Prevalence and Predictors of Third-Generation Cephalosporin Resistance in the Empirical Treatment of Spontaneous Bacterial Peritonitis

The Assessment and Efficiency of Cefixime in Upper Respiratory Tract Infections: Insights and Perspectives

Upper respiratory tract infections (URTIs) are common in patients of the pediatric age group and often lead to significant morbidity and mortality. Antibiotics such as cefixime have contributed to the management of URTIs, particularly when bacterial etiology is suspected. Several studies have evaluated the effectiveness of cefixime in pediatric URTIs, showing promising results in alleviating symptoms and reducing the duration of illness. Cefixime, a third-generation cephalosporin, exhibits broad-spectrum activity against common pathogens implicated in URTIs, including Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, which are resistant to hydrolysis by several β-lactamases. Due to its unique three-hour elimination half-life, cefixime allows for twice-daily or, in most cases, once-daily dosage. As a third-generation cephalosporin, cefixime effectively targets the common bacterial pathogens associated with these infections. Its notable efficacy is coupled with a favorable safety profile, making it a preferred choice for pediatricians and family physicians. The safety profiles of cefixime in children have been extensively studied with generally favorable outcomes. Adverse events are typically mild and infrequent, with gastrointestinal disturbances being most commonly reported. Notably, cefixime has a low propensity to induce bacterial resistance, making it a valuable option in the era of increasing antibiotic resistance. Cefixime may serve as a substitute for penicillin and first-generation cephalosporins in cases of acute upper and lower respiratory tract infections, acute otitis media, and acute uncomplicated urinary tract infections. This review aimed to provide a comprehensive outline of the use of cefixime in the treatment of URTIs in the pediatric population, focusing on its efficacy, safety, and overall clinical applications.

Nosocomial vs healthcare associated vs community acquired spontaneous bacterial peritonitis: Network meta-analysis

INTRODUCTION

Spontaneous bacterial peritonitis (SBP) is a common complication in decompensated liver cirrhosis with ascitic fluid polymorphonuclear cell count > 250/mm3. Community acquired SBP (CA-SBP) occurs within the first 48 hours after hospital admission. Nosocomial SBP (N-SBP) occurs 48-72 hours after hospitalization. Healthcare associated SBP (HA-SBP) occurs in patients hospitalized in the preceding 90 days to months. We aim to evaluate mortality and resistance patterns to third generation cephalosporin among the three types.

METHODS

Multiple databases were systematically searched from inception through August 1st, 2022. Both pairwise (direct) and network (direct + indirect) meta-analysis was performed using a random effects model and DerSimonian Laird approach. Relative Risk (RR) with 95% confidence intervals (CI) were calculated. Network meta-analysis was conducted using frequentist approach.

RESULTS

A total of 14 studies with a total of 2302 SBP episodes were evaluated. On direct meta-analysis, mortality rate was higher in N-SBP compared to HA-SBP (RR 1.84, CI 1.43- 2.37) and CA-SBP (RR 1.69, CI 1.4-1.98), but not significantly different between HA-SBP and CA-SBP (RR=1.40, CI=0.71-2.76). Resistance to third generation cephalosporins was significantly higher in N-SBP compared to HA-SBP (RR=2.02, CI 1.26-3.22) and CA-SBP (RR=3.96, CI=2.50-3.60) as well as in HA-SBP compared to CA-SBP (RR=2.25, CI=1.33-3.81).

CONCLUSIONS

Our network meta-analysis shows increased mortality and antibiotic resistance with nosocomial SBP. We recommend clearly identifying such patients to manage accordingly as well as developing guidelines geared towards nosocomial infections to be able to optimally steer resistance patterns and reduce mortality.

Emergency medicine updates: Spontaneous bacterial peritonitis

INTRODUCTION

Spontaneous bacterial peritonitis (SBP) is a common infection in patients with cirrhosis and ascites and is associated with significant risk of mortality. Therefore, it is important for emergency medicine clinicians to be aware of the current evidence regarding the diagnosis and management of this condition.

OBJECTIVE

This paper evaluates key evidence-based updates concerning SBP for the emergency clinician.

DISCUSSION

SBP is commonly due to Gram-negative bacteria, but infections due to Gram-positive bacteria and multidrug resistant bacteria are increasing. The typical presentation of SBP includes abdominal pain, worsening ascites, fever, or altered mental status in a patient with known liver disease; however, some patients may be asymptomatic or present with only mild symptoms. Paracentesis is the diagnostic modality of choice and should be performed in any patient with ascites and concern for SBP or upper gastrointestinal bleeding, or in those being admitted for a complication of cirrhosis. Ultrasound should be used to optimize the procedure. An ascites absolute neutrophil count (ANC) ≥ 250 cells/mm³ is diagnostic of SBP. Ascitic fluid should be placed in blood culture bottles to improve the culture yield. Leukocyte esterase reagent strips can be used for rapid diagnosis if available. While many patients will demonstrate coagulation panel abnormalities, routine transfusion is not recommended. Management traditionally includes a third-generation cephalosporin, but specific patient populations may require more broad-spectrum coverage with a carbapenem or piperacillin-tazobactam. Albumin infusion is associated with reduced risk of renal impairment and mortality.

CONCLUSIONS

An understanding of literature updates can improve the care of patients with suspected SBP.

Impact of Bacteria Types on the Clinical Outcomes of Spontaneous Bacterial Peritonitis

BACKGROUND AND AIMS

Cirrhotic patients presenting with spontaneous bacterial peritonitis (SBP) have elevated risk of short-term mortality. While high Model for End-Stage Liver Disease-Sodium score (MELD-Na) and ascites culture yielding multi-drug resistance (MDR) bacteria are well established risk factors for further aggravating mortality, the impact of individual, causative microorganisms and their respective pathogenesis have not been previously investigated.

METHODS

This is a retrospective study of 267 cirrhotic patients at two tertiary care hospitals undergoing paracentesis from January 2015 to January 2021 who presented with ascitic PMN count > 250 cells^/mm³. The primary outcome was SBP progression defined as death or liver transplantation within 1-month of paracentesis stratified by microorganism type.

RESULTS

Of 267 patients with SBP, the ascitic culture yielded causative microorganism in 88 cases [median age 57 years (IQR 52-64)]; 68% male; median MELD-Na 29 (IQR 23-35). The microbes isolated were E. coli (33%), Streptococcus (15%), Klebsiella (13%), Enterococcus (13%), Staphylococcus (9%) and others (18%); 41% were MDR. Cumulative incidence of SBP progression within 1-month was 91% (95% CI 67-100) for Klebsiella, 59% (95% CI 42-76) for E. coli, and 16% (95% CI 4-51) for Streptococcus. After adjusting for MELD-Na and MDR, risk of SBP progression remained elevated for Klebsiella (HR 2.07; 95% CI 0.98-4.24; p-value = 0.06) and decreased for Streptococcus (HR 0.28; 95% CI 0.06-1.21; p-value = 0.09) compared to all other bacteria.

CONCLUSION

Our study found Klebsiella-associated SBP had worse clinical outcomes while Streptococcus-associated SBP had the most favorable outcomes after accounting for MDR and MELD-Na. Thus, identification of the causative microorganism is crucial not only for optimizing the treatment but for prognostication.

Response-Guided Therapy With Cefotaxime, Ceftriaxone, or Ciprofloxacin for Spontaneous Bacterial Peritonitis: A Randomized Trial: A Validation Study of 2021 AASLD Practice Guidance for SBP

INTRODUCTION

For the treatment of spontaneous bacterial peritonitis (SBP), cefotaxime, ceftriaxone, and ciprofloxacin were used as first-line agents. However, considering the increasing rate of antibiotic resistance, it is unclear which of these drugs can be initially recommended. This study aimed to compare the current efficacy of the 3 antibiotics, namely cefotaxime, ceftriaxone, and ciprofloxacin, for the treatment of SBP in patients with cirrhosis with ascites, when guided by therapeutic responses.

METHODS

This study was a multicenter, prospective, randomized controlled trial. The inclusion criteria were 16- to 75-year-old patients with liver cirrhosis with ascites, having polymorphonuclear cell count of >250/mm 3 . We performed a follow-up paracentesis at 48 hours to decide continuing or changing the assigned antibiotics and then assessed the resolution rates at 120 and 168 hours of treatment.

RESULTS

A total of 261 patients with cirrhosis who developed SBP were enrolled. Most of the patients were diagnosed as those with SBP within 48 hours of admission. The resolution rates at 120 hours, which is the primary endpoint, were 67.8%, 77.0%, and 73.6% in the cefotaxime, ceftriaxone, and ciprofloxacin groups, respectively ( P = 0.388), by intension-to-treat analysis. The 1-month mortality was similar among the groups ( P = 0.770). The model for end-stage liver disease score and the SBP resolution were significant factors for survival.

CONCLUSION

The efficacy of empirical antibiotics, such as cefotaxime, ceftriaxone, and ciprofloxacin, against SBP was not significantly different. In addition, these antibiotics administered based on response-guided therapy were still efficacious as initial treatment for SBP, especially in those with community-acquired infections.

Korean Guidelines for Use of Antibiotics for Intra-abdominal Infections in Adults

The guidelines are intended to provide practical information for the correct use of antibiotics for intra-abdominal infections in Korea. With the aim of realizing evidence-based treatment, these guidelines for the use of antibiotics were written to help clinicians find answers to key clinical questions that arise in the course of patient care, using the latest research results based on systematic literature review. The guidelines were prepared in consideration of the data on the causative pathogens of intra-abdominal infections in Korea, the antibiotic susceptibility of the causative pathogens, and the antibiotics available in Korea.

Efficacy predictors of third-generation cephalosporins in treating spontaneous bacterial peritonitis

OBJECTIVE

Third-generation cephalosporins (3rd GCs) have recently become controversial as the first-line strategy for empirical spontaneous bacterial peritonitis (SBP) treatment. This study aimed to identify SBP treatment efficacy predictors of 3rd GCs.

METHODS

In this retrospective cohort study, 279 cirrhosis patients with SBP who received 3rd GC monotherapy for initial empirical treatment from 2013 to 2019 were included. Nonresponse was defined as a decreased ascites polymorphonuclear (PMN) count < 25% from baseline after 48 hours of antibacterial treatment. Multivariate regression analysis was used to identify efficacy predictors of 3rd GCs in treating SBP. Kaplan-Meier analysis was used to evaluate survival data.

RESULTS

The nonresponder group included 120 patients with no response, and the responder group included 159 patients with responses. The response rate to 3rd GCs was 57.0% among all patients. The common pathogens were Escherichia coli (40.6%), Staphylococcus (15.6%), Klebsiella pneumonia (12.5%), and Streptococcus (12.5%) in 32 ascites culture isolates. Nosocomial SBP (NSBP) (odds ratio [OR]: 2.371, 95% confidence interval [CI]: 1.323-4.249, P = .004), pneumonia (OR: 11.561, 95% CI: 1.876-71.257, P = .008), recurrent SBP (OR: 3.386, 95% CI: 1.804-6.357, P < .001), platelet count (≥113.5 × 109/L) (OR: 3.515, 95% CI: 1.973-6.263, P < .001), and ascites PMN count (≤0.760 × 109/L) (OR: 4.967, 95% CI: 2.553-9.663, P < .001) were independent predictors of nonresponse to 3rd GCs against SBP. Survival plot analysis at 30 days showed worse survival for the nonresponders (P = .003).

CONCLUSION

NSBP, pneumonia, recurrent SBP, increased platelet count, and lower ascites PMN count were independent predictors of nonresponse to 3rd GC in treating SBP. Nonresponse to initial antibiotic treatment was associated with worse survival.

Evaluation of the current guidelines for antibacterial therapy strategies in patients with cirrhosis or liver failure

BACKGROUND

Bacterial infections are common complications in patients with cirrhosis or liver failure and are correlated with high mortality. Clinical practice guideline (CPG) is a reference used to help clinicians make decisions. This systematic appraisal aimed to evaluate the methodological quality and summarize the recommendations of reported CPGs in these patients.

METHODS

We systematically searched CPGs published from 2008 to 2019. The methodological quality of the included CPGs was assessed using the AGREE II instrument. We extracted and compared recommendations for prophylactic and empirical treatment strategies.

RESULTS

Fourteen CPGs with a median overall score of 56.3% were included. The highest domain score was Clarity of Presentation (domain 4, 85.4%), and the lowest was for Stakeholder Involvement (domain 2, 31.3%). Three CPGs had an overall score above 80%, and 6 CPGs had a score above 90% in domain 4. Prophylaxis should be strictly limited to patients with varicose bleeding, low ascites protein levels and a history of spontaneous bacterial peritonitis. Fluoroquinolones (norfloxacin and ciprofloxacin), third-generation cephalosporins (G3) (ceftriaxone and cefotaxime) and trimethoprim-sulfamethoxazole (SXT) are recommended for preventing infections in patients with cirrhosis or liver failure. G3, β-lactam/β-lactamase inhibitor combinations (BLBLIs) and carbapenems are recommended as the first choice in empirical treatment according to local epidemiology of bacterial resistance.

CONCLUSIONS

The methodological quality of CPGs focused on patients with cirrhosis or liver failure evaluated by the AGREE II instrument is generally poor. Three CPGs that were considered applicable without modification and 6 CPGs that scored above 90% in domain 4 should also be paid more attention to by healthcare practitioners. Regarding recommendations, norfloxacin, ciprofloxacin, ceftriaxone, cefotaxime, and SXT are recommended for prophylactic treatment appropriately. G3, BLBLIs, and carbapenems are recommended for use in empirical treatment strategies.

Spontaneous bacterial peritonitis: a prospective Greek multicenter study of its epidemiology, microbiology, and outcomes

Background

Spontaneous bacterial peritonitis (SBP) is an ominous complication of decompensated cirrhosis. This study aimed to assess several epidemiological, clinical, microbiological and outcome characteristics in Greek patients with SBP, as no solid representative nationwide data of this type was available.

Methods

During a 3-year period, 77 consecutive patients with SBP (61 male; median age: 67 years; model for end-stage liver disease [MELD] score: 20), diagnosed and followed in 5 tertiary liver units, were prospectively recruited and studied. Various prognostic factors for disease outcome were studied.

Results

Thirty-eight patients had alcohol-related cirrhosis, 17 viral hepatitis, 6 non-alcoholic steatohepatitis, 6 autoimmune liver diseases, and 10 cryptogenic cirrhosis. Hepatocellular carcinoma (HCC) was present in 23 (29.9%), whereas 10 (13%) had portal vein thrombosis. The first SBP episode at baseline was community-acquired in 53 (68.8%), while in 24 (31.1%) was hospital-acquired, with predominant symptoms abdominal pain and encephalopathy. A positive ascitic culture was documented in 36% of patients in the initial episode, with almost equal gram (+) and gram (-) pathogens, including 3 multidrug-resistant pathogens. Significant factors for 6-month survival were: higher MELD score, previous b-blocker use, lower serum albumin, higher lactate on admission and need for vasopressors, while factors for 12-month survival were MELD score and lactate. For overall survival, higher MELD score and lactate along with HCC presence were negative predictive factors.

Conclusions

MELD score, lactate, albumin, HCC and treatment with vasopressors were predictive of survival in SBP patients. In hospital-acquired SBP the prevalence of difficult-to-treat pathogens was higher.

Microbiological profile of pathogens in spontaneous bacterial peritonitis secondary to liver cirrhosis: a retrospective study

Spontaneous bacterial peritonitis (SBP) is an acute bacterial infection of ascitic fluid without an obvious source. The prevalence of SBP in patients with cirrhosis is in the range of 10%–30%. With increasing use of antibiotics, there is a gradual shift in the causative flora of SBP from Gram-negative bacteria to Gram-positive and, more importantly, to drug-resistant bacteria. The aim of this retrospective study on 721 cases was to identify the prevalence of various organisms causing SBP along with their drug sensitivity and resistance patterns. A prevalence of 38.2% culture positivity was observed in our South Indian population. Escherichia coli was the most common pathogen isolated. Third-generation cephalosporins showed high rates of resistance, but a susceptibility of 74.5% to amikacin was found. Nonetheless, 42% of culture-positive isolates exhibited multidrug resistance, the highest rates being seen with Enterococcus faecium (64.2%) and Acinetobacter baumannii (71.4%).

Novel strategies for the management of bacterial and fungal infections in patients with liver cirrhosis: focus on new antimicrobials

Introduction: Liver cirrhosis is a frequent condition caused by different etiologies. Bacterial and fungal infections are common complications, representing an independent prognostic stage in patients with cirrhosis, dramatically worsening their clinical outcomes.Areas covered: The present review article addresses manifold points and to this purpose an inductive literature search of MEDLINE database through PubMed was performed. First, it provides an overview on the mechanisms underlying immune disfunctions in patients with cirrhosis, who are prone to develop infections being at higher risk than the general population. Second, commonest types of bacterial and fungal infections in patients with advanced liver disease are described, focusing on their deleterious impact as decompensating events. Third, the rise of multidrug-resistant (MDR) bacteria and fungi as causative agents of infection in cirrhotic subjects is illustrated. Eventually, the most promising novel therapeutic options against MDR pathogens and fungi are reviewed.Expert opinion: The management of bacterial and fungal infections in patients with cirrhosis is difficult, due to the frequent co-existence of renal impairment, low platelet count and other conditions that limit the antimicrobial choice. New antibacterial and antifungal compounds may overcome this issue by providing a better tolerability profile, along with equal or superior efficacy compared with older drugs.