmacokinetic/ pharmacodynamic of antimicrobials.

Metabolomics: From liver chiromancy to personalized precision medicine in advanced chronic liver disease

Currently there is a lack of accurate biomarkers for diagnosis and prognosis in advanced liver diseases. Either the occurrence of first decompensation, or diagnosis of acute on chronic liver failure, severe alcoholic hepatitis, or hepatocellular carcinoma (HCC), none of the available biomarkers are satisfactory. Metabolomics is the newest of omics, being much closer than the others to the actual phenotype and pathologic changes that characterizes a certain condition. It deals with a much wider spectrum of low molecular weight bio-compounds providing a powerful platform for discovering novel biomarkers and biochemical pathways to improve diagnostic, prognostication and therapy. Until now metabolomics was applied in a wide spectrum of liver conditions, but the findings were contradictory. This review proposes a synthesis of the existing evidences of metabolomics use in advanced chronic liver diseases, decompensated liver cirrhosis, severe alcoholic hepatitis and HCC.

Prevalence and Impact of Bacterial Infections in Children With Liver Disease-A Prospective Study

BACKGROUND AND AIMS

Risk of infections is increased in patients with Acute Liver Failure (ALF) and Decompensated Chronic Liver Disease (DCLD). We evaluated the frequency, site, type and risk-factors for bacterial infections in children with ALF and DCLD and its effect on outcome.

METHODS

ALF or DCLD children were enrolled prospectively. Clinical and laboratory details were recorded. Cultures (blood, urine and ascites) and chest X-ray were done at admission followed by weekly surveillance cultures.

RESULTS

173 patients, 68 ALF and 105 DCLD were enrolled. Infections were more common in DCLD than ALF (60/105 [57.1%] vs. 27/68 [39.7%]; P = 0.02). Ascitic fluid infection, pneumonia, urinary tract infection and bacteremia were seen in 19%, 17.9%, 13.2% and 12.1% patients respectively. Healthcare-Associated (HCA) infections were most frequent (39/87, 44.8%), followed by Nosocomial (NC, 32%) and Community-Acquired (CA, 23%). Nearly 3/4th of bacterial isolates were resistant to cephalosporins and quinolones, 23% being Multiresistant Bacteria (MRB). DCLD patients with infection had higher Child-Pugh Score (10 [6-14] vs. 7 [6-14]; OR 3.2 [1.77-5.10]: P = 0.007), need for ICU care (26/60 vs. 3/45; OR 10.70 [2.98-38.42]: P = 0.01), in-hospital mortality (24/60 vs. 8/45;OR 3.08 [1.22-7.75]: P = 0.04) and mortality at 3 month follow-up (32/60 vs. 9/45; OR 4.57 [1.87-11.12]: P = 0.00). Infection did not affect the outcome in ALF.

CONCLUSION

Infections develop in 40% ALF and 57% DCLD children. HCA and NC infections account for 77% of infections. Most culture isolates are resistant to cephalosporins and fluoroquinolones and 23% have MRB. Risk of infections is higher in DCLD patients with advanced liver disease.

Are third-generation cephalosporins still the empirical antibiotic treatment of community-acquired spontaneous bacterial peritonitis? A systematic review and meta-analysis

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is a common complication among cirrhotic patients. Guidelines recommend third-generation cephalosporins (3GCs) as empiric antibiotic therapy (EAT) of SBP. Recently, a broad-spectrum EAT was shown to be more effective than cephalosporins in the treatment of nosocomial spontaneous bacterial peritonitis (N-SBP); however, the prevalence of 3GCs-resistant bacteria is high in the nosocomial setting and broad-spectrum EAT cannot be used in all cases of SBP.

AIM

The aim of this study was to evaluate the 3GCs resistance distribution between N-SBP and community-acquired spontaneous bacterial peritonitis (CA-SBP) to clarify whether 3GCs are still an effective therapeutic intervention for CA-SBP.

METHODS

We searched for studies that reported the aetiology of SBP and the resistance profile of both gram-positive and gram-negative bacteria in MEDLINE and Google Scholar databases (since 1 January 2000 to 30 April 2017). A meta-analysis was carried out to estimate the risk difference [relative risk (RR) and 95% confidence intervals (CIs)] for 3GCs resistance in N-SBP and CA-SBP. Heterogeneity was assessed using the I-test.

RESULTS

A total of eight studies were included, including 1074 positive cultures of ascitic fluid in cirrhotic patients; 462 positive cultures were from N-SBP and, among these, 251 (54.3%) were 3GCs resistant. Six hundred and twelve positive cultures were from CA-SBP and, among these, 207 (33.8%) were 3GCs-resistant SBP. A pooled RR of 3GCs resistance in N-SBP compared with CA-SBP showed a significant difference (RR=1.67, 95% CI: 1.14-2.44; P=0.008). We carried out two subgroup analyses: the first according to the median year of study observation (before vs. since 2008) and the second according to the country of the study (China vs. others). The studies carried out before 2008 (327 SBP-positive culture) showed a significantly higher risk for 3GCs-resistant strains in N-SBP compared with CA-SBP (RR=2.36, 95% CI: 1.39-3.99; P=0.001), whereas this was not found in SBP acquired after 2008 (RR=1.24, 95% CI: 0.83-1.84; P=0.29). N-SBP occurring in China had no significantly higher risk for 3GCs-resistant strains compared with CA-SBP (RR=1.44, 95% CI: 0.87-2.37; P=0.16).

CONCLUSION

Our findings suggest that although the pooled RR of 3GCs resistance in N-SBP compared with CA-SBP show that 3GCs are still an effective option for the treatment of CA-SBP, the subanalysis of studies that enroled patients in the last decade did not show a significant higher RR of 3GCs resistance in N-SBP compared with CA-SBP. Therefore, in centres where local patterns of antimicrobial susceptibility (with low rates of 3GCs resistance) are not available, 3GCs should not be used initially for CA-SBP treatment. Future studies are needed to confirm this trend of 3GCs resistance.

Clinical states of cirrhosis and competing risks

The clinical course of cirrhosis is mostly determined by the progressive increase of portal hypertension, hyperdynamic circulation, bacterial translocation and activation of systemic inflammation. Different disease states, encompassing compensated and decompensated cirrhosis and a late decompensated state, are related to the progression of these mechanisms and may be recognised by haemodynamic or clinical characteristics. While these disease states do not follow a predictable sequence, they correspond to varying mortality risk. Acute-on-chronic liver failure may occur either in decompensated or in compensated cirrhosis and is always associated with a high short-term mortality. The increasing severity of these disease states prompted the concept of clinical states of cirrhosis. A multistate approach has been considered to describe the clinical course of the disease. Such an approach requires the assessment of the probabilities of different outcomes in each state, which compete with each other to occur first and mark the transition towards a different state. This requires the use of competing risks analysis, since the traditional Kaplan-Meier analysis should only be used in two-state settings. Accounting for competing risks also has implications for prognosis and treatment efficacy research. The aim of this review is to summarise relevant clinical states and to show examples of competing risks analysis in multistate models of cirrhosis.

Spontaneous bacterial and fungal peritonitis in patients with liver cirrhosis: A literature review

Spontaneous bacterial (SBP) and spontaneous fungal peritonitis (SFP) can be a life-threatening infection in patients with liver cirrhosis (LC) and ascites. One of the possible mechanisms of developing SBP is bacterial translocation. Although the number of polymorphonuclear cells in the culture of ascitic fluid is diagnostic for SBP, secondary bacterial peritonitis is necessary to exclude. The severity of underlying liver dysfunction is predictive of developing SBP; moreover, renal impairment and infections caused by multidrug-resistant (MDR) organism are associated with a fatal prognosis of SBP. SBP is treated by antimicrobials, but initial empirical treatment may not succeed because of the presence of MDR organisms, particularly in nosocomial infections. Antibiotic prophylaxis is recommended for patients with LC at a high risk of developing SBP, gastrointestinal bleeding, or a previous episode of SBP, but the increase in the risk of developing an infection caused by MDR organisms is a serious concern globally. Less is known about SFP in patients with LC, but the severity of underlying liver dysfunction may increase the hospital mortality. SFP mortality has been reported to be higher than that of SBP partially because the difficulty of early differentiation between SFP and SBP induces delayed antifungal therapy for SFP.

Norfloxacin is more effective than Rifaximin in avoiding bacterial translocation in an animal model of cirrhosis

BACKGROUND & AIMS

Norfloxacin administration is useful in preventing bacterial infections in cirrhosis but associated to the generation of resistant species. Rifaximin is known to reach high concentrations in the intestinal lumen without generating relevant resistance in the intestinal flora. Our aim was to compare the effect of Norfloxacin and Rifaximin on intestinal flora composition, bacterial translocation and survival in cirrhotic rats.

METHODS

Cirrhosis was induced in rats by oral administration of CCl₄ . Animals were divided into three groups: only CCl₄ (group I, n = 10); CCl₄ + Norfloxacin (group II, n = 17) and CCl₄ + Rifaximin (group III, n = 14). Gut bacterial composition, bacterial translocation and cytokine levels were measured.

RESULTS

Forty-one rats were finally included. The incidence of viable and non-viable bacterial translocation was significantly reduced in animals receiving Norfloxacin; Rifaximin also decreased the incidence of viable and non-viable bacterial translocation, but did not reach statistical significance. Serum TNF-α levels were significantly lower in antibiotic groups. Norfloxacin modified intestinal microbiota, depleting significantly more pathobionts than Rifaximin.

CONCLUSION

Norfloxacin is more effective than Rifaximin in preventing bacterial translocation in rats with cirrhosis probably because of its capacity to reduce pathobionts from intestinal microbiota.

Infections complicating cirrhosis

Patients with cirrhosis have a high risk of bacterial infections. Bacterial infections induce systemic inflammation that may lead to organ failure and acute-on-chronic liver failure (ACLF) resulting in a high risk of short term mortality. The early diagnosis and treatment of bacterial infections is essential to improve the patient's prognosis. However, in recent years, the spread of multidrug resistant (MDR) bacterial infections has reduced the efficacy of commonly used antibiotics such as third generation cephalosporins. In patients at high risk of MDR bacteria, such as those with nosocomial infections, the early administration of broad spectrum antibiotics has been shown to improve the prognosis. However, early de-escalation of antibiotics is recommended to reduce a further increase in antibiotic resistance. Strategies to prevent acute kidney injury and other organ failures should be implemented. Although prophylaxis of bacterial infections with antibiotics improves the prognosis in selected patients, their use should be limited to patients at high risk of developing infections. In this article, we review the pathogenesis and management of bacterial infections in patients with cirrhosis.

Low ascitic fluid total protein levels is not associated to the development of spontaneous bacterial peritonitis in a cohort of 274 patients with cirrhosis

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is a complication to decompensated cirrhosis. Fluoroquinolones may prevent SBP. However, predictive markers for SBP are wanted. Guidelines suggest that patients with ascitic fluid protein below 15 g/l receive fluoroquinolones to prevent SBP. This study aimed to assess the clinical utility of low ascitic fluid protein in predicting SBP in patients with cirrhosis and ascites.

METHODS

A total of 274 patients with cirrhosis and ascites underwent paracentesis between January 2010 and June 2015. Patients were followed until two years, development of SBP, initiation of ciprofloxacin, death or liver transplantation. Data were compared between groups of patients with 'high' or 'low' ascitic protein.

RESULTS

SBP developed in 31 patients (11.3%). No difference in mean ascitic fluid protein levels were found (SBP, mean: 8.5 g/l and no SBP 8.2 g/l, p = .825). SBP developed at equal rates in patients with 'high' or 'low' ascitic protein (10.8% (≤15 g/l) and 14.0% (>15 g/l), p = .599). The same trend was observed when adjusting the threshold below 10 g/l (11.9% (≤10 g/l) and 10.2% (>10 g/l), p = .697).

CONCLUSIONS

Low ascitic fluid protein does not predict SBP in patients with cirrhosis and ascites. Better markers are needed.

Toll-like receptor 4 polymorphisms and bacterial infections in patients with cirrhosis and ascites

AIM

To assess the relationship between the presence of toll-like receptor 4 (TLR4) polymorphisms and bacterial infections in cirrhotic patients with ascites.

METHODS

We prospectively included consecutive patients with cirrhosis and ascites hospitalized during a 6-year period. Patients with human immunodeficiency virus (HIV) infection or any other immunodeficiency, patients with advanced hepatocellular carcinoma (beyond Milan’s criteria) or any other condition determining poor short-term prognosis, and patients with a permanent urinary catheter were excluded. The presence of D299G and/or T399I TLR4 polymorphisms was determined by sequencing and related to the incidence and probability of bacterial infections, other complications of cirrhosis, hepatocellular carcinoma, and mortality during follow-up. A multivariate analysis to identify predictive variables of mortality in the whole series was performed.

RESULTS

We included 258 patients: 28 (10.8%) were carriers of D299G and/or T399I TLR4 polymorphisms (polymorphism group) and 230 patients were not (wild-type group). The probability of developing any bacterial infection at one-year follow-up was 78% in the polymorphism group and 69% in the wild-type group (P = 0.54). The one-year probability of presenting infections caused by gram-negative bacilli (51% vs 44%, P = 0.68), infections caused by gram-positive cocci (49% vs 40%, P = 0.53), and spontaneous bacterial peritonitis (29% vs 34%, respectively, P = 0.99) did not differ between the two groups. The one-year probability of transplant-free survival was 55% in the polymorphism group and 66% in the wild-type group (P = 0.15). Multivariate analysis confirmed that age, Child-Pugh score, active alcohol intake, previous hepatic encephalopathy, hepatocellular carcinoma and serum creatinine were associated with a higher risk of death during follow-up.

CONCLUSION

Genetic polymorphisms D299G and/or T399I of TLR4 do not seem to play a relevant role in the predisposition of cirrhotic patients with ascites to bacterial infections.

Epidemiology and risk factors for multidrug-resistant bacteria in critically ill patients with liver disease

Background and Aims:

The critically ill patients with liver disease are vulnerable to infections in both community and hospital settings. The nosocomial infections are often caused by multidrug-resistant (MDR) bacteria. The present observational study was conducted to describe the epidemiology, course, and outcome of MDR bacterial infection and identify the risk factors of such infection in critically ill patients with liver disease.

Materials and Methods:

A retrospective observational study was conducted on 106 consecutive critically patients with liver disease admitted in the Intensive Care Unit between March 2015 and February 2017. The MDR and non-MDR (non-MDR) groups were compared and the risk factors identified by multivariate analysis.

Results:

Out of the 106 patients enrolled in the study, 23 patients had infections caused by MDR bacteria. The MDR-infected patients had severe liver disease (Child–Pugh score 11 ± 2.3 vs. 7 ± 3.9; P = 0.04), longer duration of antibiotic usage (6 ± 2.7 days vs. 2 ± 1.5 days; P = 0.04), greater use of total parenteral nutrition (TPN) (73.9% vs. 62.6%; P = 0.04), and more concurrent antifungal administration (60.8% vs. 38.5%; P = 0.04). The mortality was higher in MDR group (hazard ratio = 1.86; P < 0.05). The independent predictors of MDR bacterial infection were Child–Pugh score >10, prior carbapenem use, antibiotic use for more than 10 days, TPN use, and concurrent antifungal administration.

Conclusion:

The study demonstrated a high prevalence of MDR bacterial infection in critically ill patients with a higher mortality over non-MDR bacterial infection and also identified the independent predictors of such infections.

Xuebijing Injection Combined with Antibiotics for the Treatment of Spontaneous Bacterial Peritonitis in Liver Cirrhosis: A Meta-Analysis

BACKGROUND AND AIM

Spontaneous bacterial peritonitis (SBP) is one of the most common complications of liver cirrhosis. Antibiotics are the main treatment regimen of SBP. Traditional Chinese medicine Xuebijing injection has been used in such patients. Our study aimed to overview the efficacy of Xuebijing injection combined with antibiotics for the treatment of SBP.

METHOD

We searched the PubMed, Embase, China National Knowledge Infrastructure, VIP, and Wanfang databases. The search items included "Xuebijing", "peritonitis", "liver cirrhosis", and "random" to identify all relevant randomized controlled trials (RCTs). The Cochrane risk of bias tool was used to assess the study quality. The odd ratios (ORs) with 95% confidence intervals (CIs) were calculated by using a random-effect model. Heterogeneity was also calculated.

RESULTS

A total of 9 RCTs were included. The study quality was unsatisfied. The overall (OR = 2.95, 95% CI = 1.97-4.42, p < 0.00001) and complete (OR = 2.18, 95% CI = 1.57-3.04, p < 0.00001) responses were significantly higher in the Xuebijing injection combined with antibiotics group than the antibiotics alone group. The incidence of cirrhosis related complications, including hepatic encephalopathy and hepatorenal syndrome, was lower in the Xuebijing injection combined with antibiotics group than the antibiotics alone group. No significant heterogeneity was observed among studies.

CONCLUSION

Additional use of Xuebijing injection may improve the efficacy of antibiotics for the treatment of SBP in liver cirrhosis. However, due to a low level of current evidence, we did not establish any recommendation regarding the use of Xuebijing injection for the treatment of SBP.

Investigation on outcomes and bacterial distributions of liver cirrhosis patients with gram-negative bacterial bloodstream infection

Objective

The study aimed at analyzing the epidemiology and outcomes of liver cirrhosis patients undergoing gram-negative bacterial bloodstream infection.

Results

Totally 508 eligible patients were collected, with 25.79% 30-day mortality, and 58.86% patients were confirmed as nosocomial infection. The most common isolates were Escherichia coli (48.29%) and Klebsiella pneumoniae (19.29%), and multidrug-resistant isolates accounted for 36.61%. The bacterial distributions were similar between survivors and non-survivors (P>0.05), but showed close association with acquisition sites of infection (P<0.05). Nosocomial infection (HR=1.589, 95% CI=1.004-2.517), Child-Pugh grade (HR=2.471, 95% CI=1.279-4.772), septic shock (HR=1.966, 95% CI=1.228-3.146), complications (HR=3.529, 95% CI=2.140-5.818), and WBC (HR=1.065, 95% CI=1.018-1.114) were independent indicators for 30-day mortality. β-lactamase inhibitor antibiotics exerted a high antibacterial activity.

Methods

The inpatients with liver cirrhosis developed gram-negative bacterial bloodstream infection were collected. The clinical characteristics, bacterial distribution and drug sensitivity results of patients were compared according to their 30-day survival status and acquisition sites of infections. Cox regression model was applied to evaluate the risk factors for 30-day mortality.

Conclusion

Escherichia coli and Klebsiella pneumoniae are frequently isolated from gram-negative bacterial bloodstream infection episodes in cirrhosis patients. Acquisition site of infection can influence clinical characteristics and etiological distribution. β-lactamase inhibitor antibiotics may be the first choice for empirical treatments.

Systematic review with meta-analysis: rifaximin for the prophylaxis of spontaneous bacterial peritonitis

BACKGROUND

The primary and secondary prevention of spontaneous bacterial peritonitis (SBP) is recommended in high-risk patients with cirrhosis. Several studies evaluating the efficacy of rifaximin for SBP prophylaxis have yielded conflicting results. Rifaximin has the potential advantage of preventing bacterial overgrowth and translocation without the systemic side effects of broad-spectrum antibiotics.

AIM

To evaluate the efficacy of rifaximin in the primary and secondary prevention of SBP.

METHODS

A literature search using five databases was performed to identify studies on the association between rifaximin and SBP. We performed two meta-analyses: (1) rifaximin compared to systemic antibiotics and (2) rifaximin compared to no antibiotics. Random-effect modelling was conducted to determine overall pooled estimates and 95% confidence intervals (CIs).

RESULTS

Five studies with 555 patients (295 rifaximin, 260 systemic antibiotics) compared rifaximin with systemic antibiotics. The pooled odds ratio (OR) for SBP was 0.45 (95% CI 0.16-1.27; P = .13) in patients receiving rifaximin and strengthened on sensitivity analysis (OR 0.38, 95% CI 0.19-0.76, P = .01). In the analysis comparing rifaximin with no antibiotics, there were five studies with 784 patients (186 rifaximin, 598 no antibiotics). The OR for SBP was 0.34 (95% CI 0.11-0.99; P < .05) in patients receiving rifaximin. In subgroup analysis, rifaximin reduced the risk of SBP by 47% compared to no antibiotics for primary prophylaxis and by 74% compared to systemic antibiotics for secondary prophylaxis.

CONCLUSION

Rifaximin may be effective in preventing SBP in patients with cirrhosis and ascites compared to systemically absorbed antibiotics and compared to placebo.

Nutrition and Muscle in Cirrhosis

As the cirrhosis progresses, development of complication like ascites, hepatic encephalopathy, variceal bleeding, kidney dysfunction, and hepatocellular carcinoma signify increasing risk of short term mortality. Malnutrition and muscle wasting (sarcopenia) is yet other complications that negatively impact survival, quality of life, and response to stressors, such as infection and surgery in patients with cirrhosis. Conventionally, these are not routinely looked for, because nutritional assessment can be a difficult especially if there is associated fluid retention and/or obesity. Patients with cirrhosis may have a combination of loss of skeletal muscle and gain of adipose tissue, culminating in the condition of "sarcopenic obesity." Sarcopenia in cirrhotic patients has been associated with increased mortality, sepsis complications, hyperammonemia, overt hepatic encephalopathy, and increased length of stay after liver transplantation. Assessment of muscles with cross-sectional imaging studies has become an attractive index of nutritional status evaluation in cirrhosis, as sarcopenia, the major component of malnutrition, is primarily responsible for the adverse clinical consequences seen in patients with liver disease. Cirrhosis is a state of accelerated starvation, with increased gluconeogenesis that requires amino acid diversion from other metabolic functions. Protein homeostasis is disturbed in cirrhosis due to several factors such as hyperammonemia, hormonal, and cytokine abnormalities, physical inactivity and direct effects of ethanol and its metabolites. New approaches to manage sarcopenia are being evolved. Branched chain amino acid supplementation, Myostatin inhibitors, and mitochondrial protective agents are currently in various stages of evaluation in preclinical studies to prevent and reverse sarcopenia, in cirrhosis.

An Insight into Antibiotic Resistance to Bacterial Infection in Chronic Liver Disease

BACKGROUND

End stage liver disease leads to immune dysfunction which predisposes to infection. There has been a rise in antibiotic resistant infections in these patients. There is scanty data f from India or idea regarding the same.

AIM OF THE STUDY

The present study was undertaken to determine the type of infection acquired and the prevalence of antibiotic resistant infections in cirrhotic patients at a tertiary referral center in South India.

MATERIALS AND METHODS

In this retrospective study, all consecutive cirrhotic patients hospitalized between 2011 and 2013 with a microbiologically-documented infection were enrolled. Details of previous admission and antibiotics if received were noted. In culture positive infections, the source of infection (ascites, skin, respiratory tract: sputum/endotracheal tube aspirate, pleural fluid; urine and blood) and microorganisms isolated and their antibiotic susceptibility was noted.

RESULTS

A total of 92 patients had 240 culture positive samples in the study period. Majority were Klebseilla followed by Escherichia coli and Enterococcus in nosocomial and health care associated infections. However, Enteroccocus was followed by E. coli and Klebsiella in community acquired infections. The antibiotic sensitivity pattern was analyzed for the major causative organisms such as E. coli, Klebsiella and Enterococcus. Most common resistant strains were extended spectrum beta lactamase producing enterobacteriacae (ESBL) followed by carbapenemase producing Klebsiella and methicillin resistant Staphylococcus aureus.

CONCLUSION

Noscomial infection is the most common type, with Klebsiella and E. coli and there is significant rise in ESBL producing organism.

Microbiology and antibiotic susceptibility patterns in spontaneous bacterial peritonitis: A study of two Dutch cohorts at a 10-year interval

Background

Recent investigations suggest an increasing prevalence of Gram-positive and antibiotic-resistant bacteria causing spontaneous bacterial peritonitis (SBP), probably related to changes in antibiotic prescription patterns, in particular more widespread and long-term use of antibiotic prophylaxis with quinolones.

Objective

The primary objective of this study was to assess potential changes in the microbiology of SBP in two patient cohorts studied at a 10-year interval. Further aims were to study prognostic factors and outcome of SBP.

Methods

A retrospective double-cohort study, including all ascitic cultures from patients with cirrhosis obtained 2003–2005 and 2013–2014, was conducted.

Results

In total 312 patients were included, 125 patients in the first and 187 patients in the second cohort. SBP was diagnosed in 132 of 840 analyzed ascitic fluid samples; 62 samples were culture positive. An increase of Gram-positive bacterial isolates was noted from 26% to 46% between cohorts (p = 0.122). The prevalence of multidrug-antibiotic–resistant pathogens increased from 25% to 32% (p = 0.350). Survival after SBP among the two cohorts was comparable.

Conclusion

This single-center study in the Netherlands found a modest but nonsignificant increase in the proportion of patients with SBP caused by Gram-positive bacteria and multidrug-antibiotic–resistant bacteria over a 10-year period. Our findings differ from reported data in other countries and suggest empiric antibiotic prophylaxis and treatment of SBP should be based on national and regional microbiological findings and resistance patterns.

Sepsis in alcohol-related liver disease

Alcohol-related liver disease (ALD) remains the most important cause of death due to alcohol. Infections, particularly bacterial infections, are one of the most frequent and severe complications of advanced ALDs, such as alcoholic cirrhosis and severe alcoholic hepatitis (sAH). The specific mechanisms responsible for this altered host defence are yet to be deciphered. The aim of the present study is to review the current knowledge of infectious complications in ALD and its pathophysiological mechanisms, distinguishing the role of alcohol consumption and the contribution of different forms of ALD. To date, corticosteroids are the only treatment with proven efficacy in sAH, but their impact on the occurrence of infections remains controversial. The combination of an altered host defence and corticosteroid treatment in sAH has been suggested as a cause of opportunistic fungal and viral infections. A high level of suspicion with systematic screening and prompt, adequate treatment are warranted to improve outcomes in these patients. Prophylactic or preemptive strategies in this high-risk population might be a preferable option, because of the high short-term mortality rate despite adequate therapies. However, these strategies should be assessed in well-designed trials before clinical implementation.

Predictors of Early Readmission in Patients With Cirrhosis After the Resolution of Bacterial Infections

OBJECTIVES

In patients with cirrhosis, infections represent a frequent trigger for complications, increasing frequency of hospitalizations and mortality rate. This study aimed to identify predictors of early readmission (30 days) and of mid-term mortality (6 months) in patients with liver cirrhosis discharged after a hospitalization for bacterial and/or fungal infection.

METHODS

A total of 199 patients with cirrhosis discharged after an admission for a bacterial and/or fungal infection were included in the study and followed up for a least 6 months.

RESULTS

During follow-up, 69 patients (35%) were readmitted within 30 days from discharge. C-reactive protein (CRP) value at discharge (odds ratio (OR)=1.91; P=0.022), diagnosis of acute-on-chronic liver failure during the hospital stay (OR=2.48; P=0.008), and the hospitalization in the last 30 days previous to the admission/inclusion in the study (OR=1.50; P=0.042) were found to be independent predictors of readmission. During the 6-month follow-up, 47 patients (23%) died. Age (hazard ratio (HR)=1.05; P=0.001), model of end-stage liver disease (MELD) score (HR=1.13; P<0.001), CRP (HR=1.85; P=0.001), refractory ascites (HR=2.22; P=0.007), and diabetes (HR=2.41; P=0.010) were found to be independent predictors of 6-month mortality. Patients with a CRP >10 mg/l at discharge had a significantly higher probability of being readmitted within 30 days (44% vs. 24%; P=0.007) and a significantly lower probability of 6-month survival (62% vs. 88%; P<0.001) than those with a CRP ≤10 mg/l.

CONCLUSIONS

CRP showed to be a strong predictor of early hospital readmission and 6-month mortality in patients with cirrhosis after hospitalization for bacterial and/or fungal infection. CRP values could be used both in the stewardship of antibiotic treatment and to identify fragile patients who deserve a strict surveillance program.

The impact of carbapenem resistance on clinical deterioration and mortality in patients with liver disease

BACKGROUND & AIMS

Infections with multidrug-resistant gram-negative bacteria are significantly impairing the prognosis of patients with liver disease. In particular, carbapenem resistance further narrows therapeutic options. This study investigates the impact of carbapenem-resistant gram-negative bacteria on the outcome of patients with liver disease and cirrhosis.

METHODS

Between January 2011 and July 2015, 132 patients treated at the tertiary liver transplant centre at University Hospital Frankfurt, Germany, were tested positive for carbapenem-resistant gram-negative bacteria and retrospectively analysed in this study. Risk factors for fatal outcome were evaluated using multivariate regression analysis. Competing-risk analysis was performed on patients tested positive for Enterobacteriaceae or non-fermenting species, for example, Pseudomonas aeruginosa, Acinetobacter baumannii, Stenotrophomonas maltophilia. Subgroup analysis of cirrhotic patients was performed on a matched cohort of cirrhotic patients, comparable model for end-stage liver disease and tested negative for carbapenem-resistant gram-negative bacteria.

RESULTS

97 (73.5%) and 35 (26.5%) patients were infected or colonised with carbapenem-resistant gram-negative bacteria respectively. Within the observation period, 61/132 (46.2%) patients died, with sepsis being the leading cause (38/61, 62.3%). Decompensated liver disease, sepsis and admission to intensive care unit were independent risk factors for fatal outcome. Lethal sepsis in patients positive for non-fermenting bacteria was significantly more frequent than in those positive for Enterobacteriaceae, independently from liver function. Subgroup analysis of cirrhotic patients showed that sepsis (54.9% vs 13%) and lethal sepsis were significantly more frequent after detection of carbapenem-resistant gram-negative bacteria, independently from localisation of pathogen detection.

CONCLUSIONS

Patients with advanced liver disease are prone to fatal infections caused by carbapenem-resistant gram-negative bacteria.

Types and microbiological spectrum of infections in patients with cirrhosis: A single-centre experience in Upper Egypt

BACKGROUND AND STUDY AIMS

Egypt has a high prevalence of hepatitis C virus (HCV) and high morbidity and mortality related to cirrhosis complications. Patients with cirrhosis have an increased risk of bacterial infections. Approximately 25-35% of cirrhotics had infections at admission or during hospitalisation. Data on infection among cirrhotics in Egypt are limited. This study aimed to determine the frequency and microbiological spectrum of infections in cirrhotics and possible risk factors.

PATIENTS AND METHODS

This study was conducted at a tertiary care hospital. The frequency and microbiological spectrum of infections in cirrhotics were determined. The risk factors for infection were evaluated.

RESULTS

Of the 100 patients with liver cirrhosis, 61% had infection. Ascitic fluid infection (AFI) was the most common infection (44.3%), followed by urinary tract infection (UTI) (21.3%), respiratory tract infection (RTI) (19.7%), gastroenteritis (6.6%) and skin infection (4.9%). The only risk factor for infection among cirrhotics was diabetes mellitus (DM) (p=0.047). The mean value of mid-arm muscle circumference was significantly lower in the infected group (p=0.047). Among all the cirrhotics, 32.0% had mild to moderate malnutrition and 52.0% had severe malnutrition. The frequency of infection was higher in severe malnutrition (71.2%).

CONCLUSIONS

The frequency of infections among cirrhotics was 61%. Many types of infections including AFI, RTI, UTI and skin infections were present in patients with liver cirrhosis, but AFI was the most common. DM was the only risk factor for infection, and independent predictors for infection were elevated WBC count and C-reactive protein levels. The frequency of infection was related to the degree of malnutrition.

Bacterial distributions and prognosis of bloodstream infections in patients with liver cirrhosis

Bloodstream infections (BSIs) are a frequently observed complication in liver cirrhosis patients. This study aimed to investigate the microbiological characteristics and outcomes of BSIs in patients with liver cirrhosis. We retrospectively studied 852 patients with liver cirrhosis who developed a BSI. Patient outcome was evaluated using 30-day mortality and assessed using multivariate stepwise logistic regression analysis. Antibiotic sensitivity of the pathogens was tested. Gram-negative bacteria were responsible for 59.6% of BSIs, and Gram-positive bacteria caused 40.4% of the episodes among liver cirrhosis patients. The bacterial distribution significantly differed between hospital-acquired and community-acquired infections, especially in cases caused by Gram-negative pathogens. The results of the drug sensitivity test suggested that amikacin, cefoperazone/sulbactam, and piperacillin/tazobactam highly suppressed Gram-negative infections, while vancomycin and teicoplanin strongly inhibited Gram-positive BSIs. Liver failure, liver cancer, complications, Child-Pugh grade, septic shock, administration of appropriate antibiotics within 24 h, ICU admission, nosocomial infection, and Gram nature of the bacteria were independent risk factors for 30-day mortality (P < 0.05). The choice of initial empirical antibiotics should be based on the type, severity and origin of infection and on the local epidemiological data on antibiotic resistance. Accurate evaluation of risk factors for mortality may improve appropriate therapeutic choice.

Bacterial infections and hepatic encephalopathy in liver cirrhosis-prophylaxis and treatment

Infections are common among patients with liver cirrhosis. They occur more often in cirrhotic patient groups than in the general population and result in higher mortality. One reason for this phenomenon is bacterial translocation from the intestinal lumen that occurs as a consequence of intestinal bacterial overgrowth, increased permeability and decreased motility. The most common infections in cirrhotic patients are spontaneous bacterial peritonitis and urinary tract infections, followed by pneumonia, skin and soft tissue infections. Intestinal bacterial overgrowth is also responsible for hyperammonemia, which leads to hepatic encephalopathy. All of these complications make this group of patients at high risk for mortality. The role of antibiotics in liver cirrhosis is to treat and in some cases to prevent the development of infectious complications. Based on our current knowledge, antibiotic prophylaxis should be administered to patients with gastrointestinal hemorrhage, low ascitic fluid protein concentration combined with liver or renal failure, and spontaneous bacterial peritonitis as a secondary prophylaxis, as well as after hepatic encephalopathy episodes (also as a secondary prophylaxis). In some cases, the use of non-antibiotic prophylaxis can also be considered. Current knowledge of the treatment of infections allows the choice of a preferred antibiotic for empiric therapy depending on the infection location and whether the source of the disease is nosocomial or community-acquired.

The gut microbiome and liver cancer: mechanisms and clinical translation

Hepatocellular carcinoma (HCC) is the third leading cause of worldwide cancer mortality. HCC almost exclusively develops in patients with chronic liver disease, driven by a vicious cycle of liver injury, inflammation and regeneration that typically spans decades. Increasing evidence points towards a key role of the bacterial microbiome in promoting the progression of liver disease and the development of HCC. Here, we will review mechanisms by which the gut microbiota promotes hepatocarcinogenesis, focusing on the leaky gut, bacterial dysbiosis, microbe-associated molecular patterns and bacterial metabolites as key pathways that drive cancer-promoting liver inflammation, fibrosis and genotoxicity. On the basis of accumulating evidence from preclinical studies, we propose the intestinal-microbiota-liver axis as a promising target for the simultaneous prevention of chronic liver disease progression and HCC development in patients with advanced liver disease. We will review in detail therapeutic modalities and discuss clinical settings in which targeting the gut-microbiota-liver axis for the prevention of disease progression and HCC development seems promising.

Characteristics of infection and its impact on short-term outcome in patients with acute-on-chronic liver failure

Bacterial infections are an important cause of mortality in liver failure. However, the type of infection, predictors of infection, and their impact on outcomes in patients with acute-on-chronic liver failure (ACLF) are limited.A total of 389 patients with ACLF were admitted in this retrospective, corhort study. Once admitted, clinical data including first infection site, type (community-acquired, healthcare-associated, or nosocomial), and second infection occurrence during hospitalization were collected. The outcome was mortality within 90 days. Multivariable logistic regression models were preformed to predict second infection development and 90-day mortality. Survival probability curves were calculated by the Kaplan-Meier method.Among 389 patients, 316 (81.2%) patients had infection. The 90-day mortality of patients with and without infection was 52.2% and 16.4%, respectively (P <.001). The most common first infection was healthcare associated (51.3%), followed by nosocomial (30.1%) and community-acquired infections (18.7%). Respiratory tract infection, spontaneous bacterial peritonitis, and urinary tract infection were most prevalent. Gram-positive organism was more frequently seen than gram-negative organisms. Of note, fungi accounted for 15.9% of the total infection cases. During hospitalization, 26.6% patients developed second infections. The 90-day mortality of patients developed or did not develop a second infection were 67.9% and 46.6%, respectively (P <.001). Independent predictors of 90-day mortality in infected patients with ACLF were age, white blood cell (WBC) count, model for end-stage liver disease (MELD) score, hepatic encephalopathy (HE), and second infection.Infections (regardless of first or second infection) can increase the 90-day mortality significantly in patients with ACLF. And age, WBC count, MELD score, HE, and the presence of second infection are independent risk factors affecting 90-day mortality in patients with ACLF showing infection.

Surgery for Infective Endocarditis: Outcomes and Predictors of Mortality in 360 Consecutive Patients

BACKGROUND A retrospective analysis was conducted of the early and long-term outcomes after surgery for infective endocarditis (IE). MATERIAL AND METHODS We included 360 patients with IE operated upon between 1993 and 2012. The primary endpoint was overall cumulative postoperative survival at 30 days. Secondary endpoints were early postoperative outcomes and complication rates. Factors associated with 30-day mortality were analyzed. RESULTS Mean age was 58.7±14.7 years and 26.9% (n=97) were female. The mean follow-up was 4.41±4.53 years. Postoperative survival was 81.7% at 30 days, 69.4% at 1 year, 63.3% at 5 years, and 63.3% at 10 years. Non-survivors were significantly older (p=0.014), with higher NYHA Class (p=0.002), had higher rates of preoperative diabetes mellitus (p=0.005), renal failure (p=0.001), and hepatic disease (p=0.002). Furthermore, non-survivors had higher baseline alanine aminotransferase (ALT, p=0.048), aspartate transaminase (AST, p=0.027), bilirubin (p=0.013), white cell count (WCC, p=0.034), and CRP (p=0.049). Factors associated with 30-day mortality were longer duration of surgery, CPB, and aortic cross-clamping times (p<0.001, p<0.001, and p=0.003, respectively), as well as higher RBC, FFP, and platelet transfusion requirements (p<0.001, p=0.005, and p<0.001, respectively). Multivariate logistic regression analysis revealed liver cirrhosis (OR 4.583, 95-CI: 1.096-19.170, p=0.037) and longer CPB time (OR 1.025, 95-CI 1.008-1.042, p=0.004) as independent predictors of 30-day mortality. CONCLUSIONS Surgical treatment of IE shows satisfactory early, midterm, and long-term results. Multivariate logistic regression analysis revealed cirrhosis and longer CPB time as independent predictors of 30-day mortality.

Nosocomial spontaneous bacterial peritonitis antibiotic treatment in the era of multi-drug resistance pathogens: A systematic review

AIM

To systematically review literature upon aetiology of nosocomial spontaneous bacterial peritonitis (N-SBP) given the rising importance of multidrug-resistant (MDR) bacteria.

METHODS

A literature search was performed on MEDLINE and Google Scholar databases from 2000 to 15th of November 2016, using the following search strategy: "spontaneous" AND "peritonitis".

RESULTS

The initial search through electronic databases retrieved 2556 records. After removing duplicates, 1958 records remained. One thousand seven hundred and thirty-five of them were excluded on the basis of the screening of titles and abstract, and the ensuing number of remaining articles was 223. Of these records, after careful evaluation, only 9 were included in the qualitative analysis. The overall proportion of MDR bacteria turned out to be from 22% to 73% of cases across the studies.

CONCLUSION

N-SBP is caused, in a remarkable proportion, by MDR pathogens. This should prompt a careful re-assessment of guidelines addressing the treatment of this clinical entity.