Infections caused by Escherichia coli resistant to norfloxacin in hospitalized cirrhotic patients

Impact of antimicrobial stewardship implementation on the antibiotic use and susceptibility in a Japanese long-term care hospital

BACKGROUND

Antimicrobial use (AMU) is closely related to the emergence of antimicrobial-resistant (AMR) bacteria. Meanwhile, long-term care hospitals (LTCHs) have been pointed out to be important reservoirs for AMR. However, evidence illustrating the association between AMU and AMR in LTCHs is lacking compared to that of acute care hospitals.

METHODS

We evaluated the impact of an antimicrobial stewardship (AS) program implementation, in a LTCH on AMU and antibiotic susceptibility between three periods: the pre-AS-period (pre-AS); the first period after AS implementation (post-AS 1), in which initiated recommendation the blood culture collection and definitive therapy by AS team; and the second period (post-AS 2), implementation of a balanced use of antibiotics was added.

RESULTS

After the AS implementation, a significant increase in the number of blood cultures collected was observed. Conversely, the AMU of piperacillin-tazobactam (PIPC/TAZ), which has activity against Pseudomonas aeruginosa, was increased and occupied 43.0% of all injectable AMU in post-AS 1 compared with that in pre-AS (35.5%). In the post-AS 2 period, we analyzed the %AUD and recommended hospital-wide PIPC/TAZ sparing; this resulted in the significant reduction in %AUD of PIPC/TAZ, which was associated with improved susceptibility of P. aeruginosa to PIPC/TAZ.

CONCLUSIONS

These results suggest that AS programs aimed at implementing antibiotic sparing may lead to improve AMR, highlighting the necessity of correcting overuse of a single class of antibiotics and usefulness of AMU monitoring in the LTCH setting.

Spontaneous Bacterial Peritonitis in Decompensated Liver Cirrhosis—A Literature Review

Background: Spontaneous bacterial peritonitis (SBP) is defined as a bacterial infection of the ascitic fluid without a surgically treatable intra-abdominal infection source. SBP is a common, severe complication in cirrhosis patients with ascites, and if left untreated, in-hospital mortality may exceed 90%. However, the incidence of SBP has been lowered to approx. 20% through early diagnosis and antibiotic therapy. Clinical awareness, prompt diagnosis, and immediate treatment are advised when caring for these patients to reduce mortality and morbidity. Aim: To discuss important issues comprising types of SBP, pathogenesis, bacteriology, including the emergence of multidrug-resistant (MDR) microorganisms, prompt diagnosis, risk factors, prognosis, treatment strategies, as well as recurrence prevention through antibiotic prophylaxis until liver transplantation and future trends in treating and preventing SBP in detail. Methods: This article is a literature review and appraisal of guidelines, randomized controlled trials, meta-analyses, and other review articles found on PubMed from between 1977 and 2022. Results: There are three types of SBP. Bacterial translocation from GI tract is the most common source of SBP. Therefore, two thirds of SBP cases were caused by Gram-negative bacilli, of which Escherichia coli is the most frequently isolated pathogen. However, a trend of Gram-positive cocci associated SBP has been demonstrated in recent years, possibly related to more invasive procedures and long-term quinolone prophylaxis. A diagnostic paracentesis should be performed in all patients with cirrhosis and ascites who require emergency room care or hospitalization, who demonstrate or report consistent signs/symptoms in order to confirm evidence of SBP. Distinguishing SBP from secondary bacterial peritonitis is essential because the conditions require different therapeutic strategies. The standard treatment for SBP is prompt broad-spectrum antibiotic administration and should be tailored according to community-acquired SBP, healthcare-associated or nosocomial SBP infections and local resistance profile. Albumin supplementation, especially in patients with renal impairment, is also beneficial. Selective intestinal decontamination is associated with a reduced risk of bacterial infection and mortality in high-risk group. Conclusions: The standard treatment for SBP is prompt broad-spectrum antibiotic administration and should be tailored according to community-acquired SBP, healthcare-associated or nosocomial SBP infections and local resistance profile. Since the one-year overall mortality rates for SBP range from 53.9 to 78%, liver transplantation should be seriously considered for SBP survivors who are good candidates for transplantation. Further development of non-antibiotic strategies based on pathogenic mechanisms are also urgently needed.

Indications for medical antibiotic prophylaxis and potential targets for antimicrobial stewardship intervention: a narrative review

BACKGROUND

Most of the antimicrobial stewardship (AMS) literature has focused on antimicrobial consumption for the treatment of infections, for the prophylaxis of surgical site infection and for the prevention of endocarditis. The role of AMS for medical antibiotic prophylaxis (AP) has not been adequately addressed.

AIMS

To identify targets for AMS interventions for medical AP in adult patients.

SOURCES

Targeted searches were conducted in PubMed.

CONTENT

The various indications for medical AP and relevant evidence from practice guidelines are outlined. The following were identified as potential targets for AMS interventions: (a) addressing under-utilization of antibiotic-sparing strategies (e.g. for recurrent urinary tract infections, recurrent soft-tissue infections, recurrent exacerbations associated with bronchiectasis or chronic obstructive pulmonary disease), (b) reducing unnecessary AP beyond recommended indications (e.g. for acute pancreatitis, bite wounds, or urinary catheter manipulations), (c) reducing the use of AP with a broader spectrum than necessary, (d) reducing the use of AP for longer than the recommended duration (e.g. AP for prevention of osteomyelitis in open fractures or AP in high-risk neutropenia), (e) evaluating the role of antibiotic cycling to prevent the emergence of resistance during prolonged AP (e.g. in recurrent urinary tract infections or prophylaxis for spontaneous bacterial peritonitis), and (f) addressing research gaps regarding appropriate indications or antibiotic regimens for medical prophylaxis.

IMPLICATIONS

This review summarizes current trends in AP and proposes targets for AMS interventions.

Recognition of Antibiotic Resistance in Spontaneous Bacterial Peritonitis Caused by Escherichia coli in Liver Cirrhotic Patients in Civil Hospital Karachi

Introduction

Spontaneous bacterial peritonitis (SBP) is the most common life-threatening infection in patients with ascites due to liver cirrhosis. The infection is most commonly caused by the bacterium Escherichia coli, commonly referred to as E. coli. Over the past few years, the incidence of antimicrobial resistance against E. coli has risen drastically, leading to increased morbidity and mortality.

Methods

This cross-sectional study was conducted to determine the pattern of resistance using variations of antibiotics against E. coli, to prevent its empirical usage and initiate an appropriate target antibiotic therapy. The data were collected from May 2017 to October 2017 and included a total of 184 patients. The patients had previously been diagnosed with chronic liver disease and had presented with E. coli-induced SBP in the medicine wards at Civil Hospital, Karachi, which is the largest tertiary care hospital in the city. All participants underwent diagnostic paracentesis, and the ascitic fluid samples were sent to labs for culture and sensitivity to antibiotics.

Results

The sample population consisted of 184 participants, of which two-thirds (63.6%; n=117/184) of the population consisted of males. The mean age of the participants was 47.6±10.7 years. More than half of the patients had hepatitis C (54.9%; n=101/184) while the remaining were diagnosed with hepatitis B (45.1%; n=83/184). The ascitic fluid showed varying percentages of resistance for drugs, with no resistance to imipenem and meropenem while ciprofloxacin showed the highest resistance in eradicating the bacterium, E. coli. Additionally, a statistical correlation was tested between drug resistance and factors like age, gender, duration of liver disease, and duration of ascites. Ciprofloxacin and tetracycline showed a positive correlation between the resistance of these drugs and the age, gender, and duration of chronic liver disease in the participants while trimethoprim/sulfamethoxazole, amoxicillin/clavulanic acid, and piperacillin/tazobactam showed a positive association with the duration of ascites.

Conclusion

A rapid diligent intervention of cirrhotic patients with complicated ascites is crucial to alleviate patient mortality. Due to the rising bacterial resistance, primarily, epidemiological patterns should be assessed and analyzed in our regional hospitals, and then, antibiotics should be prescribed meticulously.

Daily Norfloxacin vs. Weekly Ciprofloxacin to Prevent Spontaneous Bacterial Peritonitis: A Randomized Controlled Trial

OBJECTIVES

For the prevention of spontaneous bacterial peritonitis (SBP) in cirrhotic patients with ascites, norfloxacin 400 mg per day is recommended as a standard regimen. This study aims to investigate whether ciprofloxacin once weekly administration is not inferior to norfloxacin once daily administration for the prevention of SBP.

METHODS

This is an investigator-initiated open-label randomized controlled trial conducted at seven tertiary hospitals in South Korea. Liver cirrhosis patients with ascites were screened, and enrolled in this randomized controlled trial if ascitic protein ≤1.5 g/dL or the presence of history of SBP. Ascitic polymorphonucleated cell count needed to be <250/mm³. Patients were randomly assigned into norfloxacin daily or ciprofloxacin weekly group, and followed-up for 12 months. Primary endpoint was the prevention of SBP.

RESULTS

One hundred twenty-four patients met enrollment criteria and were assigned into each group by 1:1 ratio (62:62). Seven patients in the norfloxacin group and five patients in the ciprofloxacin group were lost to follow-up. SBP developed in four patients (4/55) and in three patients (3/57) in each group, respectively (7.3% vs. 5.3%, P = 0.712). The transplant-free survival rates at 1 year were comparable between the groups (72.7% vs. 73.7%, P = 0.970). Incidence of infectious complication, hepatorenal syndrome, hepatic encephalopathy, and variceal bleeding rates were not significantly different (all P = ns). The factors related to survival were models representing underlying liver function.

CONCLUSION

Once weekly ciprofloxacin was as effective as daily norfloxacin for the prevention of SBP in cirrhotic patients with ascites.

Evaluation and management of variceal bleeding

Acute variceal bleeding is one of the most fatal complications of cirrhosis and is responsible for about one-third of cirrhosis-related deaths. Therefore, every effort should be made to emergently resuscitate the patients, start pharmacotherapy as soon as possible and do endoscopic therapy in a timely manner. Despite the recent advances in treatment, mortality rate is still high. We provide a comprehensive review of evaluation and management of variceal bleeding.

The impact of infection by multidrug-resistant agents in patients with cirrhosis. A multicenter prospective study

BACKGROUND & AIMS

Bacterial strains resistant to antibiotics are a serious clinical challenge. We assessed the antibiotic susceptibility of bacteria isolated from infections in patients with cirrhosis by a multicentre investigation.

RESULTS

Three hundred and thirteen culture-positive infections (173 community acquired [CA] and 140 hospital acquired [HA]) were identified in 308 patients. Urinary tract infections, spontaneous bacterial peritonitis and bacteremias were the most frequent. Quinolone-resistant Gram-negative isolates were 48%, 44% were extended-spectrum beta-lactamase producers and 9% carbapenem resistant. In 83/313 culture-positive infections (27%), multidrug-resistant agents (MDRA) were isolated. This prevalence did not differ between CA and HA infections. MDRA were identified in 17 of 37 patients on quinolone prophylaxis, and in 46 of 166 not on prophylaxis (45% vs 27%; P<.03). In 287 cases an empiric antibiotic therapy was undertaken, in 37 (12.9%) this therapy failed. The in-hospital mortality rate of this subset of patients was significantly higher compared to patients who received an effective broad(er)-spectrum therapy (P=.038). During a 3-month follow-up, 56/203 culture-positive patients (27.6%) died, 24/63 who have had MDRA-related infections (38%) and 32/140 who have had antibiotic-susceptible infections (22.8%) (P=.025). Multivariate analysis disclosed MDRA infection, age, hepatocellular carcinoma, bilirubin, international normalized ratio and the occurrence of portal hypertension-related complications independent predictors of death.

CONCLUSIONS

Infection by MDRA is frequent in patients with cirrhosis and the prognosis is severe, especially in patients unresponsive to empiric antibiotic therapy.

[Isolation of Candida spp. from ascites in cirrhotic patients]

The isolation of Candida spp. in ascites of cirrhotic patients is an uncommon situation in clinical practice. Factors that have been associated with increased susceptibility to primary fungal peritonitis are exposure to broad-spectrum antibiotics and immunosuppression, a typical situation of these patients. We report seven episodes of Candida spp. isolation in ascites of cirrhotic patients detected in our hospital during the past 15years.

Long-term use of antibiotics and proton pump inhibitors predict development of infections in patients with cirrhosis

BACKGROUND & AIMS

Bacterial infections, particularly repeated infections, are significant causes of morbidity and mortality among patients with cirrhosis. We investigated and characterized risk factors for repeat infections in these patients.

METHODS

In a prospective study, we collected data from 188 patients hospitalized with cirrhosis and infections and enrolled in the North American Consortium for the Study of End-Stage Liver Disease (12 centers). Patients were followed up for 6 months after hospital discharge and data were analyzed on type of infections and factors associated with subsequent infections.

RESULTS

Six months after hospital discharge, 14% of subjects had received liver transplants, 27% died, and 59% were alive without liver transplantation. After discharge, 45% had subsequent infections, but only 26% of the subsequent infections occurred at the same site. Compared with patients not re-infected, patients with repeat infections were older and a higher proportion used proton pump inhibitors (PPIs) (P = .006), rifaximin (P < .001), or prophylactic therapy for spontaneous bacterial peritonitis (SBP) (P < .001). Logistic regression showed that SBP prophylaxis (odds ratio [OR], 3.44; 95% confidence interval [CI], 1.56-7.63), PPI use (OR, 2.94; 95% CI, 1.39-6.20), SBP at hospital admission (OR, 0.37; 95% CI, 0.15-0.91), and age (OR, 1.06; 95% CI, 1.02-1.11) were independent predictors of subsequent infections.

CONCLUSIONS

Patients hospitalized with cirrhosis and infections are at high risk for subsequent infections, mostly at different sites, within 6 months of index infection resolution. Those at highest risk include previously infected older patients receiving PPIs and/or SBP prophylaxis, although these associations do not prove that these factors cause the infections. New strategies are needed to prevent infections in patients with cirrhosis.

Ciprofloxacin usage and bacterial resistance patterns in Crohn's disease patients with abscesses

BACKGROUND

Ciprofloxacin is the antibiotic most frequently used in the treatment of Crohn's disease (CD). We attempted to identify the microorganisms present in CD-related intra-abdominal abscesses, their ciprofloxacin resistance patterns, and the clinical impact.

METHODS

Microorganisms, their ciprofloxacin resistance, and clinical outcomes were retrospectively analyzed in 78 CD patients with intra-abdominal abscesses, who underwent percutaneous drainage between March 1991, and November 2011.

RESULTS

The median time from diagnosis of CD to abscess drainage was 59.5 months (range, 1 to 178 mo). As for bacteriology, the no-growth proportion was 38.5% (n=30), and 69 microorganisms belonging to 11 genera were isolated from the other 48 (61.5%) patients. Of the 69 microorganisms, 65 were bacteria, including 30 (43.4%) gram-positive, 28 (40.6%) gram-negative aerobes, 7 (10.1%) gram-negative anaerobes, and 4 (4.1%) fungi. Streptococci spp. (25, 36.2%) were the most common bacteria, followed by Escherichia coli (18, 26.1%). Nineteen of the 28 gram-negative aerobes (67.9%) were resistant to ciprofloxacin, including 14 of 18 (77.8%) E. coli isolates. When we compared clinical characteristics and treatment outcomes in 17 patients with ciprofloxacin-resistant and 8 with ciprofloxacin-sensitive bacteria, we found that disease duration from diagnosis to drainage (97.2 vs. 50.7 mo, P=0.03) and median length of hospitalization (40 vs. 31 d, P=0.03) was significantly longer in the former.

CONCLUSIONS

When gram-negative aerobes were isolated from abscesses in CD patients, more than two thirds were resistant to ciprofloxacin. Providers should consider this high rate of ciprofloxacin resistance when choosing first-line antibiotic treatment for CD-related intra-abdominal abscesses.

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.

Role of prophylactic antibiotics in cirrhotic patients with variceal bleeding

Bacterial infections are common in cirrhotic patients with acute variceal bleeding, occurring in 20% within 48 h. Outcomes including early rebleeding and failure to control bleeding are strongly associated with bacterial infection. However, mortality from variceal bleeding is largely determined by the severity of liver disease. Besides a higher Child-Pugh score, patients with hepatocellular carcinoma are particularly susceptible to infections. Despite several hypotheses that include increased use of instruments, greater risk of aspiration pneumonia and higher bacterial translocation, it remains debatable whether variceal bleeding results in infection or vice versa but studies suggest that antibiotic prophylaxis prior to endoscopy and up to 8 h is useful in reducing bacteremia and spontaneous bacterial peritonitis. Aerobic gram negative bacilli of enteric origin are most commonly isolated from cultures, but more recently, gram positives and quinolone-resistant organisms are increasingly seen, even though their clinical significance is unclear. Fluoroquinolones (including ciprofloxacin and norfloxacin) used for short term (7 d) have the most robust evidence and are recommended in most expert guidelines. Short term intravenous cephalosporin (especially ceftriaxone), given in a hospital setting with prevalent quinolone-resistant organisms, has been shown in studies to be beneficial, particularly in high risk patients with advanced cirrhosis.

Effects of the adjunctive probiotic VSL#3 on portal haemodynamics in patients with cirrhosis and large varices: a randomized trial

BACKGROUND

Probiotics, by altering gut flora, may favourably alter portal haemodynamics in patients with cirrhosis.

AIM

To investigate the effect of probiotics on portal pressure in patients with cirrhosis.

METHODS

Randomized double-blind placebo-controlled trial conducted in G.B. Pant Hospital, New Delhi. A total of 94 cirrhotic patients having large oesophageal varices without history of variceal bleeding were randomized to three treatment groups and given 2 months' treatment with propranolol plus placebo, propranolol plus antibiotics (norfloxacin 400 mg BD) or propranolol plus probiotic (VSL#3, 900 billion/day) randomly assigned in 1:1:1 ratio. Outcome measures were change in Hepatic venous pressure gradient (HVPG): Response rate (Percentage of patients having a decrease from baseline of ≥20% or to ≤12 mm Hg) and changes from baseline; biochemical markers of inflammation: changes from baseline.

RESULTS

Adjunctive probiotics increased the response rate compared with propranolol alone (58% vs. 31%, P = 0.046), similar to adjunctive antibiotics (54%). The mean fall in HVPG was greater with either adjunctive probiotics (3.7 mm Hg vs. 2.1 mm Hg, P = 0.061) or adjunctive antibiotics (3.4 mm Hg) than with propranolol alone. Both adjunctive therapies were associated with greater decreases in TNF-α levels (in both peripheral and hepatic venous blood) that resulted from propranolol-only treatment. No clinically relevant between-group differences were observed in the type or frequency of adverse events.

CONCLUSIONS

Adjunctive probiotic (VSL#3) improved the response rate to propranolol therapy and was safe and well tolerated in patients with cirrhosis. Adjunctive probiotic therapy merits further study for reduction in portal pressure.

The role of rifaximin in the primary prophylaxis of spontaneous bacterial peritonitis in patients with liver cirrhosis

BACKGROUND

Primary prophylaxis of spontaneous bacterial peritonitis (SBP) may provide a survival advantage in cirrhotic patients with ascites and has become an integral part of clinical practice. Rifaximin is a poorly absorbable antibiotic with a broad spectrum of antibacterial action and has low risk of introducing bacterial resistance.

AIM

To determine whether rifaximin is associated with decreasing the risk of SBP and improving transplant-free survival in cirrhotic patients with ascites.

METHODS

The medical records of all adult patients with liver cirrhosis and large ascites justifying paracentesis evaluated in our clinic (2003 to 2007) were reviewed. Patients were stratified into 2 groups by the use of rifaximin. Patients were excluded if they had received another antibiotic for SBP prophylaxis or had a history of SBP before rifaximin therapy.

RESULTS

A total of 404 patients were included, of whom 49 (12%) received rifaximin. The rifaximin and nonrifaximin groups were comparable with regards to age, sex, and race. The median follow-up time was 4.2 [1.0, 17.1] months. During this time period, 89% of patients on rifaximin remained SBP free compared with 68% of those not on rifaximin (P=0.002). After adjusting for Model of End-Stage Liver Disease score, Child-Pugh score, serum sodium, and ascitic fluid total protein, there was a 72% reduction in the rate of SBP in the rifaximin group (hazard ratio=0.28; 95% confidence interval, 0.11-0.71; P=0.007). The group treated with rifaximin also demonstrated a transplant-free survival benefit compared with those not on rifaximin (72% vs. 57%, P=0.045).

CONCLUSIONS

Intestinal decontamination with rifaximin may prevent SBP in cirrhotic patients with ascites. Prospective randomized controlled trials are needed to confirm this finding.

The new epidemiology of nosocomial bacterial infections in cirrhosis: therapeutical implications

Cirrhotic patients are at increased risk of developing infection, sepsis and death. Enterobacteriaceae and nonenterococcal streptococci are the main bacteria responsible for spontaneous and urinary infections in this population. Prompt and appropriate treatment is basic in the management of cirrhotic patients with infection. Third-generation cephalosporins continue to be the gold-standard antibiotic treatment of the majority of infections acquired in the community because responsible strains are usually susceptible to β-lactams. By contrary, nosocomial infections are nowadays frequently caused by multiresistant bacteria (extended-spectrum β-lactamase-producing Enterobacteriaceae, Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, and vancomycin-resistant enterococci among others) that are nonsusceptible to the main antibiotics. Treatment of these infections requires the use of broader spectrum antibiotics (carbapenems) or of antibiotics that are active against specific resistant bacteria (glycopeptides, linezolid, daptomycin, amikacin and colistin). Empirical antibiotic schedules must be adapted to the local epidemiological pattern of antibiotic resistance. Careful restriction of antibiotic prophylaxis to the high-risk population is also mandatory to reduce the spread of multiresistant bacteria in cirrhosis.

Management of bacterial infections in cirrhosis

Bacterial infections are very frequent in advanced cirrhosis and become the first cause of death of these patients. Despite numerous experimental data and significant advances in the understanding of the pathogenesis of sepsis in cirrhosis, the outcome remains poor. Classical diagnostic parameters such as C-reactive protein and SIRS criteria have less diagnostic capacity in the cirrhotic population, often delaying the diagnosis and the management of bacterial infection. Prompt and appropriate empirical antibiotic treatment of infection and early resuscitation of patients with severe sepsis or septic shock are essential in determining patient's outcome. A strategy of careful restriction of prophylactic antibiotics to the high-risk populations could reduce the spread of multidrug resistant bacteria. This review is focused on the currently recommended diagnostic, therapeutic and prophylactic strategies for bacterial infections in the cirrhotic population.

Effects of pentoxifylline on intestinal bacterial overgrowth, bacterial translocation and spontaneous bacterial peritonitis in cirrhotic rats with ascites

BACKGROUND

Prophylaxis of spontaneous bacterial peritonitis with norfloxacin has been associated to development of antibiotic resistance. We investigated whether pentoxifylline compared to norfloxacin reduces bacterial translocation and spontaneous bacterial peritonitis in rats with CCl(4)-induced cirrhosis and ascites.

METHOD

After development of cirrhosis and ascites, animals were randomly allocated to receive pentoxifylline (16 mg/kg/d every 8h, oral route, n=13) or placebo (n=12) for 15 days. An additional group of 8 cirrhotic rats was given norfloxacin (5mg/kg/d for 15 days). Six healthy rats served as controls. Cecal flora and the prevalence of bacterial translocation and spontaneous bacterial peritonitis were analysed. Serum and ascitic fluid levels of TNF-alpha and cecal levels of malondialdehyde were also measured.

RESULTS

Pentoxifylline in comparison to placebo reduced intestinal bacterial overgrowth (21% vs. 67%, p=0.04), bacterial translocation to cecal lymph nodes (23% vs. 75%, p=0.03) and prevented spontaneous bacterial peritonitis (0% vs. 33%, p=0.04) by Enterobacteriaceae. Norfloxacin administration induced similar results. Pentoxifylline (0.18 ± 0.10 nmol/mg), but not norfloxacin (0.25 ± 0.13; p=0.02), significantly reduced cecal mucosal levels of malondialdehyde compared to placebo (0.33 ± 0.16; p=0.03).

CONCLUSION

In cirrhotic rats with ascites: (a) pentoxifylline as well as norfloxacin reduced intestinal bacterial overgrowth and bacterial translocation and prevented spontaneous bacterial peritonitis; (b) pentoxifylline, but not norfloxacin, reduced oxidative stress in cecal mucosal.

Increased intestinal permeability as a predictor of bacterial infections in patients with decompensated liver cirrhosis and hemorrhage

BACKGROUND AND AIM

There have been no trials comparing the prophylactic effect of oral quinolone and intravenous cephalosporin antibiotics and elucidating the predictive factors for the occurrence of bacterial infections in cirrhotic patients with gastrointestinal bleeding in Asian-Pacific region.

METHODS

One hundred and thirteen patients with advanced liver cirrhosis and active gastrointestinal hemorrhage were enrolled in our study. The patients were randomly allocated into either the oral ciprofloxacin group (n = 50, 500 mg every 12 h) or the intravenous ceftriaxone group (n = 63, 2.0 g per day for 7 days).

RESULTS

Proven or possible infections were significantly more frequent in the patients in the oral ciprofloxacin group (34.0%) than the intravenous ceftriaxone group (14.3%, P = 0.002). The intestinal permeability index (IPI, mean [SD]) measured the day after admission was significantly higher in the patients with proven or possible infections (1.45 [0.96]) compared with the no infection group (0.46 [0.48], P <0.01). By multivariate analysis, oral ciprofloxacin prophylaxis and higher IPI at the time of inclusion were independent and significant predictors for proven or possible infections. By receiver operating characteristic curve analysis, the best cutoff value of IPI for the prediction of the occurrence of bacterial infection was 0.62%.

CONCLUSIONS

The frequency of proven or possible infections was significantly lower in the intravenous ceftriaxone group compared with the oral ciprofloxacin group. The IPI measured the day after admission is a good clinical parameter predicting the occurrence of infection in these patients.

Prevention and management of bacterial infections in cirrhosis

Patients with cirrhosis of liver are at risk of developing serious bacterial infections due to altered immune defenses. Despite the widespread use of broad spectrum antibiotics, bacterial infection is responsible for up to a quarter of the deaths of patients with liver disease. Cirrhotic patients with gastrointestinal bleed have a considerably higher incidence of bacterial infections particularly spontaneous bacterial peritonitis. High index of suspicion is required to identify infections at an early stage in the absence of classical signs and symptoms. Energetic use of antibacterial treatment and supportive care has decreased the morbidity and mortality over the years; however, use of antibiotics has to be judicious, as their indiscriminate use can lead to antibiotic resistance with potentially disastrous consequences. Preventive strategies are still in evolution and involve use of antibiotic prophylaxis in patients with gastrointestinal bleeding and spontaneous bacterial infections and selective decontamination of the gut and oropharynx.

The nationwide study of bacterial pathogens associated with urinary tract infections conducted by the Japanese Society of Chemotherapy

This study was conducted by the Japanese Society of Chemotherapy and is the first nationwide study on bacterial pathogens isolated from patients with urinary tract infections at 28 hospitals throughout Japan between January 2008 and June 2008. A total of 688 bacterial strains were isolated from adult patients with urinary tract infections. The strains investigated in this study are as follows: Enterococcus faecalis (n = 140), Escherichia coli (n = 255), Klebsiella pneumoniae (n = 93), Proteus mirabilis (n = 42), Serratia marcescens (n = 44), and Pseudomonas aeruginosa (n = 114). The minimum inhibitory concentrations of 39 antibacterial agents used for these strains were determined according to the Clinical and Laboratory Standards Institute (CLSI) manual. All Enterococcus faecalis strains were susceptible to ampicillin and vancomycin. Although a majority of the E. faecalis strains were susceptible to linezolid, 11 strains (7.8%) were found to be intermediately resistant. The proportions of fluoroquinolone-resistant Enterococcus faecalis, Escherichia coli, Proteus mirabilis, and S. marcescens strains were 35.7%, 29.3%, 18.3%, and 15.2%, respectively. The proportions of E. coli, P. mirabilis, K. pneumoniae, and S. marcescens strains producing extended-spectrum β-lactamase were 5.1%, 11.9%, 0%, and 0%, respectively. The proportions of Pseudomonas aeruginosa strains resistant to carbapenems, aminoglycosides, and fluoroquinolones were 9.2%, 4.4%, and 34.8%, respectively, and among them, 2 strains (1.8%) were found to be multidrug resistant. These data present important information for the proper treatment of urinary tract infections and will serve as a useful reference for periodic surveillance studies in the future.

[Ascites, hepatorenal syndrome and spontaneous bacterial peritonitis in patients with portal hypertension]

Ascites, hepatic encephalopathy and variceal hemorrhage are three major complications of portal hypertension. The diagnostic evaluation of ascites involves an assessment of its etiology by determining the serum-ascites albumin gradient and the exclusion of spontaneous bacterial peritonitis. Ascites is primarily related to an inability to excrete an adequate amount of sodium into urine, leading to a positive sodium balance. Sodium restriction and diuretic therapy are keys of ascites control. But, with the case of refractory ascites, large volume paracentesis and transjugular portosystemic shunts are required. In hepatorenal syndrome, splanchnic vasodilatation with reduction in effective arterial volume causes intense renal vasoconstriction. Splanchnic and/or peripheral vasoconstrictors with albumin infusion, and renal replacement therapy are only bridging therapy. Liver transplantation is the only definitive modality of improving the long term prognosis.

Therapeutic strategies and emergence of multiresistant bacterial strains

Spontaneous bacterial peritonitis (SBP) is one of the most serious complications occurring in cirrhotic patients with ascites. Therefore, an effective therapy is always required starting immediately after diagnosis. There are three aims of therapy: (1) to eradicate the bacterial strain responsible of the infection; (2) to prevent renal failure; and (3) to prevent SBP recurrence. The first end point is achievable by means of a large-spectrum antibiotic therapy. Empirical antibiotic therapy can be started with a third-generation cephalosporin, amoxicillin-clavulanate or a quinolone. The effectiveness of antibiotics should be verified by determining the percent reduction of polymorphonuclear cells count in the ascitic fluid. If bacteria result to be resistant to the empirical therapy, a further antibiotic must be given according to the in vitro bacterial susceptibility. In most cases, a 5-day antibiotic therapy is enough to eradicate the bacterial strain. Severe renal failure occurs in about 30% of patients with SBP, independently of the response to antibiotics, and it is associated with elevated mortality. The early administration of large amount of human albumin showed to be able to reduce the episodes of renal failure and to improve survival. After the resolution of an episode of SBP, the recurrence is frequent. Therefore, an intestinal decontamination with oral norfloxacin has been shown to significantly reduce this risk and is widely practised. However, such a long-term prophylaxis, as well as the current increased use of invasive procedures, favours the increase of bacterial infections, including SBP, contracted during the hospitalization (nosocomial infections) and sustained by multi-resistant bacteria. This involves the necessity to use a different strategy of antibiotic prophylaxis as well as a more strict surveillance of patients at risk.

Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis

BACKGROUND & AIMS

A staged prognostic model of cirrhosis based on varices, ascites, and bleeding has been proposed. We analyzed data on infections in patients with cirrhosis to determine whether it is also a prognostic factor.

METHODS

Studies were identified by MEDLINE, EMBASE, COCHRANE, and ISI Web of Science searches (1978-2009); search terms included sepsis, infection, mortality, and cirrhosis. Studies (n = 178) reporting more than 10 patients and mortality data were evaluated (225 cohorts, 11,987 patients). Mortality after 1, 3, and 12 months was compared with severity, site, microbial cause of infection, etiology of cirrhosis, and publication year. Pooled odds ratio of death was compared for infected versus noninfected groups (18 cohorts, 2317 patients).

RESULTS

Overall median mortality of infected patients was 38%: 30.3% at 1 month and 63% at 12 months. Pooled odds ratio for death of infected versus noninfected patients was 3.75 (95% confidence interval, 2.12-4.23). In 101 studies that reported spontaneous bacterial peritonitis (7062 patients), the median mortality was 43.7%: 31.5% at 1 month and 66.2% at 12 months. In 30 studies that reported bacteremia (1437 patients), the median mortality rate was 42.2%. Mortality before 2000 was 47.7% and after 2000 was 32.3% (P = .023); mortality was reduced only at 30 days after spontaneous bacterial peritonitis (49% vs 31.5%; P = .005).

CONCLUSIONS

In patients with cirrhosis, infections increase mortality 4-fold; 30% of patients die within 1 month after infection and another 30% die by 1 year. Prospective studies with prolonged follow-up evaluation and to evaluate preventative strategies are needed.

Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding

BACKGROUND

Bacterial infections are a frequent complication in patients with cirrhosis and upper gastrointestinal bleeding. Antibiotic prophylaxis seems to decrease the incidence of bacterial infections. Oral antibiotics, active against enteric bacteria, have been commonly used as antibiotic prophylaxis in patients with cirrhosis and upper gastrointestinal bleeding. This is an update of a Cochrane review first published in 2002.

OBJECTIVES

To assess the benefits and harms of antibiotic prophylaxis in cirrhotic patients with upper gastrointestinal bleeding.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index EXPANDED until June 2010. In addition, we handsearched the references of all identified studies.

SELECTION CRITERIA

Randomised clinical trials comparing different types of antibiotic prophylaxis with no intervention, placebo, or another antibiotic to prevent bacterial infections in cirrhotic patients with upper gastrointestinal bleeding.

DATA COLLECTION AND ANALYSIS

Three authors independently assessed trial quality, risk of bias, and extracted data. We contacted study authors for additional information. Association measures were relative risk (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes.

MAIN RESULTS

Twelve trials (1241 patients) evaluated antibiotic prophylaxis compared with placebo or no antibiotic prophylaxis. All trials were at risk of bias. Antibiotic prophylaxis compared with no intervention or placebo was associated with beneficial effects on mortality (RR 0.79, 95% CI 0.63 to 0.98), mortality from bacterial infections (RR 0.43, 95% CI 0.19 to 0.97), bacterial infections (RR 0.36, 95% CI 0.27 to 0.49), rebleeding (RR 0.53, 95% CI 0.38 to 0.74), days of hospitalisation (MD -1.91, 95% CI -3.80 to -0.02), bacteraemia (RR 0.25, 95% CI 0.15 to 0.40), pneumonia (RR 0.45, 95% CI 0.27 to 0.75), spontaneous bacterial peritonitis (RR 0.29, 95% CI 0.15 to 0.57), and urinary tract infections (RR 0.23, 95% CI 0.12 to 0.41). No serious adverse events were reported. The trials showed no significant heterogeneity of effects. Another five trials (650 patients) compared different antibiotic regimens. Data could not be combined as each trial used different antibiotic regimen. None of the examined antibiotic regimen was superior to the control regimen regarding mortality or bacterial infections.

AUTHORS' CONCLUSIONS

Prophylactic antibiotic use in patients with cirrhosis and upper gastrointestinal bleeding significantly reduced bacterial infections, and seems to have reduced all-cause mortality, bacterial infection mortality, rebleeding events, and hospitalisation length. These benefits were observed independently of the type of antibiotic used; thus, no specific antibiotic can be preferred. Therefore, antibiotic selection should be made considering local conditions such as bacterial resistance profile and treatment cost.

Antibiotic prophylaxis for spontaneous bacterial peritonitis in cirrhotic patients with ascites, without gastro-intestinal bleeding

BACKGROUND

Spontaneous bacterial peritonitis is frequent among cirrhotic patients, associated with significant morbidity and mortality. Selective intestinal decontamination employing antibiotics is a proposed prophylactic measure. While data regarding this modality among cirrhotic patients with gastrointestinal bleeding exist, there is insufficient data synthesis regarding cirrhotic patients with ascites and no gastrointestinal bleeding.

OBJECTIVES

To assess whether antibiotic prophylaxis decreases spontaneous bacterial peritonitis and mortality among cirrhotic patients with ascites and no gastrointestinal bleeding.

SEARCH STRATEGY

We identified relevant randomised trials by searching trial registries of The Cochrane Hepato-Biliary Group and The Cochrane Collaboration, medical literature search engines, and reviewing all literature we found on the topic until February 2009.

SELECTION CRITERIA

We searched for randomised clinical trials assessing prophylactic treatment among adult cirrhotic patients with ascites and no gastrointestinal bleeding, comparing antibiotic therapy with no intervention, placebo, or with another antibiotic regimen.

DATA COLLECTION AND ANALYSIS

Three independent authors searched for and collected the trials and extracted relevant data. Four other independent authors validated the findings and assessed them. The studies were assessed for design, patient and intervention characteristics, and quality. A meta-analysis was performed to estimate measures of association between antibiotic prophylaxis and spontaneous bacterial peritonitis or mortality.

MAIN RESULTS

Nine trials were included in the review. Seven trials, comparing antibiotics to placebo or no treatment, were meta-analysed. Systematic bias in design or publication is suggested by trial results. The randomisation results suggest that the probability that true randomisation took place in all trials is very small and the report of most trials regarding design was poor. The proportion of participants with spontaneous bacterial peritonitis varied between the trials from 15% to 50%. The calculated relative risks (95% confidence interval) of spontaneous bacterial peritonitis and mortality among patients treated with antibiotics compared with no treatment/placebo were 0.20 (0.11 to 0.37) and 0.61 (0.43 to 0.87). There were very few reports of adverse events.

AUTHORS' CONCLUSIONS

The pooled estimates suggest that antibiotic prophylaxis might be prudent among cirrhotic patients with ascites and no gastrointestinal bleeding. However, poor trial methodology and report coupled with findings suggesting systematic bias in publication and design reflect the fragility of these findings. Potential hazard to society and the patients themselves from resistant pathogens should be considered when promoting long-lasting antibiotic prophylaxis. It seems that recommending antibiotic prophylaxis is still far from being a substantiated prevention strategy. Trials of better design, well reported, and of longer follow-up are greatly needed.

Genetic background of Escherichia coli isolates from patients with spontaneous bacterial peritonitis: relationship with host factors and prognosis

Spontaneous bacterial peritonitis (SBP) is a severe complication in patients with cirrhosis and ascites. It is predominantly caused by Escherichia coli. The phylogenetic group and virulence genotype of E. coli isolates causing SBP were investigated, and the association of these characteristics with host factors and prognosis was examined. Seventy-six episodes of E. coli SBP that occurred over a 9-year period were studied. The phylogenetic group of the isolates and the presence of 36 virulence factor genes were investigated. The influence of bacterial and host factors on in-hospital mortality was assessed by multiple logistic regression. Phylogenetic groups A, B1, B2 and D were found in 26%, 4%, 46% and 24% of the isolates, respectively. Virulence factor genes were more frequent in B2 isolates than in non-B2 isolates (mean virulence score 15.4 vs. 7.3, p <10(-4)). Ciprofloxacin resistance was significantly associated with non-B2 groups and a low virulence score. Host factors independently associated with a shift from B2 to non-B2 isolates were norfloxacin prophylaxis (OR 13.01, p 0.0213) and prothrombin ratio (OR 1.04 for a 10% decrease, p 0.0211). The model for end-stage liver disease (MELD) score (OR 1.83, p 0.0007) and hospital-acquired SBP (OR 4.13, p 0.0247) were independent predictors of in-hospital mortality. In contrast, outcome was not influenced by the phylogenetic group or the virulence profile. These findings indicate that the characteristics of E. coli isolates causing SBP vary with the severity of liver disease and with fluoroquinolone prophylaxis. Host factors are more important than bacterial factors in predicting in-hospital mortality.

Emergence of fluoroquinolone resistance in outpatient urinary Escherichia coli isolates

BACKGROUND

Because of high rates of trimethoprim-sulfamethoxazole resistance in Escherichia coli, Denver Health switched to levofloxacin as the initial therapy for urinary tract infections (UTIs) in 1999. We evaluated the effects of that switch 6 years later.

METHODS

Levofloxacin prescriptions per 1000 outpatient visits and levofloxacin resistance in outpatient E. coli were evaluated over time. E. coli isolated in 2005 were further characterized by specimen source and antimicrobial susceptibilities. Risk factors for levofloxacin-resistant E. coli UTI among nonpregnant adult outpatients were evaluated in a case-control study.

RESULTS

Between 1998 and 2005, levofloxacin use increased from 3.1 to 12.7 prescriptions per 1000 visits (P<.01) and resistance in outpatients increased from 1% to 9% (P<.01). Although prescriptions for sulfonamide antibiotics decreased by half during the same period, E. coli resistance to trimethoprim-sulfamethoxazole increased from 26.1% to 29.6%. Levofloxacin-resistant E. coli were more likely resistant to other antibiotics than levofloxacin-susceptible isolates (90% vs 43%, P<.0001). Risk factors for levofloxacin-resistant E. coli UTI were hospitalization (odds ratio for each week of hospitalization, 2.0; 95% confidence interval, 1.0-3.9) and use of levofloxacin (odds ratio, 5.6; 95% confidence interval, 2.1-27.5) within the previous year.

CONCLUSION

Fluoroquinolone prescriptions increased markedly after an institutional policy change for empiric treatment of UTI, and a rapid increase in fluoroquinolone resistance among outpatient E. coli followed. Risk factors for infection with resistant E. coli were recent hospitalization and levofloxacin use. Risk factors should be considered before initiating empiric treatment with a fluoroquinolone.

Bacterial DNA in patients with cirrhosis and noninfected ascites mimics the soluble immune response established in patients with spontaneous bacterial peritonitis

Bacterial infections and severity of associated inflammatory reaction influence prognosis in patients with advanced cirrhosis. We compared the innate immune response to bacterial DNA (bactDNA) translocation with that caused by viable bacteria translocation in patients with spontaneous bacterial peritonitis and the relationship between the cytokine response and serum levels of bactDNA. The bactDNA translocation was investigated in 226 patients with cirrhosis and noninfected ascites, 22 patients with spontaneous bacterial peritonitis, and 10 patients with ascites receiving continuous norfloxacin. Serum and ascitic fluid tumor necrosis factor alpha, interferon-gamma, interleukin-12, and nitric oxide metabolites were measured via enzyme-linked immunosorbent assay. Bacterial genomic identifications were made via amplification and sequencing of the 16S ribosomal RNA gene and digital quantization with DNA Lab-on-chips. The bactDNA was present in 77 noninfected patients (34%) and in all cases of spontaneous bacterial peritonitis, even in those with culture-negative ascitic fluid. No patient receiving norfloxacin showed bactDNA translocation. Levels of all cytokines were similar in patients with bactDNA translocation or spontaneous bacterial peritonitis and significantly higher than in patients without bactDNA or in those receiving norfloxacin. Serum bactDNA concentration paralleled levels of all cytokines and nitric oxide in a series of patients with bactDNA translocation or spontaneous bacterial peritonitis followed during 72 hours. Antibiotic treatment in the series of patients with spontaneous bacterial peritonitis did not abrogate bactDNA translocation in the short term.

CONCLUSION

bactDNA translocation-associated cytokine response is indistinguishable from that in patients with spontaneous bacterial peritonitis and is dependent on bactDNA concentration. Norfloxacin abrogates bactDNA translocation and cytokine response.

Norfloxacin and trimethoprim-sulfamethoxazole therapy have similar efficacy in prevention of spontaneous bacterial peritonitis

BACKGROUND AND AIM

Although norfloxacin (N) is widely accepted as the drug of choice for spontaneous bacterial peritonitis (SBP) prophylaxis, there is data to suggest that trimethoprim-sulfamethoxazole (TS) may be similarly effective. However, no studies have compared the efficacy and safety of N and TS in SBP prophylaxis. The aim of this retrospective analysis was to compare outcomes in patients who received either N or TS for the prevention of SBP.

METHODS

Records of all cirrhotic patients prescribed either N or TS for SBP prevention between April 2001 and May 2004 were reviewed. Data collected included age, sex, Child-Pugh score, ascitic protein concentration, etiology of liver disease, infections (SBP, bacteremia, and extraperitoneal infections), side-effects, and survival.

RESULTS

Sixty-nine patients (18 female, 51 male), mean age 53.9 +/- 10.6 years, were prescribed N (n = 37) or TS (n = 32). The Child-Pugh score, model for end-stage liver disease score, and the prevalence of a low ascitic protein (<15 g/L) were similar between the groups (12.0 vs 12.4, 19.7 vs 18.2, and 78% vs 84%, respectively, P > 0.05). Fourteen (38%) infections occurred in the N group and 16 (50%) in the TS group (P > 0.05). Eight patients (21.6%) in the N group and nine (28%) in the TS group developed SBP (P > 0.05). The rates of liver transplantation (10 vs 13), adverse events (two in each group) and death (13 vs 14) were similar in the two treatment groups.

CONCLUSIONS

Our findings suggest N and TS have similar efficacy in preventing SBP. This has significant implications for both the cost of SBP prophylaxis and the prevalence of fluoroquinolone resistance in patients with cirrhosis.

Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis

BACKGROUND & AIMS

Norfloxacin is highly effective in preventing spontaneous bacterial peritonitis recurrence in cirrhosis, but its role in the primary prevention of this complication is uncertain.

METHODS

Patients with cirrhosis and low protein ascitic levels (<15 g/L) with advanced liver failure (Child-Pugh score > or = 9 points with serum bilirubin level > or = 3 mg/dL) or impaired renal function (serum creatinine level > or = 1.2 mg/dL, blood urea nitrogen level > or = 25 mg/dL, or serum sodium level < or = 130 mEq/L) were included in a randomized controlled trial aimed at comparing norfloxacin (35 patients) vs placebo (33 patients) in the primary prophylaxis of spontaneous bacterial peritonitis. The main end points of the trial were 3-month and 1-year probability of survival. Secondary end points were 1-year probability of development of spontaneous bacterial peritonitis and hepatorenal syndrome.

RESULTS

Norfloxacin administration reduced the 1-year probability of developing spontaneous bacterial peritonitis (7% vs 61%, P < .001) and hepatorenal syndrome (28% vs 41%, P = .02), and improved the 3-month (94% vs 62%, P = .003) and the 1-year (60% vs 48%, P = .05) probability of survival compared with placebo.

CONCLUSIONS

Primary prophylaxis with norfloxacin has a great impact in the clinical course of patients with advanced cirrhosis. It reduces the incidence of spontaneous bacterial peritonitis, delays the development of hepatorenal syndrome, and improves survival.

Bacterial infection-related morbidity and mortality in cirrhosis

OBJECTIVES

Bacterial infections are acknowledged causes of morbidity and mortality in cirrhotic patients; yet, apart from spontaneous bacterial peritonitis, other infection issues have been understudied. We evaluated the existing medical data on infectious risks and related preventive and treatment data for cirrhotic patients.

METHODS

Medical literature search through MEDLINE, using a variety of keywords focused on: (a) immunodeficiency parameters of cirrhosis and attempts at therapeutic reversal, (b) relative incidence of various focal infections and implications for prevention, and (c) specific pathogens posing a risk in cirrhosis and availability of preventive strategies.

RESULTS

Immunodeficiency in cirrhosis is multifactorial and might not be reversed by isolated interventions. Epidemiologic data on the incidence of specific infections and risk factors are scarce, only Child-Pugh stage C being a common denominator. A variety of common, such as Staphylococcus aureus, Streptococcus pneumoniae, and Mycobacterium tuberculosis, as well as uncommon pathogens possess significant risks in cirrhosis. Certain aspects of these risks remain though unrecognized.

CONCLUSIONS

To better understand the overall burden of bacterial infections on cirrhotic patients' survival, more data on preventive efficacy of pneumococcal vaccination, on the overall burden of tuberculosis, and the relative incidence of specific infections as endocarditis are warranted.

[Bacterial infections in liver cirrhosis]

Bacterial infections are well described complications of cirrhosis that greatly increase mortality rates. Two factors play important roles in the development of bacterial infections in these patients: the severity of liver disease and gastrointestinal haemorrhage. The most common infections are spontaneous bacterial peritonitis, urinary tract infections, pneumonia and sepsis. Gram-negative and gram-positive bacteria are equal causative organisms. For primary prophylaxis, short-term antibiotic treatment (oral norfloxacin or ciprofloxacin) is indicated in cirrhotic patients (with or without ascites) admitted with gastrointestinal haemorrhage (variceal or non-variceal). Administration of norfloxacin is advisable for hospitalized patients with low ascitic protein even without gastrointestinal haemorrhage. The first choice in empirical treatment of spontaneous bacterial peritonitis is the iv. III. generation cephalosporin; which can be switched for a targeted antibiotic regime based on the result of the culture. The duration of therapy is 5-8 days. Amoxicillin/clavulanic acid and fluoroquinolones--patients not on prior quinolone prophylaxis--were shown to be as effective and safe as cefotaxime. In patients with evidence of improvement, iv. antibiotics can be switched safely to oral antibiotics after 2 days. In case of renal dysfunction, iv albumin should also be administered. Long-term antibiotic prophylaxis is recommended in patients who have recovered from an episode of spontaneous bacterial peritonitis (secondary prevention). For "selective intestinal decontamination", poorly absorbed oral norfloxacin is the preferred schedule. Oral ciprofloxacin or levofloxacin (added gram positive spectrum) all the more are reasonable alternatives. Trimethoprim/sulfamethoxazole is only for patients who are intolerant to quinolones. Prophylaxis is indefinite until disappearance of ascites, transplant or death. Long-term prophylaxis is currently not recommended for patients without previous spontaneous bacterial peritonitis episode, not even when refractory ascites or low ascites protein content is present.

Spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis (SBP) is the infection of ascitic fluid in the absence of any intra-abdominal, surgically treatable source of infection. Despite timely diagnosis and treatment its reported incidence in ascitic patients varies between 7-30%. Ascitic paracentesis remains the chief diagnostic procedure. Automated cell counters have the same diagnostic accuracy as the manual measurement of white cells. Lately, the use of leucocyte reagent strips (dipsticks) has emerged as a useful alternative. Examination of the fluid is not complete unless the sample is inoculated in blood culture bottles. Treatment is currently with third-generation cephalosporins or oral quinolones. Following a single episode of SBP patients should have long term antibiotic prophylaxis.

Risk factors associated with resistance to ciprofloxacin in clinical bacterial isolates from intensive care unit patients

OBJECTIVE

To determine risk factors and outcomes associated with ciprofloxacin resistance in clinical bacterial isolates from intensive care unit (ICU) patients.

DESIGN

Prospective cohort study.

SETTING

Twenty-bed medical-surgical ICU in a Canadian tertiary care teaching hospital.

PATIENTS

All patients admitted to the ICU with a stay of at least 72 hours between January 1 and December 31, 2003.

METHODS

Prospective surveillance to determine patient comorbidities, use of medical devices, nosocomial infections, use of antimicrobials, and outcomes. Characteristics of patients with a ciprofloxacin-resistant gram-negative bacterial organism were compared with characteristics of patients without these pathogens.

RESULTS

Ciprofloxacin-resistant organisms were recovered from 20 (6%) of 338 ICU patients, representing 38 (21%) of 178 nonduplicate isolates of gram-negative bacilli. Forty-nine percent of Pseudomonas aeruginosa isolates and 29% of Escherichia coli isolates were resistant to ciprofloxacin. In a multivariate analysis, independent risk factors associated with the recovery of a ciprofloxacin-resistant organism included duration of prior treatment with ciprofloxacin (relative risk [RR], 1.15 per day [95% confidence interval {CI}, 1.08-1.23]; P<.001), duration of prior treatment with levofloxacin (RR, 1.39 per day [95% CI, 1.01-1.91]; P=.04), and length of hospital stay prior to ICU admission (RR, 1.02 per day [95% CI, 1.01-1.03]; P=.005). Neither ICU mortality (15% of patients with a ciprofloxacin-resistant isolate vs 23% of patients with a ciprofloxacin-susceptible isolate; P=.58) nor in-hospital mortality (30% vs 34%; P=.81) were statistically significantly associated with ciprofloxacin resistance.

CONCLUSIONS

ICU patients are at risk of developing infections due to ciprofloxacin-resistant organisms. Variables associated with ciprofloxacin resistance include prior use of fluoroquinolones and duration of hospitalization prior to ICU admission. Recognition of these risk factors may influence antibiotic treatment decisions.

Infection et rupture de varice œsophagienne au cours de la cirrhose

Endotoxemia and bacterial infection are frequent in patients with cirrhosis. They alter systemic and splanchnic hemodynamics, worsen coagulation disorders, impair liver function and thus may induce variceal bleeding. In variceal bleeding, bacterial infection favours failure to control bleeding, early rebleeding, and death. In patients with cirrhosis and variceal bleeding, antibiotic-prophylaxis decreases bacterial infection and the incidence of early rebleeding, and, more important, significantly decreases the death rate in these patients.

[Spontaneous bacterial peritonitis due to methicillin-resistant Staphylococcus aureus in patients with cirrhosis]

A substantial epidemiologic change in the etiology of spontaneous bacterial peritonitis (SBP) has been observed in recent years. Gram-positive, as well as multiresistant bacteria, have emerged as an important cause of SBP mainly among hospitalized patients. In this setting, SBP caused by methicillin-resistant Staphylococcus aureus (MRSA) could become a major clinical problem in the near future. We present two cases of SBP due to MRSA without clinical response to vancomycin, even though in vitro sensitivity was observed in both cases. We review the current literature on the incidence and clinical significance of SBP due to MRSA infection in cirrhotic patients, as well as its prevention and treatment.

Prevention and treatment of infections in patients with cirrhosis

Patients with cirrhosis have altered immune defenses and are considered immunocompromised individuals. Changes in gut motility, mucosal defense and microflora allow for translocation of enteric bacteria into mesenteric lymph nodes and the blood stream. Additionally, the cirrhotic liver is ineffective at clearing bacteria and associated endotoxins from the blood thus allowing for seeding of the sterile peritoneal fluid. Thus, hospitalised cirrhotic patients, particularly those with gastrointestinal hemorrhage, are at high risk of developing bacterial infections, the most common being spontaneous bacterial peritonitis. Given the significant morbidity and mortality associated with spontaneous bacterial peritonitis and the fact that half of the cases are community acquired, all hospitalised cirrhotic patients should have a diagnostic paracentesis to exclude infection. Those admitted with gastrointestinal bleed and a negative paracentesis require short-term prophylaxis with norfloxacin. A third generation cephalosporin is the treatment of choice for spontaneous bacterial peritonitis and, once the acute infection is resolved, secondary prophylaxis with oral norfloxacin is warranted. Patients who develop renal dysfunction at the time of active infection have the highest mortality and require adjunctive albumin therapy. This article reviews the pathogenesis of SBP, the evidence behind the antibiotics used, the rationale for adjunctive albumin therapy in the setting of acute renal failure, and the role of prophylactic antibiotics in specific high-risk populations.

Changes in the Profiles of Causative Agents and Antibiotic Resistance Rate for Spontaneous Bacterial Peritonitis: an Analysis of Cultured Microorganisms in Recent 12 Years

BACKGROUNDS/AIMS

The causative agents for spontaneous bacterial peritonitis (SBP) and antibiotic resistance rate vary according to the regions and time. This study evaluated the recent changes in the profiles of microorganisms and antibiotic resistance rate for the choice of effective antibiotics in treating SBP.

METHODS

The clinical records of 1,018 episodes of SBP from November, 1994 to December, 2005, were analyzed retrospectively. The profiles of the causative agents for SBP and the rate of antibiotic resistance were compared in every 4-year-term.

RESULTS

The microorganisms were isolated in 394 out of 1018 episodes (38.7%). Gram negative and positive organisms constituted 71.6% and 21.3%, respectively. The five most commonly isolated organisms were E. coli (35.8%), K. pneumoniae (15.5%), viridans Streptococci (10.4%), S. pneumoniae (4.8%) and Aeromonas group (4.6%). The rate of E. coli resistant to cefotaxime (0%, 5.4%, 7.4%) and ciprofloxacin (4.3%, 21.6%, 28.4%) were increased in recent years. In the gram positive organisms, all isolates of viridans Streptococci and Pneumococci were sensitive to cefotaxime and ciprofloxacin. Recently, methicillin-resistant Staphylococcus aureus (MRSA) (28%) and vancomycin-resistant Enterococci (VRE) (31%) have been isolated. In each period, the overall antibiotic resistance rates to cefotaxime were 12.5%, 14.0%, 14.8%, to ciprofloxacin were 3.1%, 16.7%, 18.0%, and to imipenem were 4.7%, 7.0%, 4.2%.

CONCLUSIONS

Cefotaxime may still be the choice of primary empirical antibiotics for the treatment of SBP in Korea because the rate of resistance is acceptable. However, it is important to be aware of the recent increase in ciprofloxacin-resistant E. coli, extended spectrum beta-lactamase (ESBL)-producing gram negative bacilli, MRSA and VRE.

Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage

BACKGROUND & AIMS

Oral norfloxacin is the standard of therapy in the prophylaxis of bacterial infections in cirrhotic patients with gastrointestinal hemorrhage. However, during the last years, the epidemiology of bacterial infections in cirrhosis has changed, with a higher incidence of infections caused by quinolone-resistant bacteria. This randomized controlled trial was aimed to compare oral norfloxacin vs intravenous ceftriaxone in the prophylaxis of bacterial infection in cirrhotic patients with gastrointestinal bleeding.

METHODS

One hundred eleven patients with advanced cirrhosis (at least 2 of the following: ascites, severe malnutrition, encephalopathy, or bilirubin >3 mg/dL) and gastrointestinal hemorrhage were randomly treated with oral norfloxacin (400 mg twice daily; n = 57) or intravenous ceftriaxone (1 g/day; n = 54) for 7 days. The end point of the trial was the prevention of bacterial infections within 10 days after inclusion.

RESULTS

Clinical data were comparable between groups. The probability of developing proved or possible infections, proved infections, and spontaneous bacteremia or spontaneous bacterial peritonitis was significantly higher in patients receiving norfloxacin (33% vs 11%, P = .003; 26% vs 11%, P = .03; and 12% vs 2%, P = .03, respectively). The type of antibiotic used (norfloxacin), transfusion requirements at inclusion, and failure to control bleeding were independent predictors of infection. Seven gram-negative bacilli were isolated in the norfloxacin group, and 6 were quinolone resistant. Non-enterococcal streptococci were only isolated in the norfloxacin group. No difference in hospital mortality was observed between groups.

CONCLUSIONS

Intravenous ceftriaxone is more effective than oral norfloxacin in the prophylaxis of bacterial infections in patients with advanced cirrhosis and hemorrhage.

Is Antibiotic Cycling the Answer to Preventing the Emergence of Bacterial Resistance in the Intensive Care Unit?

Antibiotic resistance has emerged as an important determinant of mortality for patients in the intensive care unit (ICU) setting. This is largely due to the increasing presence of pathogenic microorganisms with resistance to existing antibiotic agents, resulting in the administration of inappropriate treatment. Escalating antibiotic resistance has also been associated with greater overall health care costs, as a result of prolonged hospitalizations and convalescence associated with failure of antibiotic treatment, the need to develop new antibiotic agents, and the implementation of broader infection control and public health interventions aimed at curbing the spread of antibiotic-resistant pathogens. Antibiotic cycling has been advocated as a tool to reduce the occurrence of antibiotic resistance, especially in the ICU setting. Unfortunately, the cumulative evidence to date suggests that antibiotic cycling has limited efficacy for preventing antibiotic resistance. Nevertheless, a strategy whereby multiple or all classes of antibiotics are available for use (i.e., antibiotic heterogeneity) can be part of a broader effort aimed at curtailing antibiotic resistance within ICUs. Such efforts should be routine, given the limited availability of new antibiotic drug classes for the foreseeable future.

Trimethoprim-sulfamethoxazole versus norfloxacin in the prophylaxis of spontaneous bacterial peritonitis in cirrhosis

BACKGROUND

The prognosis of patients with chronic liver disease and spontaneous bacterial peritonitis is poor, being of great importance its prevention.

AIM

To compare the effectiveness of trimethoprim-sulfamethoxazole versus norfloxacin for prevention of spontaneous bacterial peritonitis in patients with cirrhosis and ascites.

PATIENTS AND METHODS

Fifty seven patients with cirrhosis and ascites were evaluated between March 1999 and March 2001. All of them had a previous episode of spontaneous bacterial peritonitis or had ascitic fluid protein concentration < or = 1 g/dL and/or serum bilirubin > or = 2.5 mg/dL. The patients were randomly assigned to receive either 800/160 mg/day of trimethoprim-sulfamethoxazole 5 days a week or 400 mg of norfloxacin daily. The mean time of observation was 163 days for the norfloxacin group and 182 days for the trimethoprim-sulfamethoxazole group. In the statistical analysis, differences were considered significant at the level of 0.05.

RESULTS

According to the inclusion criteria, 32 patients (56%) were treated with norfloxacin and 25 (44%) with trimethoprim-sulfamethoxazole. Spontaneous bacterial peritonitis occurred in three patients receiving norfloxacin (9.4%) and in four patients receiving trimethoprim-sulfamethoxazole (16.0%). Extraperitoneal infections occurred in 10 patients receiving norfloxacin (31.3%) and in 6 patients receiving trimethoprim-sulfamethoxazole (24.0%). Death occurred in seven patients (21.9%) who received norfloxacin and in five (20.0%) who received trimethoprim-sulfamethoxazole. Side effects occurred only in the trimethoprim-sulfamethoxazole group.

CONCLUSION

In spite of the reduced number of patients and time of observation, trimethoprim-sulfamethoxazole and norfloxacin were equally effective in spontaneous bacterial peritonitis prophylaxis, suggesting that trimethoprim-sulfamethoxazole is a valid alternative to norfloxacin.

Pharmacologic treatment of portal hypertension in the prevention of community-acquired spontaneous bacterial peritonitis

INTRODUCTION

Given that beta-blockers reduce the incidence of bacterial translocation in cirrhotic rats, the aim of this study was to compare the long-term incidence of spontaneous bacterial peritonitis in cirrhotic patients submitted to pharmacologic versus endoscopic treatment to prevent variceal rebleeding.

PATIENTS AND METHODS

Two hundred and thirty patients with variceal hemorrhage were included in two previous randomized trials performed to compare the efficacy of medication (nadolol plus isosorbide mononitrate, n=115) versus endoscopic treatment (n=115) with sclerotherapy or ligation for the prevention of rebleeding.

RESULTS

The mean follow-up was 23+/-1.4 months. The characteristics of the patients and the number of patients on long-term prophylaxis with norfloxacin were similar in both groups. The incidence of spontaneous bacterial peritonitis was lower in the medication group (9 versus 14.7%, P=NS). The probability of spontaneous bacterial peritonitis was also lower in the medication group (6 versus 12% at 1 year, 22 versus 36% at 5 years; P=0.08), due to a significantly lower probability of community-acquired spontaneous bacterial peritonitis in this group (1 versus 10% at 1 year, 18 versus 32% at 5 years; P=0.02). Patients with no hemodynamic response to therapy had a significantly higher probability to develop community-acquired spontaneous bacterial peritonitis during follow-up than hemodynamic responders (P<0.03). Long-term probability of developing community-acquired spontaneous bacterial peritonitis is lower in patients submitted to pharmacologic treatment for preventing variceal rebleeding than in those submitted to endoscopic treatment.

CONCLUSION

Long-term pharmacologic prophylaxis of variceal rebleeding contributes to the prevention of community-acquired spontaneous bacterial peritonitis.

Association between Fluoroquinolone Resistance and Mortality in Escherichia coli and Klebsiella pneumoniae Infections: The Role of Inadequate Empirical Antimicrobial Therapy

BACKGROUND

The prevalence of fluoroquinolone (FQ) resistance among Escherichia coli and Klebsiella pneumoniae has increased markedly in recent years. However, the impact of FQ resistance on mortality remains unknown.

METHODS

To identify the association between FQ resistance and mortality, we conducted a retrospective cohort study of hospitalized patients with infections due to FQ-resistant strains and FQ-susceptible strains of E. coli and K. pneumoniae between 1 January 1998 and 30 June 1999.

RESULTS

Of 123 patients with FQ-resistant infection, 16 (13.0%) died, compared with 4 (5.7%) of 70 patients with FQ-susceptible infection (odds ratio [OR], 2.47; 95% confidence interval [CI], 0.75-10.53). After adjustment for other significant risk factors and confounders, there remained an independent association between FQ-resistant infection and mortality (adjusted OR, 4.41; 95% CI, 1.03-18.81). Patients with FQ-resistant infection were significantly less likely to have received antimicrobial therapy with activity against the infecting pathogen within the first 24 h and 48 h of infection (P=.002 and P<.001, respectively). The association between FQ resistance and mortality was no longer significant, after adjusting for inadequate empirical therapy.

CONCLUSIONS

FQ resistance is an independent risk factor for mortality in patients with health care-acquired E. coli and K. pneumoniae infections. This may be explained, at least in part, by a delay in the initiation of appropriate antimicrobial therapy in patients with FQ-resistant infection. These results highlight the grave clinical consequences of FQ resistance and emphasize the importance of efforts designed to curb the increase in the prevalence of resistance to these agents.