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

Clinical outcomes of spontaneous bacterial peritonitis due to extended-spectrum beta-lactamase-producing Escherichia coli or Klebsiella pneumoniae: a retrospective cohort study

PURPOSE

The aim of this study was to (1) evaluate the clinical outcomes of spontaneous bacterial peritonitis (SBP) due to extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli or Klebsiella pneumoniae (EK) and (2) investigate the relationship between the adequacy of initial antibiotic treatments and patient outcomes.

METHODS

We conducted a retrospective cohort study of cirrhotic patients with SBP caused by EK. We evaluated the 30-day mortality rate and used Cox proportional hazard models to identify risk factors for mortality.

RESULTS

Between January 2006 and December 2012, a total of 231 episodes of SBP due to EK were recorded. Among them, 52 were caused by ESBL-producing EK (ESBL-EK). The 30-day mortality rate was significantly higher in patients with SBP due to ESBL-EK than in those with non-ESBL-producing EK (non-ESBL-EK) (34.6 vs. 18.4 %, respectively; p = 0.013). Multivariate analysis revealed that ESBL production [adjusted HR (aHR) 1.82, 95 % confidence interval (CI) 1.00-3.31], nosocomial infection (aHR 2.24, 95 % CI 1.26-3.95), septic shock (aHR 4.84, 95 % CI 2.70-8.65), higher Child-Pugh score (aHR 1.57, 95 % CI 1.28-1.92), and higher Charlson comorbidity index (aHR 1.37, 95 % CI 1.15-1.64) were independent risk factors for 30-day mortality in the total cohort. When we analyzed patients with SBP due to ESBL-EK separately, septic shock (aHR 3.64, 95 % CI 1.40-9.77), accompanying bacteremia (aHR 3.71, 95 % CI 1.37-10.08), and hepatocellular carcinoma (aHR 3.21, 95 % CI 1.20-8.56) were independent risk factors.

CONCLUSIONS

Both 7- and 30-day mortalities for SBP due to ESBL-EK were significantly higher than for SBP due to non-ESBL-EK. Initial antibiotic choice was not associated with poor clinical outcomes in patients with SBP due to ESBL-EK.

Bacterial infections in cirrhosis: a position statement based on the EASL Special Conference 2013

Bacterial infections are very common and represent one of the most important reasons of progression of liver failure, development of liver-related complications, and mortality in patients with cirrhosis. In fact, bacterial infections may be a triggering factor for the occurrence of gastrointestinal bleeding, hypervolemic hyponatremia, hepatic encephalopathy, kidney failure, and development of acute-on-chronic liver failure. Moreover, infections are a very common cause of repeated hospitalizations, impaired health-related quality of life, and increased healthcare costs in cirrhosis. Bacterial infections develop as a consequence of immune dysfunction that occurs progressively during the course of cirrhosis. In a significant proportion of patients, infections are caused by gram-negative bacteria from intestinal origin, yet gram-positive bacteria are a frequent cause of infection, particularly in hospitalized patients. In recent years, infections caused by multidrug-resistant bacteria are becoming an important clinical problem in many countries. The reduction of the negative clinical impact of infections in patients with cirrhosis may be achieved by a combination of prophylactic measures, such as administration of antibiotics, to reduce the occurrence of infections in high-risk groups together with early identification and management of infection once it has developed. Investigation on the mechanisms of altered gut microflora, translocation of bacteria, and immune dysfunction may help develop more effective and safe methods of prevention compared to those that are currently available. Moreover, research on biomarkers of early infection may be useful in early diagnosis and treatment of infections. The current manuscript reports an in-depth review and a position statement on bacterial infections in cirrhosis.

Low Levels of 25-Hydroxy Vitamin D are Independently Associated with the Risk of Bacterial Infection in Cirrhotic Patients

OBJECTIVES:

Low levels of vitamin D are associated with a higher mortality in cirrhotic patients, but the role of this deficiency is still unknown. The purpose of this study was to assess the levels of vitamin D in cirrhotic patients with and without bacterial infection.

METHODS:

25-hydroxy (25-OH) vitamin D was assessed by immunoassay in 88 patients hospitalized in our hepatology unit.

RESULTS:

The causes of cirrhosis were mainly alcohol (70%), hepatitis C (10%), or both (9%). Infections (n=38) mainly included bacteriemia (21%), urinary tract infections (24%), and spontaneous bacterial peritonitis (29%). A severe deficiency in vitamin D (<10 ng/ml) was observed in 56.8% of patients. Infections were more frequent in patients with a severe deficiency compared with the others (54 vs. 29%, P=0.02). A severe deficiency in vitamin D was a predictive factor of infection (odds ratio=5.44 (1.35–21.97), P=0.017) independently of the Child–Pugh score (odds ratio=2.09 (1.47–2.97) P=0.00004) and the C-reactive protein level (odds ratio=1.03 (1.002–1.052), P=0.03) in a logistic regression also including the alanine amino transferase (not significant). By a Cox regression analysis, only the presence of an infection was significantly associated with mortality (relative risk=3.24 (1.20–8.76), P=0.02) in a model also associating the Child–Pugh score (not significant) and the presence of a severe deficiency in vitamin D (not significant).

CONCLUSIONS:

Low levels of 25-OH vitamin D were independently associated with bacterial infections in cirrhotic patients. The impact of 25-OH vitamin D supplementation on the infection rate and death of cirrhotic patients should be assessed in randomized trials.

Evolving epidemiology and antimicrobial resistance in spontaneous bacterial peritonitis: a two-year observational study

BACKGROUND

Current recommendations for empirical antimicrobial therapy in spontaneous bacterial peritonitis (SBP) are based on quite old trials. Since microbial epidemiology and the management of patients have changed, whether these recommendations are still appropriate must be confirmed.

METHODS

An observational study that exhaustively collected the clinical and biological data associated with positive ascitic fluid cultures was conducted in four French university hospitals in 2010-2011.

RESULTS

Two hundred and sixty-eight documented positive cultures were observed in 190 cirrhotic patients (median age 61.5 years, 58.5% Child score C). Of these, 57 were classified as confirmed SBP and 140 as confirmed bacterascites. The predominant flora was Gram-positive cocci, whatever the situation (SBP, bacterascites, nosocomial/health-care related or not). Enteroccocci (27.7% E. faecium) were isolated in 24% of the episodes, and in 48% from patients receiving quinolone prophylaxis. E. coli were susceptible to amoxicillin-clavulanate and to third-generation cephalosporins in 62.5% and 89.5% of cases, respectively. No single antibiotic allowed antimicrobial coverage of more than 60%. Only combinations such as amoxicillin + third-generation cephalosporin or cotrimoxazole allowed coverage close to 75-80% in non-nosocomial episodes. Combinations based on broader spectrum antibiotics should be considered for empirical therapy of nosocomial infections.

CONCLUSIONS

Our study confirmed the changing spectrum of pathogens in SBP and bacterascites, and the need for more complex antibiotic strategies than those previously recommended. Our findings also underline the need for new clinical trials conducted in the current epidemiological context.

Cirrhosis and its complications: Evidence based treatment

Cirrhosis results from progressive fibrosis and is the final outcome of all chronic liver disease. It is among the ten leading causes of death in United States. Cirrhosis can result in portal hypertension and/or hepatic dysfunction. Both of these either alone or in combination can lead to many complications, including ascites, varices, hepatic encephalopathy, hepatocellular carcinoma, hepatopulmonary syndrome, and coagulation disorders. Cirrhosis and its complications not only impair quality of life but also decrease survival. Managing patients with cirrhosis can be a challenge and requires an organized and systematic approach. Increasing physicians’ knowledge about prevention and treatment of these potential complications is important to improve patient outcomes. A literature search of the published data was performed to provide a comprehensive review regarding the management of cirrhosis and its complications.

A randomized controlled study of trimethoprim-sulfamethoxazole versus norfloxacin for the prevention of infection in cirrhotic patients

OBJECTIVE

To prospectively compare norfloxacin (N) with trimethoprim-sulfamethoxazole (T-S) in preventing infection in cirrhotic patients.

METHODS

Cirrhotic patients at high risk of spontaneous bacterial peritonitis (SBP) were recruited and assigned N (400 mg daily) or T-S (160/800 mg daily). Patients were followed up for 12 months. The primary end-point was the incidence of infection. Secondary end-points included the incidence of SBP, bacteremia, extraperitoneal infection requiring antibiotic treatment, liver transplantation, death, side effects and rate of resistance to N or T-S.

RESULTS

A total of 80 patients with a mean age of 53.0 ± 9.3 years were prescribed N (n = 40) or T-S (n = 40). Child-Pugh status, model for end-stage liver disease and risk factors for SBP were similar between the groups. There were 10 episodes of infections in the N group and 9 in the T-S group (P = 0.79). Two patients each in the N and T-S group developed SBP (P = 0.60). There was a difference in the rate of transplantation favoring N (P = 0.03) but not death. The number of adverse events for N (n = 7) and T-S (n = 10) were similar (P = 0.59), with T-S being associated with an increased risk of developing a definite or probable adverse event compared to N (22.5% vs 0%, P = 0.01).

CONCLUSIONS

This study failed to demonstrate a difference between N and T-S groups in their effects on preventing infection in patients with liver cirrhosis. T-S can be considered an alternative first-line therapy for infection prophylaxis.

Risk factor of community-onset spontaneous bacterial peritonitis caused by fluoroquinolone-resistant Escherichia coli in patients with cirrhosis

BACKGROUND & AIMS

Despite the high prevalence of antimicrobial-resistant Escherichia coli in hospital-acquired infections, the clinical epidemiology of fluoroquinolone (FQ) resistance in community-onset spontaneous bacterial peritonitis (SBP) in patients with cirrhosis is not well understood. This study was performed to evaluate clinical features and risk factors for community-onset SBP caused by FQ-resistant E. coli.

METHODS

A case-control control study was performed using cases of community-onset SBP from June 2000 to August 2011 at Samsung Medical Center (Seoul, Korea). Patients with FQ-resistant E. coli were designated as case patients. A control group I (CG I) patient was defined as a person whose clinical sample yielded FQ-susceptible E. coli, and a control group II (CG II) patient was defined as a person with a negative culture result.

RESULTS

A total of 82 subjects with community-onset SBP caused by E. coli were identified, of which 26 (31.7%) were FQ-resistant E. coli infection. Fifty-seven matched subjects were randomly selected for CG II. Compared with CG I, previous SBP episodes (OR, 4.91; 95% CI, 1.50-16.53; P = 0.010), prior use of FQ within 30 days (OR, 7.05; 95% CI, 1.17-42.38; P = 0.033), and third-generation cephalosporin resistance (OR, 17.68; 95% CI, 1.67-187.26; P = 0.017) were significantly associated with FQ-resistant E. coli. Compared with CG II, a previous SBP episode was significantly associated with FQ-resistant E. coli (OR, 4.20; 95% CI, 1.50-11.80; P = 0.006).

CONCLUSION

FQ-resistant E. coli is a significant cause of community-onset SBP, with relation to previous SBP episodes, recent FQ use and third-generation cephalosporin resistance.

Terlipressin and albumin for type-1 hepatorenal syndrome associated with sepsis

BACKGROUND & AIMS

Terlipressin and albumin is the standard of care for classical type-1 hepatorenal syndrome (HRS) not associated with active infections. However, there is no information on efficacy and safety of this treatment in patients with type-1 HRS associated with sepsis. Study aim was to investigate the effects of early treatment with terlipressin and albumin on circulatory and kidney function in patients with type-1 HRS and sepsis and assess factors predictive of response to therapy.

METHODS

Prospective study in 18 consecutive patients with type-1 HRS associated with sepsis.

RESULTS

Treatment was associated with marked improvement in arterial pressure and suppression of the high levels of plasma renin activity and norepinephrine. Response to therapy (serum creatinine <1.5mg/dl) was achieved in 12/18 patients (67%) and was associated with improved 3-month survival compared to patients without response. Non-responders had significantly lower baseline heart rate, poor liver function tests, slightly higher serum creatinine, and higher Child-Pugh and MELD scores compared to responders. Interestingly, non-responders had higher values of CLIF-SOFA score compared to responders (14±3 vs. 8±1, respectively p<0.001), indicating greater severity of acute-on-chronic liver failure (ACLF). A CLIF-SOFA score ⩾11 had 92% sensitivity and 100% specificity in predicting no response to therapy. No significant differences were observed between responders and non-responders in baseline urinary kidney biomarkers. Treatment was safe and no patient required withdrawal of terlipressin.

CONCLUSIONS

Early treatment with terlipressin and albumin in patients with type-1 HRS associated with sepsis is effective and safe. Patients with associated severe ACLF are unlikely to respond to treatment.

Bacterial infections in cirrhosis

Bacterial infections occur in 25-35 % of cirrhotics admitted to hospital. Health-care associated and hospital acquired (nosocomial) infections are the most common epidemiology, with community acquired infections less common (15-30 %). Spontaneous bacterial peritonitis and urinary infections are the most common sites, with spontaneous bacteremia, pneumonia, cellulitis and other sites being less common. The risk of infection is increased among subjects with more severe liver disease and an infection in the past 6 months. Bacteria are isolated from approximately half of patients with a clinical diagnosis of infection. Gram-negative enterobacteriaceae are the most common organisms among community acquired infections; Gram-positive cocci are the most common organisms isolated among subjects with nosocomial infections. Up to 30 % of hospital associated infections are with multidrug resistant bacteria. Consequently, empiric antibiotic therapy that is recommended for community acquired infections is often inadequate for nosocomial infections. Infections worsen liver function. In-hospital and 1-year mortality of cirrhotics with infections is significantly higher than among cirrhotics without infection. In-hospital complications of infections, such as severe sepsis and septic shock, and mortality, are increased among subjects with multidrug-resistant infections as compared with cirrhotics with susceptible bacteria. Short-term antibiotic prophylaxis of cirrhotics with upper gastrointestinal bleeding and long-term antibiotic prophylaxis of selected cirrhotics with spontaneous bacterial peritonitis reduces infections and improves survival. Albumin administration to cirrhotics with SBP and evidence of advanced liver disease improves survival. The benefit of albumin administration to cirrhotics with infections other than SBP is under investigation.

Immunosuppression in acutely decompensated cirrhosis is mediated by prostaglandin E2

Liver disease is one of the leading causes of death worldwide. Patients with cirrhosis display an increased predisposition to and mortality from infection due to multimodal defects in the innate immune system; however, the causative mechanism has remained elusive. We present evidence that the cyclooxygenase (COX)-derived eicosanoid prostaglandin E2 (PGE2) drives cirrhosis-associated immunosuppression. We observed elevated circulating concentrations (more than seven times as high as in healthy volunteers) of PGE2 in patients with acute decompensation of cirrhosis. Plasma from these and patients with end-stage liver disease (ESLD) suppressed macrophage proinflammatory cytokine secretion and bacterial killing in vitro in a PGE2-dependent manner via the prostanoid type E receptor-2 (EP2), effects not seen with plasma from patients with stable cirrhosis (Child-Pugh score grade A). Albumin, which reduces PGE2 bioavailability, was decreased in the serum of patients with acute decompensation or ESLD (<30 mg/dl) and appears to have a role in modulating PGE2-mediated immune dysfunction. In vivo administration of human albumin solution to these patients significantly improved the plasma-induced impairment of macrophage proinflammatory cytokine production in vitro. Two mouse models of liver injury (bile duct ligation and carbon tetrachloride) also exhibited elevated PGE2, reduced circulating albumin concentrations and EP2-mediated immunosuppression. Treatment with COX inhibitors or albumin restored immune competence and survival following infection with group B Streptococcus. Taken together, human albumin solution infusions may be used to reduce circulating PGE2 levels, attenuating immune suppression and reducing the risk of infection in patients with acutely decompensated cirrhosis or ESLD.

Changing options for prevention and treatment of infections in cirrhosis

OPINION STATEMENT

Bacterial infections are more frequent and severe in cirrhosis. Most prevalent infections are spontaneous bacterial peritonitis (SBP) and urinary infections followed by pneumonia, cellulitis and bacteremia. Cirrhosis increases the risk of sepsis, severe sepsis and death. Early diagnosis and adequate treatment of infections is essential in the management of cirrhotic patients. Recent data show that currently recommended empirical antibiotic therapy, mainly based on the use of β-lactams, is effective in community-acquired infections, but frequently fails in nosocomial and healthcare-associated infections. A marked increase in the prevalence of multidrug resistant (MDR) bacteria in the healthcare environment explains this finding. Patients developing nosocomial infections or with extended lengths of hospitalization are at higher risk for second infections that are associated with poor prognosis. Antibiotic strategies should therefore be selected according to the type, severity and site of acquisition of infection, and be adapted to the local epidemiological pattern of antibiotic resistance. Treatment of MDR bacteria requires the use of broader spectrum antibiotics (carbapenems) or those active against specific resistant bacteria (glycopeptides, linezolid, daptomycin, amikacin, colistin). Restriction of antibiotic prophylaxis to the high-risk populations, prevention of antibiotic overuse, and early de-escalation policies are also mandatory to prevent the spread of MDR bacteria in cirrhosis.

Impact of rifaximin on the frequency and characteristics of spontaneous bacterial peritonitis in patients with liver cirrhosis and ascites

Background

Rifaximin is a non-absorbable antibiotic used to prevent relapses of hepatic encephalopathy which may also be a candidate for prophylaxis of spontaneous bacterial peritonitis (SBP).

Aim

To detect the impact of rifaximin on the occurrence and characteristics of SBP.

Methods

We prospectively studied all hospitalized patients that underwent a diagnostic paracentesis in our department from March 2012 to April 2013 for SBP and recorded all clinical data including type of SBP prophylaxis, prior use of rifaximin, concomitant complications of cirrhosis, as well as laboratory results and bacteriological findings. Patients were divided into the following three groups: no antibiotic prophylaxis, prophylaxis with rifaximin or with systemically absorbed antibiotic prophylaxis.

Results

Our study cohort comprised 152 patients with advanced liver cirrhosis, 32 of whom developed SBP during the study period. As expected, our study groups differed regarding a history of hepatic encephalopathy and SBP before inclusion into the study. None of the 17 patients on systemic antibiotic prophylaxis developed SBP while 8/27 patients on rifaximin and 24/108 without prophylaxis had SBP (p = 0.02 and p = 0.04 versus systemic antibiotics, respectively). In general, episodes of SBP were similar for patients treated with rifaximin and those without any prophylaxis. However, Escherichia coli and enterococci were dominant in the ascites of patients without any prophylaxis, while mostly klebsiella species were recovered from the ascites samples in the rifaximin group.

Conclusion

Rifaximin pretreatment did not lead to a reduction of SBP occurrence in hospitalized patients with advanced liver disease. However, the bacterial species causing SBP were changed by rifaximin.

Type-1 hepatorenal syndrome associated with infections in cirrhosis: natural history, outcome of kidney function, and survival

Type-1 hepatorenal syndrome (HRS) is a common complication of bacterial infections in cirrhosis, but its natural history remains undefined. To assess the outcome of kidney function and survival of patients with type-1 HRS associated with infections, 70 patients diagnosed during a 6-year period were evaluated prospectively. Main outcomes were no reversibility of type-1 HRS during treatment of the infection and 3-month survival. Forty-seven (67%) of the 70 patients had no reversibility of type-1 HRS during treatment of the infection. [Correction to previous sentence added March 10, 2014, after first online publication: "Twenty-three (33%)" was changed to "Forty-seven (67%)."] The main predictive factor of no reversibility of type-1 HRS was absence of infection resolution (no reversibility: 96% versus 48% in patients without and with resolution of the infection; P < 0.001). Independent predictive factors of no reversibility of type-1 HRS were age, high baseline serum bilirubin, nosocomial infection, and reduction in serum creatinine <0.3 mg/dL at day 3 of antibiotic treatment. No reversibility was also associated with severity of circulatory dysfunction, as indicated by more marked activity of the vasoconstrictor systems. In the whole series, 3-month probability of survival was only 21%. Factors associated with poor prognosis were baseline serum bilirubin, no reversibility of type-1 HRS, lack of resolution of the infection, and development of septic shock after diagnosis of type-1 HRS.

CONCLUSION

Type-1 HRS associated with infections is not reversible in two-thirds of patients with treatment of infection only. No reversibility of type-1 HRS is associated with lack of resolution of the infection, age, high bilirubin, and no early improvement of kidney function and implies a poor prognosis. These results may help advance the management of patients with type-1 HRS associated with infections.

Risk factors and outcome of bacterial infections in cirrhosis

Viable and non-viable pathological bacterial translocation promote a self-perpetuating circle of dysfunctional immune activation and systemic inflammation facilitating infections and organ failure in advanced cirrhosis. Bacterial infections and sepsis are now recognized as a distinct stage in the natural progression of chronic liver disease as they accelerate organ failure and contribute to the high mortality observed in decompensated cirrhosis. The increasing knowledge of structural, immunological and hemodynamic pathophysiology in advanced cirrhosis has not yet translated into significantly improved outcomes of bacterial infections over the last decades. Therefore, early identification of patients at the highest risk for developing infections and infection-related complications is required to tailor the currently available measures of surveillance, prophylaxis and therapy to the patients in need in order to improve the detrimental outcome of bacterial infections in cirrhosis.

Management of infections in cirrhotic patients: report of a consensus conference

The statements produced by the consensus conference on infection in end-stage liver disease promoted by the Italian Association for the Study of the Liver, are here reported. The topics of epidemiology, risk factors, diagnosis, prophylaxis, and treatment of infections in patient with compensated and decompensated liver cirrhosis were reviewed by a scientific board of experts who proposed 26 statements that were graded according to level of evidence and strength of recommendation, and approved by an independent jury. Each topic was explored focusing on the more relevant clinical questions. By systematic literature search of available evidence, comparison and discussion of expert opinions, pertinent statements answering specific questions were presented and approved. Short comments were added to explain the basis for grading evidence particularly on case of controversial areas.

Current Management Strategies for Acute Esophageal Variceal Hemorrhage

Acute esophageal variceal hemorrhage is one of the clinical events that define decompensated cirrhosis and is associated with high rates of morbidity and mortality. Although recent treatment strategies have led to improved outcomes, variceal hemorrhage still carries a 6-week mortality rate of 15-20%. Current standards in its treatment include antibiotic prophylaxis, infusion of a vasoactive drug and endoscopic variceal ligation. The placement of a transjugular intrahepatic portosystemic shunt (TIPS) is considered for patients that have treatment failure or recurrent bleeding. Recurrent hemorrhage is prevented with the combination of a non-selective beta-blocker and endoscopic variceal ligation. These recommendations however assume that all patients with cirrhosis are equal. Based on a review of recent evidence, a strategy in which patients are stratified by Child class, the main predictor of outcomes, is proposed.

Third-generation cephalosporin-resistant spontaneous bacterial peritonitis: a single-centre experience and summary of existing studies

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is the most prevalent bacterial infection in patients with cirrhosis. Although studies from Europe have reported significant rates of resistance to third-generation cephalosporins, there are limited SBP-specific data from centres in North America.

OBJECTIVE

To evaluate the prevalence of, predictors for and clinical impact of third-generation cephalosporin-resistant SBP at a Canadian tertiary care centre, and to summarize the data in the context of the existing literature.

METHODS

SBP patients treated with both antibiotics and albumin therapy at a Canadian tertiary care hospital between 2003 and 2011 were retrospectively identified. Multivariate logistic regression was used to determine independent predictors of third-generation cephalosporin resistance and mortality.

RESULTS

In 192 patients, 25% of infections were nosocomial. Forty per cent (77 of 192) of infections were culture positive; of these, 19% (15 of 77) were resistant to third-generation cephalosporins. The prevalence of cephalosporin resistance was 8% with community-acquired infections, 17% with health care-associated infections and 41% with nosocomial acquisition. Nosocomial acquisition of infection was the only predictor of resistance to third-generation cephalosporins (OR 4.0 [95% CI 1.04 to 15.2]). Thirty-day mortality censored for liver transplantation was 27% (50 of 184). In the 77 culture-positive patients, resistance to third-generation cephalosporins (OR 5.3 [1.3 to 22]) and the Model for End-stage Live Disease score (OR 1.14 [1.04 to 1.24]) were independent predictors of 30-day mortality.

CONCLUSIONS

Third-generation cephalosporin-resistant SBP is a common diagnosis and has an effect on clinical outcomes. In an attempt to reduce the mortality associated with resistance to empirical therapy, high-risk subgroups should receive broader empirical antibiotic coverage.

Ascites and spontaneous bacterial peritonitis: recommendations from two United States centers

Cirrhosis affects millions of people throughout the world. Two of the most serious complications of liver cirrhosis are ascites and spontaneous bacterial peritonitis (SBP). The development of ascites is related to the severity of portal hypertension and is an indicator of increased mortality. Although sodium restriction and diuretic therapy have proven effective, some patients may not respond appropriately or develop adverse reactions to diuretic therapy. In such cases, interventions such as transjugular intrahepatic portosystemic shunt (TIPS) placement are warranted. SBP is a complication of ascites that confers a very high mortality rate. Recognition and prompt treatment of this condition is essential to prevent serious morbidity and mortality. Initiation of prophylaxis in SBP remains controversial. Given the burden of liver cirrhosis on the health care system, ascites and SBP will continue to provide challenges for the primary care provider, hospitalist, internist, and gastroenterologist alike.

Infections of the Liver

The portal vein carries blood from the gastrointestinal tract to the liver and in so doing carries microbes as well. The liver may therefore be involved in infections with a myriad number of microbial organisms. While some of these infections most commonly occur in the immunocompromised host, others affect the immune competence. Hepatic infections may be primary in nature or secondary, as part of systemic or contagious disease. The purpose of this chapter is to provide a brief overview of the various infections of the liver in the pediatric patient.

Relative adrenal insufficiency in decompensated cirrhosis: Relationship to short-term risk of severe sepsis, hepatorenal syndrome, and death

The prevalence of relative adrenal insufficiency (RAI) in critically ill cirrhosis patients with severe sepsis is over 60% and associated features include poor liver function, renal failure, refractory shock, and high mortality. RAI may also develop in noncritically ill cirrhosis patients but its relationship to the clinical course has not yet been assessed. The current study was performed in 143 noncritically ill cirrhosis patients admitted for acute decompensation. Within 24 hours after hospitalization adrenal function, plasma renin activity, plasma noradrenaline and vasopressin concentration, and serum levels of nitric oxide, interleukin-6 and tumor necrosis factor alpha were determined. RAI was defined as a serum total cortisol increase <9 μg/dL after 250 μg of intravenous corticotropin from basal values <35 μg/dL. Patients were followed for 3 months. RAI was detected in 26% of patients (n = 37). At baseline, patients with RAI presented with lower mean arterial pressure (76 ± 12 versus 83 ± 14 mmHg, P = 0.009) and serum sodium (131 ± 7 versus 135 ± 5 mEq/L, P = 0.007) and higher blood urea nitrogen (32 ± 24 versus 24 ± 15 mg/dl, P = 0.06), plasma renin activity (7.1 ± 9.9 versus 3.4 ± 5.6 ng/mL*h, P = 0.03), and noradrenaline concentration (544 ± 334 versus 402 ± 316 pg/mL, P = 0.02). During follow-up, patients with RAI exhibited a higher probability of infection (41% versus 21%, P = 0.008), severe sepsis (27% versus 9%, P = 0.003), type-1 hepatorenal syndrome (HRS) (16% versus 3%, P = 0.002), and death (22% versus 7%, P = 0.01).

CONCLUSION

RAI is frequent in noncritically ill patients with acute decompensation of cirrhosis. As compared with those with normal adrenal function, patients with RAI have greater impairment of circulatory and renal function, higher probability of severe sepsis and type-1 HRS, and higher short-term mortality.

Non-hemorrhagic acute complications associated with cirrhosis and portal hypertension

Timely recognition and management of acute complications of cirrhosis is of significant importance in order to reduce morbidity and mortality, especially in the hospitalized patient. In this review, we present a practical approach to the identification and management of non-hemorrhagic acute complications of cirrhosis, specifically bacterial infections, acute kidney injury, and acute exacerbation of hepatic encephalopathy, focusing on patient stratification.

Role of proton pump inhibitors in the occurrence and the prognosis of spontaneous bacterial peritonitis in cirrhotic patients with ascites

BACKGROUND

Proton pump inhibitors (PPIs) facilitate intestinal bacterial translocation. No robust data exist demonstrating that PPIs increase the risk of spontaneous bacterial peritonitis (SBP) and that PPIs worsen the prognosis of SBP patients. PPI use might be unsuitable for cirrhotic patients.

AIMS

To analyse: (i) the role of PPIs in the occurrence of SBP in cirrhotic patients; (ii) their impact on the prognosis of SBP patients; and (iii) the suitability of their use.

METHODS

In this retrospective case-control study, PPI use was first assessed in cirrhotic patients consecutively admitted with SBP (group I) and in a control group that included the same number of uninfected cirrhotic patients with ascites (group II). Afterwards, the impact of PPIs on SBP was assessed in group I by comparing survival of patients with and without PPIs.

RESULTS

A total of 102 patients were included, 51 in each group. (i) SBP patients were more frequently treated by PPIs than controls (49 vs. 25%, P = 0.014). (ii) In group I, patients with (n = 25) and without (n = 26) PPIs had similar survival rates at 1 month (64.0 ± 9.6% vs. 59.4 ± 10.0%), 3 months (41.2 ± 10.2% vs. 44.6 ± 10.6%), and 1 year (26.6 ± 9.6% vs. 28.9 ± 10.1%), and similar median age at death (53 vs. 57 years). (iii) The reason for PPI use was inappropriate or undocumented in 34% of group I and II.

CONCLUSIONS

Proton pump inhibitors were more frequently used in SBP patients than in controls, but did not influence the prognosis in SBP. Overuse of PPIs was encountered in one-third of cirrhotic patients and should be avoided.

The 22/11 risk prediction model: a validated model for predicting 30-day mortality in patients with cirrhosis and spontaneous bacterial peritonitis

OBJECTIVES

Clinicians do not have a validated tool for estimating the short-term mortality associated with spontaneous bacterial peritonitis (SBP). Accurate prognosis assessment is important for risk stratification and for individualizing therapy. We aimed therefore to develop and validate a model for the prediction of 30-day mortality in SBP patients receiving standard medical treatment (antibiotics and if indicated by guidelines, intravenous albumin therapy).

METHODS

We retrospectively identified SBP patients treated at a tertiary care center between 2003 and 2011 (training set). Multivariate regression modeling and receiver operating characteristic (ROC) curves were utilized for statistical analysis. An external data set of 109 SBP patients was utilized for validation.

RESULTS

Of the 184 patients in the training set, 66% were men with a median age of 55 years, a median MELD (Model for End-Stage Liver Disease) score of 20, and a 30-day mortality of 27%. Peripheral blood leukocyte count ≥11×10⁹ cells/l (odds ratio (OR) 2.5; 95% confidence interval CI: 1.2-5.2) and MELD score ≥22 (OR 4.6; 95% CI: 2.3-9.6) were independent predictors of 30-day mortality. Patients with neither, one, or both variables had 30-day mortality rates of 8%, 32%, and 52%, respectively. The findings in the validation set mirrored the training set.

CONCLUSIONS

In cirrhotic patients with SBP receiving standard therapy, MELD score ≥22 and peripheral blood leukocyte count ≥11×10⁹ cells/l are validated independent predictors of mortality. The mortality in a patient without either poor prognostic variable is ≤10% and with both variables is ≥50%. Trials aiming to reduce mortality should target patients in the moderate-risk to high-risk groups.

Impact of chronic liver disease in intensive care unit acquired pneumonia: a prospective study

PURPOSE

To assess the impact of chronic liver disease (CLD) on ICU-acquired pneumonia.

METHODS

This was a prospective, observational study of the characteristics, microbiology, and outcomes of 343 consecutive patients with ICU-acquired pneumonia clustered according to the presence of CLD.

RESULTS

Sixty-seven (20%) patients had CLD (67% had liver cirrhosis, LC), MELD score 26 ± 9, 20% Child-Pugh class C). They presented higher severity scores than patients without CLD both on admission to the ICU (APACHE II, LC 19 ± 6 vs. other CLD 18 ± 6 vs. no CLD 16 ± 6; p < 0.001; SOFA, 10 ± 3 vs. 8 ± 4 vs. 7 ± 3; p < 0.001) and at onset of pneumonia (APACHE II, 19 ± 6 vs. 17 ± 6 vs. 16 ± 5; p = 0.001; SOFA, 11 ± 4 vs. 9 ± 4 vs. 7 ± 3; p < 0.001). Levels of CRP were lower in patients with LC than in the other two groups (day 1, 6.5 [2.5-11.5] vs. 13 [6-23] vs. 15.5 [8-24], p < 0.001, day 3, 6 [3-12] vs. 16 [9-21] vs. 11 [5-20], p = 0.001); all the other biomarkers were higher in LC and other CLD patients. LC patients had higher 28- and 90-day mortality (63 vs. 28%, p < 0.001; 72 vs. 38%, p < 0.001, respectively) than non-CLD patients. Presence of LC was independently associated with decreased 28- and 90-day survival (95% confidence interval [CI], 1.982-17.250; p = 0.001; 95% confidence interval [CI], 2.915-20.699, p = 0.001, respectively).

CONCLUSIONS

In critically ill patients with ICU-acquired pneumonia, CLD is associated with a more severe clinical presentation and poor clinical outcomes. Moreover, LC is independently associated with 28- and 90-day mortality. The results of this study are important for future trials focused on mortality.

Increasing frequency of gram-positive cocci and gram-negative multidrug-resistant bacteria in spontaneous bacterial peritonitis

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is historically caused by Gram-negative bacteria (GNB) almost exclusively Enterobacteriaceae. Recently, an increasing rate of infections with Gram-positive cocci (GPC) and multidrug-resistant (MDR) microorganisms was demonstrated.

AIMS

To assess possible recent changes of the bacteria causing SBP in cirrhotic patients.

METHODS

We retrospectively recorded 47 cases (66% males) during a 4-year-period (2008-2011).

RESULTS

Twenty-eight (60%) patients had healthcare-associated infections while 15 (32%) received prophylactic quinolone treatment. GPC were found to be the most frequent cause (55%). The most prevalent organisms in a descending order were Streptococcus spp (n = 10), Enterococcus spp (n = 9), Escherichia coli (n = 8), Klebsiella pneumonia (n = 5), methicillin-sensitive Staphylococcus aureus (n = 4) and coagulase-negative Staphylococcus spp (n = 3). Nine of the isolated bacteria (19%) were MDR, including carbapenemase-producing K. pneumonia (n = 4), followed by extended-spectrum beta-lactamase-producing E. coli (n = 3) and Pseudomonas aeruginosa (n = 2). MDR bacteria were more frequently isolated in healthcare-associated than in community-acquired infections (100% vs 50%, P = 0.006), in patients receiving long-term quinolone prophylaxis (67% vs 24%, P = 0.013) and in those with advanced liver disease as suggested by higher MELD score (28 vs 19, P = 0.012). More infections with GNB than GPC were healthcare-associated (81% vs 42%, P = 0.007). Third-generation cephalosporin resistance was observed in 49% and quinolone resistance in 47%.

CONCLUSIONS

GPC were the most frequent bacteria in culture-positive SBP and a variety of drug-resistant microorganisms have emerged. As a result of high rates of resistance in currently recommended therapy and prophylaxis, the choice of optimal antibiotic therapy is vital in the individual patient.

Non-selective beta-blockers are not associated with serious infections in veterans with cirrhosis

BACKGROUND

Studies evaluating outcomes associated with non-selective beta-blockers (NSBB) in cirrhosis have yielded mixed results. A major cause of death in decompensated cirrhosis is infection.

AIM

To determine the effect of NSBB use on serious infections (requiring hospitalisation) in compensated and decompensated cirrhosis.

METHODS

Using data from the US Veterans Health Administration from 2001-2009, we identified two cohorts: compensated cirrhotics (n = 12,656) and decompensated cirrhotics (n = 4834). From each cohort, we identified new NSBB users and propensity-matched them 1:1 to non-users (n = 1836 each in compensated users/non-users and n = 1462 each in decompensated users/non-users). They were followed up for serious infections (median time: 3.1 years), death and transplant. We estimated adjusted hazard ratios (HR) and 95% confidence intervals (CI) from Cox regression models.

RESULTS

Death or transplantation occurred in 0.7% compensated and 2.7% of decompensated patients. Among decompensated cirrhotics, death (P = 0.0061) and transplantation (P = 0.0086) occurred earlier in NSBB users compared with non-users. Serious infections were observed in 4.8% of compensated cirrhotics and in 13.7% of decompensated cirrhotics. There was no difference in the rate of serious infection development in new NSBB users compared with non-users in the compensated (adjusted HR: 0.90, CI: 0.59-1.36) or in the decompensated group (adjusted HR: 1.10, CI: 0.96-1.25).

CONCLUSION

The use of non-selective beta-blockers in U.S. veterans is not associated with an increased rate of serious infections in compensated or decompensated cirrhosis.

Management of varices in patients with cirrhosis

Variceal bleeding remains a life-threatening condition with a 6-week mortality rate of ∼20%. Prevention of variceal bleeding can be achieved using nonselective β-blockers (NSBBs) or endoscopic band ligation (EBL), with NSBBs as the first-line treatment. EBL should be reserved for cases of intolerance or contraindications to NSBBs. Although NSBBs cannot be used to prevent varices, if the hepatic venous pressure gradient (HVPG) is ≤10 mmHg, prognosis is excellent. Survival after acute variceal bleeding has improved over the past three decades, but patients with Child-Pugh grade C cirrhosis remain at greatest risk. Vasoactive drugs combined with endoscopic therapy and antibiotics are the best therapeutic strategy for these patients. Transjugular intrahepatic portosystemic shunts (TIPS) should be used in patients with uncontrolled bleeding or those who are likely to have difficult-to-control bleeding. Rebleeding from varices occurs in ∼60% of patients 1-2 years after the initial bleeding episode, with a mortality rate of 30%. Secondary prophylaxis should start at day 6 after initial bleeding using a combination of NSBBs and EBL. TIPS with polytetrafluoroethylene-covered stents are the preferred option in patients who fail combined treatment with NSBBs and EBL. Despite the improvement in patient survival, further studies are needed to direct the management of patients with gastro-oesophageal varices and variceal bleeding.

Antibiotics for the treatment of hepatic encephalopathy

The treatment of hepatic encephalopathy (HE) is complex and therapeutic regimens vary according to the acuity of presentation and the goals of therapy. Most treatments for HE rely on manipulating the intestinal milieu and therefore antibiotics that act on the gut form a key treatment strategy. Prominent antibiotics studied in HE are neomycin, metronidazole, vancomycin and rifaximin. For the management of the acute episode, all antibiotics have been tested. However the limited numbers studied, adverse effects (neomycin oto- and nephrotoxicity, metronidazole neurotoxicity) and potential for resistance emergence (vancomycin-resistant enterococcus) has limited the use of most antibiotics, apart from rifaximin which has the greatest evidence base. Rifaximin has also demonstrated, in conjunction with lactulose, to prevent overt HE recurrence in a multi-center, randomized trial. Despite its cost in the US, rifaximin may prove cost-saving by preventing hospitalizations for overt HE. In minimal/covert HE, rifaximin is the only systematically studied antibiotic. Rifaximin showed improvement in cognition, inflammation, quality-of-life and driving simulator performance but cost-analysis does not favor its use at the current time. Antibiotics, especially rifaximin, have a definite role in the management across the spectrum of HE.

Surveillance of antibiotic susceptibility of Enterobacteriaceae isolated from urine samples collected from community patients in a large metropolitan area, 2010–2012

Antibiotic susceptibilities of large cohorts of Enterobacteriaceae isolated from urine collected in the community are scarce. We report the susceptibilities of Enterobacteriaceae isolated from urine of non-selected community populations in a metropolitan area (Leeds and Bradford, UK) over 2 years. Isolates (n = 6614) were identified as follows: Escherichia coli (n = 5436), Klebsiella spp. (n = 525), Proteus mirabilis (n = 305), and 15 other species (n = 290); 58 isolates were unidentified. Ampicillin resistance was observed in 53% E. coli and 28% P. mirabilis; ⩾34% E. coli and P. mirabilis were non-susceptible to trimethoprim compared to 20% Klebsiella spp.; nitrofurantoin resistance was observed in 3% E. coli and 15% Klebsiella spp. The occurrence of extended-spectrum β-lactamases (ESBL) was low (6%), as was non-susceptibility to carbapenems, cefipime and tigecycline (<2%). Further surveillance is required to monitor this level of resistance and additional clinical studies are needed to understand the impact on the outcome of current empirical prescribing decisions.

Antibiotic application in cirrhotic patients with extended-spectrum b-lactamase producing E. coli infection

AIM: To investigate the antibiotic application in cirrhotic patients with extended-spectrum b-lactamase (ESBL)-producing Escherichia coli (E. coli) infection.

METHODS: The data for cirrhotic inpatients with ESBL-producing E. coli infection from 2006 to 2011 were collected, and demographic profiles, clinical characteristics, and efficacy of anti-infection treatment were retrospectively analyzed.

RESULTS: A total of 911 infections were found among 4065 cirrhotic patients, of whom 455 were culture-positive. Fifty cirrhotic patients had ESBL-producing E. coli infection. Quinolones (mainly levofloxacin) were primarily used in 23 (46%) cases, third-generation cephalosporins in 16 (32%) cases, and β-lactam/β-lactamase inhibitors in 11 (22%) cases. These three groups of patients showed no significant difference in the clinical outcome (P > 0.05). A switch to another antibiotic was found in 28 (56%) cases. Twenty-two cases (56%) responded to antibiotic therapy, 13 cases (26%) did not respond, and nine cases (18%) died. Compared to the death group, the survival group had significantly different Child-Pugh A (P < 0.05) and initial use of quinolones (P < 0.05). Compared to the non-response group, the response group had significantly different Child-Pugh C (P < 0.05) and bacteremia (P < 0.05). Neither hepatic encephalopathy nor upper gastrointestinal hemorrhage differed significantly between the survival and death group.

CONCLUSION: The efficacy of initial use of empirical antibiotics is very low in cirrhotic patients with ESBL-producing E. coli infection. Compared to third-generation cephalosporins, quinolones are more effective as the first treatment. Liver function-protecting support therapy should be strengthened when treating such infection. Accurate bacterial identification and antimicrobial susceptibility test should be performed to provide timely targeted therapy.

Spontaneous bacterial peritonitis by Pasteurella multocida under treatment with rifaximin

Spontaneous bacterial peritonitis (SBP) is a life-threatening complication of liver cirrhosis. Recently, rifaximin, a non-absorbable antibiotic which is used to prevent recurrent hepatic encephalopathy, has been proposed as effective prophylaxis for SBP. Here, we present an unusual case of SBP under treatment with rifaximin. A 50-year-old woman with liver cirrhosis was admitted because of tense ascites and abdominal pain. She was under long-term oral prophylaxis with rifaximin due to hepatic encephalopathy. Paracentesis revealed SBP caused by Pasteurella multocida, which was sensitive to multiple antibiotics, including rifaximin. Treatment with ceftriaxone resulted in rapid resolution of the peritonitis and restoration of the patient. Since P. multocida is usually transmitted from pets, the patient's cat was tested and could be identified as the most likely source of infection. This case should elicit our awareness that uncommon pathogens and unusual routes of transmission may lead to SBP, despite antibacterial prophylaxis with non-absorbable antibiotics. Nevertheless, such infections may still remain sensitive to systemic therapy with conventional antibiotics.

A French national survey on the use of antibiotic prophylaxis in cirrhotic patients

BACKGROUND

Guidelines recommend antibiotic prophylaxis (AP) in well-selected groups of cirrhotic patients, but the impact of these recommendations has not been assessed in France.

AIM

To evaluate AP prescription tendencies for gastrointestinal bleeding, and primary and secondary prophylaxis of spontaneous bacterial peritonitis (SBP).

METHODS

Practitioners (n = 1,159) working in general hospitals (GH) or in university hospitals (UH) received a self-administered questionnaire.

RESULTS

Three hundred and eighty-nine (33.6%; GH 35% and UH 30.4%) practitioners responded. AP was prescribed by 97.7%, 72.3% and 94.8% of practitioners, without significant differences between UH and GH, respectively, for gastrointestinal bleeding (quinolones 48.2%, third-generation cephalosporins 27.7% and amoxicillin-clavulanic acid 22.2%), primary (quinolones 97.2%) and secondary prophylaxis of SBP (quinolones 99%). For gastrointestinal bleeding, ofloxacin (47.6%) and norfloxacin (37.4%) were the main quinolones prescribed, and ceftriaxone (77%) was the main third-generation cephalosporin prescribed. The principal reasons for prescribing AP were a decrease in bacterial infection (88.9% for gastrointestinal bleeding, 91.3% for primary and 94.3% for secondary prophylaxis of SBP), a recommendation by a consensus conference (83%, 38% and 74.4% respectively) and an improvement in survival (72.8%, 41.3% and 57.7% respectively). Only 31.7% of practitioners (39.6% for UH vs. 28.6% for GH; P = 0.038) believed that AP may reduce the risk of bleeding recurrence. Reported side effects (28%) of AP mainly concerned the risk of quinolone resistance (62% of cases).

CONCLUSION

Antibiotic prophylaxis is well-recognized by French practitioners, but its routine use depends on the expertise of practitioners. Quinolones remain the main antibiotic class prescribed irrespective of the type of prophylaxis.

Mortality after urinary tract infections in patients with advanced cirrhosis - Relevance of acute kidney injury and comorbidities

BACKGROUND

Bacterial infections increase mortality four-fold in patients with decompensated cirrhosis. However, specific mortality associated with urinary tract infections (UTI) in cirrhosis is not known.

METHODS

Retrospective single-centre analysis of all hospitalized patients with cirrhosis and ascites who underwent first paracentesis between 2006 and 2011 to determine 90-day mortality associated with UTI defined as pyuria with significant bacteriuria using Cox proportional hazard models.

RESULTS

A total of 108 patients with at least one episode of UTI and 291 with exclusion of UTI were identified. Bacterial infections other than UTI were diagnosed in 136 (34%) of patients at the time of urine analysis. Female gender, Child-Pugh stage C, higher grade of ascites and systemic inflammatory response syndrome were associated with UTI. After adjustment for liver function and co-morbidity, the hazard ratios (HR) of death within 90 days after urine analysis were 2.08 (95% CI 1.28-3.38) in patients with UTI, 2.93 (1.90-4.52) in patients with other bacterial infections and 3.39 (2.03-5.65) in patients with UTI and concomitant infection. Independent predictors of death after UTI were renal dysfunction at presentation (HR 2.52; 95% CI 2.52), subsequent acute kidney injury within 48 h after diagnosis (4.57; 2.54-8.24), concomitant bacterial infection (1.77; 1.04-3.00) and malignant comorbidity (1.85; 1.03-3.30). The combination of these factors was more accurate in predicting 90-day mortality than the MELD score or C-reactive protein.

CONCLUSIONS

The presence of UTI indicates an increased risk of 90-day mortality in patients with advanced cirrhosis. Renal dysfunction and comorbidities are predictors of death in these patients.

Diagnosis and management of bacterial infections in decompensated cirrhosis

Bacterial infections are one of the most frequent complications in cirrhosis and result in high mortality rates. Patients with cirrhosis have altered and impaired immunity, which favours bacterial translocation. Episodes of infections are more frequent in patients with decompensated cirrhosis than those with compensated liver disease. The most common and life-threatening infection in cirrhosis is spontaneous bacterial peritonitis followed by urinary tract infections, pneumonia, endocarditis and skin and soft-tissue infections. Patients with decompensated cirrhosis have increased risk of developing sepsis, multiple organ failure and death. Risk factors associated with the development of infections are severe liver failure, variceal bleeding, low ascitic protein level and prior episodes of spontaneous bacterial peritonitis (SBP). The prognosis of these patients is closely related to a prompt and accurate diagnosis. An appropriate treatment decreases the mortality rates. Preventive strategies are the mainstay of the management of these patients. Empirical antibiotics should be started immediately following the diagnosis of SBP and the first-line antibiotic treatment is third-generation cephalosporins. However, the efficacy of currently recommended empirical antibiotic therapy is very low in nosocomial infections including SBP, compared to community-acquired episodes. This may be associated with the emergence of infections caused by Enterococcus faecium and extended-spectrum β-lactamase-producing Enterobacteriaceae, which are resistant to the first line antimicrobial agents used for treatment. The emergence of resistant bacteria, underlines the need to restrict the use of prophylactic antibiotics to patients with the greatest risk of infections. Nosocomial infections should be treated with wide spectrum antibiotics. Further studies of early diagnosis, prevention and treatment are needed to improve the outcomes in patients with decompensated cirrhosis.

Second infections independently increase mortality in hospitalized patients with cirrhosis: the North American consortium for the study of end-stage liver disease (NACSELD) experience

Bacterial infections are an important cause of mortality in cirrhosis, but there is a paucity of multicenter studies. The aim was to define factors predisposing to infection-related mortality in hospitalized patients with cirrhosis. A prospective, cohort study of patients with cirrhosis with infections was performed at eight North American tertiary-care hepatology centers. Data were collected on admission vitals, disease severity (model for endstage liver disease [MELD] and sequential organ failure [SOFA] scores), first infection site, type (community-acquired, healthcare-associated [HCA] or nosocomial), and second infection occurrence during hospitalization. The outcome was mortality within 30 days. A multivariate logistic regression model predicting mortality was created. 207 patients (55 years, 60% men, MELD 20) were included. Most first infections were HCA (71%), then nosocomial (15%) and community-acquired (14%). Urinary tract infections (52%), spontaneous bacterial peritonitis (SBP, 23%) and spontaneous bacteremia (21%) formed the majority of the first infections. Second infections were seen in 50 (24%) patients and were largely preventable: respiratory, including aspiration (28%), urinary, including catheter-related (26%), fungal (14%), and Clostridium difficile (12%) infections. Forty-nine patients (23.6%) who died within 30 days had higher admission MELD (25 versus 18, P < 0.0001), lower serum albumin (2.4 g/dL versus 2.8 g/dL, P = 0.002), and second infections (49% versus 16%, P < 0.0001) but equivalent SOFA scores (9.2 versus 9.9, P = 0.86). The case fatality rate was highest for C. difficile (40%), respiratory (37.5%), and spontaneous bacteremia (37%), and lowest for SBP (17%) and urinary infections (15%). The model for mortality included admission MELD (odds ratio [OR]: 1.12), heart rate (OR: 1.03) albumin (OR: 0.5), and second infection (OR: 4.42) as significant variables.

CONCLUSION

Potentially preventable second infections are predictors of mortality independent of liver disease severity in this multicenter cirrhosis cohort.

High prevalence of antibiotic-resistant bacterial infections among patients with cirrhosis at a US liver center

BACKGROUND & AIMS

There are limited data on the prevalence or predictors of antibiotic-resistant bacterial infections (AR-BI) in hospitalized patients with cirrhosis in North America. Exposure to systemic antibiotics is a risk factor for AR-BI; however, little is known about the effects of the increasingly used oral nonabsorbed antibiotics.

METHODS

We analyzed data from patients with cirrhosis and bacterial infections hospitalized in a liver unit at a US hospital between July 2009 and November 2010. Multivariate logistic regression was used to determine predictors of AR-BI. Data were analyzed on the first bacterial infection of each patient (n = 115), and a sensitivity analysis was performed on all infectious episodes per patient (n = 169).

RESULTS

Thirty percent of infections were nosocomial. Urinary tract infections (32%) and spontaneous bacterial peritonitis (24%) were most common. Of the 70 culture-positive infections, 33 (47%) were found to be antibiotic resistant (12 were vancomycin-resistant Enterococci, 9 were extended-spectrum β-lactamase-producing Enterobacteriaceae, 7 were quinolone-resistant gram-negative rods, and 5 were methicillin-resistant Staphylococcus aureus). Exposure to systemic antibiotics within 30 days before infection was associated independently with AR-BI, with an odds ratio (OR) of 13.5 (95% confidence interval [CI], 2.6-71.6). Exposure to only nonabsorbed antibiotics (rifaximin) was not associated with AR-BI (OR, 0.4; 95% CI, 0.04-2.8). In a sensitivity analysis, exposure to systemic antibiotics within 30 days before infection and nosocomial infection was associated with AR-BI (OR, 5.2; 95% CI, 1.5-17.7; and OR, 4.2; 95% CI, 1.4-12.5, respectively).

CONCLUSIONS

The prevalence of AR-BI is high in a US tertiary care transplant center. Exposure to systemic antibiotics within 30 days before infection (including those used for prophylaxis of spontaneous bacterial peritonitis), but not oral nonabsorbed antibiotics, is associated with development of an AR-BI.

Spontaneous bacterial peritonitis due to carbapenemase-producing Klebsiella pneumoniae: the last therapeutic challenge

Multidrug-resistant infections represent an increasing problem in the management of hospitalized patients worldwide. With respect to Gram-negative infections, carbapenems are an important antimicrobial class for the treatment of infections caused by extended-spectrum beta lactamase producers enterobacteriaceae. However, the emergence of novel β-lactamases with direct carbapenem-hydrolyzing activity has contributed toward an increased prevalence of carbapenem-resistant enterobacteriaceae. Recent reports have described the spread of carbapenemase-producing Klebsiella pneumoniae across the world. There are very few existing agents that can be used against these pathogens and there are limited options on the horizon. In recent years, the epidemiology of bacterial strains involved in the pathogenesis of spontaneous bacterial peritonitis has also been changing rapidly. In this setting, we report the first case of nosocomial spontaneous bacterial peritonitis due to carbapenemase-producing K. pneumoniae.