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Sturm L, Hirose M, Stolz L, Schultheiss M, Zoldan K, Reincke M, Huber JP, Kaeser R, Boettler T, Thimme R, Albert E, Busch H, Künstner A, Bettinger D. Proton pump inhibitor treatment aggravates bacterial translocation in patients with advanced cirrhosis and portal hypertension. mBio 2023; 14:e0049223. [PMID: 37623323 PMCID: PMC10653923 DOI: 10.1128/mbio.00492-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/02/2023] [Indexed: 08/26/2023] Open
Abstract
IMPORTANCE Long-term prescription of proton pump inhibitors (PPIs) in patients with cirrhosis is common practice. However, in recent years, several observational studies have reported increased complications and negative prognostic effects of PPI treatment in these patients. Judging the significance of these associations is complicated by the fact that a plausible underlying pathomechanism has not been identified so far. In the present study, we address this important issue by investigating the impact of PPI treatment on subclinical bacterial translocation from the gut into the blood stream in patients with advanced cirrhosis and portal hypertension. Indeed, we report significantly aggravated bacterial translocation in cirrhosis patients receiving PPI treatment. This finding is highly relevant, as bacterial translocation is known to promote the development of complications and impair prognosis in patients with cirrhosis. Hence, the present study could establish a plausible link between PPI treatment and adverse effects in cirrhosis.
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Affiliation(s)
- Lukas Sturm
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
- Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Misa Hirose
- Luebeck Institute of Experimental Dermatology, University of Luebeck, Luebeck, Germany
| | - Laura Stolz
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
| | - Michael Schultheiss
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
- Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katharina Zoldan
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
| | - Marlene Reincke
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
| | - Jan Patrick Huber
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
| | - Rafael Kaeser
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
- IMM-PACT-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Boettler
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
| | - Robert Thimme
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
| | - Elisabeth Albert
- Luebeck Institute of Experimental Dermatology, University of Luebeck, Luebeck, Germany
| | - Hauke Busch
- Luebeck Institute of Experimental Dermatology, University of Luebeck, Luebeck, Germany
- Institute for Cardiogenetics, University of Luebeck, Luebeck, Germany
| | - Axel Künstner
- Luebeck Institute of Experimental Dermatology, University of Luebeck, Luebeck, Germany
- Institute for Cardiogenetics, University of Luebeck, Luebeck, Germany
| | - Dominik Bettinger
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
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Clinical Characteristics, Antimicrobial Resistance, and Outcomes of Patients with Invasive Pneumococcal Disease in Ningxia Hui Autonomous Region, China, 2013-2021. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2022; 2022:1262884. [PMID: 36545503 PMCID: PMC9763006 DOI: 10.1155/2022/1262884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 11/26/2022] [Accepted: 11/29/2022] [Indexed: 12/14/2022]
Abstract
Objectives This study aimed to analyze the clinical features, antibiotic susceptibility profiles, and outcomes of patients with invasive pneumococcal disease (IPD) at a hospital in Ningxia Hui Autonomous Region, to provide the basis for improving the clinical treatment effect. Methods Patients with IPD were retrospectively collected from 2013 to 2021. Clinical manifestations, laboratory tests, antimicrobial susceptibility, antibiotic treatment, and outcomes of the disease were analyzed. Results In this study, we identified 127 IPD cases, of whom 49 (38.6%) had meningitis and 78 (61.4%) had bacteremia. The median ages of pediatric cases and adult cases were 2 years (IQR: 0-5) and 52.5 years (IQR: 35-62), respectively. There were 27 and 45 males in the pediatric and adult groups, and no significant gender difference in the different age groups (p = 0.584) was found. Of 75 cases with underlying diseases, pneumonia (11%), malignancy (11%), hypertension (9.4%), and hepatic cirrhosis (7.9%) were the most common. The incidence of underlying diseases was even higher in the adult group (67.1%) than in the pediatric group (47.1%) (p = 0.028). The frequency of fever, cough, and seizures was significantly higher in the pediatric group than in the adult group, with p-values of 0.004, 0.004, and 0.001, respectively. The percentage of neutrophils in the blood was significantly higher in the adult cases than in the pediatric cases (p < 0.001). Furthermore, there was a significantly higher WBC count (p < 0.001), percentage of neutrophils (p = 0.012), and protein level (p = 0.019) in the CSF samples in the adult patients compared to pediatric patients. The susceptibility rates of S. pneumoniae isolates to vancomycin, linezolid, and levofloxacin were 100%. The susceptibility rates of penicillin were 98.7% and 34.1% in bacteremia and meningitis patients, respectively. Most isolates were resistant to erythromycin, clindamycin, tetracycline, and azithromycin. The most common antibiotic treatment was β-lactams. Seven (5.5%) patients died during hospitalization, and 38 (29.9%) patients' health deteriorated. Conclusion These results may provide a reference basis for the diagnosis and empiric treatment of IPD in the region.
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Cortese F, Fransvea P, Saputelli A, Ballardini M, Baldini D, Gioffre A, Marcello R, Sganga G. Streptococcus pneumoniae primary peritonitis mimicking acute appendicitis in an immunocompetent patient: a case report and review of the literature. J Med Case Rep 2019; 13:126. [PMID: 31029142 PMCID: PMC6486957 DOI: 10.1186/s13256-019-2038-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Accepted: 02/28/2019] [Indexed: 12/31/2022] Open
Abstract
Introduction Primary peritonitis without an identifiable intra-abdominal source is extremely rare in healthy individuals; it is commonly seen in cases of nephrotic syndrome, cirrhosis and end-stage liver disease, ascites, immunosuppression, and inflamed peritoneum due to pre-existing autoimmune and oncological conditions. Case presentation We present the case of a 68-year-old Caucasian woman operated on due to acute abdomen with a provisional diagnosis of acute appendicitis. During the operation a small amount of free intra-abdominal fluid was found. Her uterus, ovaries, and fallopian tubes were macroscopically normal. Therefore, with the suspicion of appendicitis, appendectomy was performed. Her blood cultures were negative while peritoneal fluid was positive for capsulated form of Streptococcus pneumoniae. A 30-day follow-up was performed and she was asymptomatic without any sign of infection. Discussion Streptococcus pneumoniae commonly causes upper respiratory tract infection and cutaneous infections. It very rarely causes gastrointestinal infection and it is very rarely responsible for primary peritonitis and septic shock syndrome. Conclusion Pneumococcal peritonitis has a rare occurrence and represents a clinical challenge because of its subtle and non-specific clinical findings. The interest in our case lays in the relatively rare diagnosis of primary peritonitis mimicking acute appendicitis.
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Affiliation(s)
- Francesco Cortese
- Emergency Surgery and Trauma Care Unit - St Filippo Neri Hospital, Rome, Italy
| | - Pietro Fransvea
- Faculty of Medicine and Psychology, University of Rome "La Sapienza", St. Andrea's Hospital, Via Di Grottarossa, 1035-39, 00189, Rome, Italy.
| | - Alessandra Saputelli
- Faculty of Medicine and Psychology, University of Rome "La Sapienza", St. Andrea's Hospital, Via Di Grottarossa, 1035-39, 00189, Rome, Italy.,Emergency Surgery and Trauma Care Unit - St Filippo Neri Hospital, Rome, Italy
| | | | - Daniela Baldini
- Anatomical Pathology - St Filippo Neri Hospital, Rome, Italy
| | - Aldo Gioffre
- Emergency Surgery and Trauma Care Unit - St Filippo Neri Hospital, Rome, Italy
| | - Roberto Marcello
- Diagnostic and Interventional Radiology Unit - St Filippo Neri Hospital, Rome, Italy
| | - Gabriele Sganga
- UOC Chirurgia d'Urgenza, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University, Rome, Italy
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Cuomo G, Brancaccio G, Stornaiuolo G, Manno D, Gaeta GL, Mussini C, Puoti M, Gaeta GB. Bacterial pneumonia in patients with liver cirrhosis, with or without HIV co-infection: a possible definition of antibiotic prophylaxis associated pneumonia (APAP). Infect Dis (Lond) 2017; 50:125-132. [PMID: 28851249 DOI: 10.1080/23744235.2017.1367414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Introducion: Bacterial infections frequently complicate liver cirrhosis. The aim of this study was to identify risk factors and clinical impact of bacterial pneumonia in patients with cirrhosis. MATERIALS AND METHODS Bacterial infection prevalence study: consecutive patients with cirrhosis were enroled over a six-month period in 13 Italian centres. Pneumonia and other infections were diagnosed by standard methods. Pneumonia study: cirrhotic patients with pneumonia were enroled for an additional six-month period and HIV-positive patients were included. RESULTS Pneumonia was the fourth most frequent infection. In the two parts of the study, 79 cases of pneumonia were recorded and 441 patients with cirrhosis without infections served as controls. Seventy-eight patients had extra-pulmonary infections. There were no clinical differences between HIV-negative and -positive cases with pneumonia. Previous gastro-intestinal bleeding (p = .02) and long-term prophylactic antibiotic use (p < .0001) were associated with pneumonia. Hospital stay was longer and renal failure more frequent than in patients without infections. Pneumonia was hospital acquired (HAP) in 6 cases, healthcare associated (HCAP) in 24 and community acquired (CAP) in 28. A new category of antibiotic prophylaxis associated pneumonia (APAP) was proposed for 21 cases. Cultures were positive in 21/79 patients (26.6%) with Gram-positive isolates in 57%. Unfavourable outcomes were recorded in 11.4% of the cases (3.6% of CAP, 33% of HAP, 12.5% of HCAP and 14.3% of APAP). CONCLUSIONS Receiving antibiotic prophylaxis was associated with pneumonia and the study identified a new sub-group of patients, who require broad spectrum initial antibiotic therapy.
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Affiliation(s)
- Gianluca Cuomo
- a AO Policlinico di Modena, Clinic of Infectious Diseases , Modena , Italy
| | - Giuseppina Brancaccio
- b Second University of Naples, Infectious Diseases and Viral Hepatitis Unit , Naples , Italy
| | - Gianfranca Stornaiuolo
- b Second University of Naples, Infectious Diseases and Viral Hepatitis Unit , Naples , Italy
| | - Daniela Manno
- c Department of Infectious Diseases , University of Brescia , Brescia , Italy
| | - Giuseppe L Gaeta
- d Department of Human and Social Sciences , University of Naples L'Orientale , Naples , Italy
| | - Cristina Mussini
- a AO Policlinico di Modena, Clinic of Infectious Diseases , Modena , Italy
| | - Massimo Puoti
- e Infectious Diseases Department , AO Ospedale Niguarda Cà Granda , Milan , Italy
| | - Giovanni B Gaeta
- b Second University of Naples, Infectious Diseases and Viral Hepatitis Unit , Naples , Italy
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Kim T, Hong SI, Park SY, Jung J, Chong YP, Kim SH, Lee SO, Kim YS, Woo JH, Lim YS, Sung H, Kim MN, Choi SH. Clinical Features and Outcomes of Spontaneous Bacterial Peritonitis Caused by Streptococcus pneumoniae: A Matched Case-Control Study. Medicine (Baltimore) 2016; 95:e3796. [PMID: 27258513 PMCID: PMC4900721 DOI: 10.1097/md.0000000000003796] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Streptococcus pneumoniae is a well-known cause of spontaneous bacterial peritonitis (SBP) in cirrhotic patients. However, little information is available regarding clinical characteristics and outcomes of SBP caused by S. pneumoniae. It has been suggested that spontaneous pneumococcal peritonitis (SPP) often spreads hematogenously from concomitant pneumococcal pneumonia, and is associated with a higher rate of mortality.During the period between January 1997 and December 2013, 50 SPP cases were identified. These cases were then age/sex-matched with 100 patients with SBP due to causes other than S. pneumoniae (controls).SPP accounted for 4.3% (50/1172) of all culture-proven SBPs. The baseline Child-Pugh class, etiology of cirrhosis, and model for end-stage liver disease scores were comparable for the 2 groups. SPP patients were more likely than control patients to have a community-acquired infection (90.0% vs. 76.0%; P = 0.04), concurrent bacteremia (84.0% vs. 59.0%; P = 0.002), and to present with variceal bleeding (10.0% vs. 1.0%; P = 0.02). None of the study patients had pneumococcal pneumonia. The most common initial empirical therapy for both groups was third-generation cephalosporins (96.0% vs. 91.0%; P = 0.34) which was active against a significantly higher proportion of the cases than of the controls (97.8% vs. 78.7%; P = 0.003). Thirty-day mortality was significantly lower in the case group than in the control group (10.0% vs. 24.0%; P = 0.04).SPP was not associated with pneumococcal pneumonia and showed lower mortality than SBP caused by other organisms. However, the present study was constrained by the natural limitations characteristic of a small, retrospective study. Therefore, large-scale, well-controlled studies are required to demonstrate the influence of SPP on mortality, which was marginal in the present study.
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Affiliation(s)
- Taeeun Kim
- From the Department of Infectious Diseases (TK, SIH, SYP, JJ, YPC, S-HK, S-OL, YSK, JHW, S-HC); Department of Gastroenterology (Y-SL); and Department of Laboratory Medicine (HS, M-NK), Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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Bunchorntavakul C, Chamroonkul N, Chavalitdhamrong D. Bacterial infections in cirrhosis: A critical review and practical guidance. World J Hepatol 2016; 8:307-321. [PMID: 26962397 PMCID: PMC4766259 DOI: 10.4254/wjh.v8.i6.307] [Citation(s) in RCA: 134] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 11/23/2015] [Accepted: 01/29/2016] [Indexed: 02/06/2023] Open
Abstract
Bacterial infection is common and accounts for major morbidity and mortality in cirrhosis. Patients with cirrhosis are immunocompromised and increased susceptibility to develop spontaneous bacterial infections, hospital-acquired infections, and a variety of infections from uncommon pathogens. Once infection develops, the excessive response of pro-inflammatory cytokines on a pre-existing hemodynamic dysfunction in cirrhosis further predispose the development of serious complications such as shock, acute-on-chronic liver failure, renal failure, and death. Spontaneous bacterial peritonitis and bacteremia are common in patients with advanced cirrhosis, and are important prognostic landmarks in the natural history of cirrhosis. Notably, the incidence of infections from resistant bacteria has increased significantly in healthcare-associated settings. Serum biomarkers such as procalcitonin may help to improve the diagnosis of bacterial infection. Preventive measures (e.g., avoidance, antibiotic prophylaxis, and vaccination), early recognition, and proper management are required in order to minimize morbidity and mortality of infections in cirrhosis.
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Bartoletti M, Giannella M, Lewis RE, Viale P. Bloodstream infections in patients with liver cirrhosis. Virulence 2016; 7:309-19. [PMID: 26864729 DOI: 10.1080/21505594.2016.1141162] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Bloodstream infections are a serious complication in patients with liver cirrhosis. Dysregulated intestinal bacterial translocation is the predominant pathophysiological mechanism of infections in this setting. For this reason enteric Gram-negative bacteria are commonly encountered as the first etiological cause of infection. However, through the years, the improvement in the management of cirrhosis, the recourse to invasive procedures and the global spread of multidrug resistant pathogens have importantly changed the current epidemiology. Bloodstream infections in cirrhotic patients are characterized by high mortality rate and complications including metastatic infections, infective endocarditis, and endotipsitis (or transjugular intrahepatic portosystemic shunt-related infection). For this reason early identification of patients at risk for mortality and appropriated therapeutic management is mandatory. Liver cirrhosis can significantly change the pharmacokinetic behavior of antimicrobials. In fact hypoproteinaemia, ascitis and third space expansion and impairment of renal function can be translated in an unpredictable drug exposure.
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Affiliation(s)
- Michele Bartoletti
- a Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna , Bologna , Italy
| | - Maddalena Giannella
- a Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna , Bologna , Italy
| | - Russell Edward Lewis
- a Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna , Bologna , Italy
| | - Pierluigi Viale
- a Infectious Diseases Unit, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, University of Bologna , Bologna , Italy
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Park H, Jang KJ, Jang W, Park SH, Park JY, Jeon TJ, Oh TH, Shin WC, Choi WC, Sinn DH. Appropriate empirical antibiotic use and 30-d mortality in cirrhotic patients with bacteremia. World J Gastroenterol 2015; 21:3587-3592. [PMID: 25834324 PMCID: PMC4375581 DOI: 10.3748/wjg.v21.i12.3587] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 12/01/2014] [Accepted: 01/08/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze whether prompt and appropriate empirical antibiotic (AEA) use is associated with mortality in cirrhotic patients with bacteremia.
METHODS: A total of 102 episodes of bacteremia in 72 patients with cirrhosis were analyzed. AEA was defined as a using or starting an antibiotic appropriate to the isolated pathogen at the time of bacteremia. The primary endpoint was 30-d mortality.
RESULTS: The mortality rate at 30 d was 30.4% (31/102 episodes). Use of AEA was associated with better survival at 30 d (76.5% vs 46.9%, P = 0.05), and inappropriate empirical antibiotic (IEA) use was an independent factor associated with increased mortality (OR = 3.24; 95%CI: 1.50-7.00; P = 0.003, adjusted for age, sex, Child-Pugh Class, gastrointestinal bleeding, presence of septic shock). IEA use was more frequent when the isolated pathogen was a multiresistant pathogen, and when infection was healthcare-related or hospital-acquired.
CONCLUSION: AEA use was associated with increased survival of cirrhotic patients who developed bacteremia. Strategies for AEA use, tailored according to the local epidemiological patterns, are needed to improve survival of cirrhotic patients with bacteremia.
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Hung IFN, Tantawichien T, Tsai YH, Patil S, Zotomayor R. Regional epidemiology of invasive pneumococcal disease in Asian adults: epidemiology, disease burden, serotype distribution, and antimicrobial resistance patterns and prevention. Int J Infect Dis 2013; 17:e364-73. [PMID: 23416209 DOI: 10.1016/j.ijid.2013.01.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Revised: 01/05/2013] [Accepted: 01/08/2013] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To summarize published data on the clinical and economic burden, epidemiology, antimicrobial resistance levels, serotype prevalence, and prevention strategies for pneumococcal disease among adults in Asia. METHODS We performed a systematic search of the PubMed database for relevant, peer-reviewed articles published between January 1995 and December 2011, covering China, Hong Kong, India, Indonesia, Japan, Malaysia, Pakistan, the Philippines, Singapore, South Korea, Taiwan, Thailand, and Vietnam. RESULTS Taiwan and Thailand had the most comprehensive epidemiological data on adult pneumococcal disease. Very little relevant data were found for Indonesia, Pakistan, the Philippines, and Vietnam; surveillance is urgently needed in these countries. The emergence and spread of resistance emphasize the importance of vaccination to prevent infection in adults at increased risk for serious pneumococcal disease. Vaccination policies and opinions on the efficacy of vaccination vary widely in Asian countries, although a new option in the form of a pneumococcal conjugate vaccine is now available. CONCLUSIONS Increased awareness of the public health and economic benefits of pneumococcal vaccination is critically needed to help both the public and policymakers in making changes to vaccination policies in the region. Maximizing access to pneumococcal vaccines will decrease the number of hospitalizations, complications, and deaths associated with pneumococcal disease.
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Affiliation(s)
- Ivan Fan-Ngai Hung
- Department of Medicine, University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong.
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Bunchorntavakul C, Chavalitdhamrong D. Bacterial infections other than spontaneous bacterial peritonitis in cirrhosis. World J Hepatol 2012; 4:158-68. [PMID: 22662285 PMCID: PMC3365435 DOI: 10.4254/wjh.v4.i5.158] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 09/08/2011] [Accepted: 04/25/2012] [Indexed: 02/06/2023] Open
Abstract
Cirrhotic patients are immunocompromised with a high risk of infection. Proinflammatory cytokines and hemodynamic circulation derangement further facilitate the development of serious consequences of infections. Other than spontaneous bacterial peritonitis, bacteremia and bacterial infections of other organ systems are frequently observed. Gram-negative enteric bacteria are the most common causative organism. Other bacterial infections, such as enterococci, Vibrio spp., Aeromonas spp., Clostridium spp., Listeria monocytogenes, Plesiomonas shigelloides and Mycobacterium tuberculosis are more prevalent and more virulent. Generally, intravenous third generation cephalosporins are recommended as empirical antibiotic therapy. Increased incidences of gram-positive and drug-resistant organisms have been reported, particularly in hospital-acquired infections and in patients receiving quinolones prophylaxis. This review focuses upon epidemiology, microbiology, clinical features and treatment of infections in cirrhosis other than spontaneous bacterial peritonitis, including pathogen-specific and liver disease-specific issues.
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Affiliation(s)
- Chalermrat Bunchorntavakul
- Chalermrat Bunchorntavakul, Division of Gastroenterology and Hepatology, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 12000, Thailand
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Spontaneous bacterial peritonitis due to streptococcus pneumoniae--case report. POLISH JOURNAL OF SURGERY 2012; 83:283-6. [PMID: 22166482 DOI: 10.2478/v10035-011-0044-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Spontaneous bacterial peritonitis is caused by infection of ascitic fluid without any apparent intraabdominal source of infection. The disease most commonly occurs in patients with cirrhosis and 70% of cases of infections are caused by pathogenes from gastrointestinal tract. The article presents the case of 38-year-old patient with spontaneous peritonitis who was treated surgically. The primary nature of the disease was confirmed by laparotomy and bacteriological examination results (Streptoccocus pneumonia) of ascitic fluid. After 54 days of hospitalisation and undergoing re-laparotomy, he was discharged in good condition.
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Viasus D, Garcia-Vidal C, Castellote J, Adamuz J, Verdaguer R, Dorca J, Manresa F, Gudiol F, Carratalà J. Community-acquired pneumonia in patients with liver cirrhosis: clinical features, outcomes, and usefulness of severity scores. Medicine (Baltimore) 2011; 90:110-118. [PMID: 21358441 DOI: 10.1097/md.0b013e318210504c] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
We performed an observational analysis of a prospective cohort of nonimmunocompromised hospitalized adults with community-acquired pneumonia (CAP) to determine the epidemiology, clinical features, and outcomes of patients with liver cirrhosis. We also analyzed the prognostic value of several severity scores. Of 3420 CAP episodes, 90 occurred in patients with liver cirrhosis. The median value of the Model for End-Stage Liver Disease (MELD) was 14 (range, 6-36). On the Child-Pugh (CP) score, 56% of patients were defined as grade B and 22% as grade C. Patients with liver cirrhosis were younger (61.8 vs. 66.8 yr; p = 0.001) than patients without cirrhosis, more frequently presented impaired consciousness at admission (33% vs. 14%; p < 0.001) and septic shock (13% vs. 6%; p = 0.011), and were more commonly classified in high-risk Pneumonia Severity Index (PSI) classes (classes IV-V) (74% vs. 58%; p = 0.002). Streptococcus pneumoniae (47% vs. 33%; p = 0.009) and Pseudomonas aeruginosa (4.4% vs. 0.9%; p = 0.001) were more frequently documented in patients with cirrhosis. Bacteremia was also more common in these patients (22% vs. 13%; p = 0.023). Areas under the curve (AUCs) from disease-specific scores (MELD, CP, PSI, and CURB-65 [confusion, urea, respiratory rate, blood pressure, and age ≥65 yr]) were comparable in predicting severe disease (30-d mortality and intensive care unit [ICU] admission). A new score based on MELD, multilobar pneumonia, and septic shock at admission (MELD-CAP) had an AUC of 0.945 (95% confidence interval [CI], 0.872-0.983) for predicting severe disease and was significantly different from other scores. Early (5.6% vs. 2.1%; p = 0.048) and overall (14.4% vs. 7.4%; p < 0.024) mortality rates were higher in cirrhotic patients than in patients without cirrhosis. Factors associated with mortality were impaired consciousness, multilobar pneumonia, ascites, acute renal failure, bacteremia, ICU admission, and MELD score. Among the severity scores, MELD-CAP was the only score associated with severe disease (odds ratio [OR], 1.33; 95% CI, 1.09-1.52) and mortality (OR, 1.21; 95% CI, 1.03-1.42). In conclusion, CAP in patients with liver cirrhosis presents a distinctive clinical picture and is associated with higher mortality than is found in patients without cirrhosis. The severity of hepatic dysfunction plays an important role in the development of adverse events. Cirrhosis-specific scores may be useful for predicting and stratifying cirrhotic patients with CAP who have a high risk of severe disease.
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Affiliation(s)
- Diego Viasus
- From Departments of Infectious Diseases (DV, CG, JA, FG, J. Carratalà), Hepatology and Liver Transplant (J. Castellote), Microbiology (RV), and Respiratory Medicine (JD, FM), Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), University of Barcelona. L'Hospitalet de Llobregat, Barcelona, Spain
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Isolated Pneumococcal Bacteremia. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2011. [DOI: 10.1097/ipc.0b013e3181f69a0d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Arvaniti V, D'Amico G, Fede G, Manousou P, Tsochatzis E, Pleguezuelo M, Burroughs AK. Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis. Gastroenterology 2010; 139:1246-56, 1256.e1-5. [PMID: 20558165 DOI: 10.1053/j.gastro.2010.06.019] [Citation(s) in RCA: 776] [Impact Index Per Article: 55.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2010] [Revised: 05/18/2010] [Accepted: 06/08/2010] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Vasiliki Arvaniti
- The Sheila Sherlock Liver Centre, and University Department of Surgery, Royal Free Hospital and University College London, London, United Kingdom
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