Multidrug-resistant bacterial infections in cirrhotic patients: an epidemiological study

Antibiotics in decompensated liver disease - who, when and for how long?

INTRODUCTION

Bacterial infections are a leading cause of hospitalization and mortality in patients with decompensated cirrhosis. Antibiotic prophylaxis in cirrhotic patients has demonstrated significant short-term reductions in bacterial infections in randomized controlled trials, but at the cost of drug resistance and with uncertain survival benefits.

AREAS COVERED

This review examines antibiotic use in cirrhosis, focusing on patients most likely to benefit from antibiotic prophylaxis, management strategies for infections through risk-based antibiotic selection and timely treatment initiation, challenges posed by the emergence of multidrug-resistant organisms, and principles of antimicrobial stewardship.

EXPERT OPINION

The efficacy of prophylaxis has decreased over time, and current registry data have questioned its use, emphasizing the need for better risk-based individualized strategies. When bacterial infections occur, the efficacy of antimicrobial therapies depends heavily on local epidemiological patterns and individual patient risk factors, necessitating tailored antibiotic selection based on regional resistance data and specific clinical scenarios. Nosocomial infections, colonization with multidrug-resistant organisms, and prior exposure to systemic antibiotics are key risk factors that should guide empirical therapy selection. Until evidence-based algorithms are available, clinicians should continue to adopt individualized approaches, guided by available evidence, local specificities, and antimicrobial stewardship principles to optimize patient outcomes.

Clinical impact of multidrug-resistant bacterial infections in patients with cirrhosis

Aim: Recently, the emergency of multidrug-resistant organisms (MDRO) has complicated the management of bacterial infections (BI) in cirrhosis. We aimed to assess their clinical impact on patients with decompensated cirrhosis. Methods: A retrospective study included consecutive cirrhotic patients hospitalized for acute decompensation (AD) between January 2010 and December 2019. Results: A total of 518 AD admissions in 219 patients were included, with 260 BI episodes (50.2%). MDRO prevalence was 38.2% of the total isolates. Recent antibiotic use (OR = 4.91), nosocomial infection (OR = 2.95), and healthcare-associated infection (OR = 3.45) were their main risk factors. MDROs were associated with empiric treatment failure (OR = 23.42), a higher prevalence of sepsis (OR = 4.93), ACLF (OR = 3.42) and mortality. Conclusion: The clinical impact of MDROs was pejorative, with an increased risk of empiric treatment failure, organ failure and death.

Colonization with Carbapenem-Resistant Enterobacteriaceae Contributes to Unfavorable Outcomes in End-Stage Liver Disease Patients

Carbapenem-resistant Enterobacteriaceae (CRE) are the highest priority pathogens of the World Health Organization, and their prevalence in end-stage liver disease (ESLD) patients is increasing. CRE colonization is an independent risk factor for CRE infections. We aimed to assess risk factors and explore the relationship between CRE colonization, infection, and prognosis in patients with ESLD. A total of 311 patients with ESLD were screened for CRE colonization by fecal swabs from October 2020 to January 2022. Antimicrobial susceptibility was tested using the broth microdilution method. Carbapenem resistance genes, multilocus sequence type, and capsular serotype were analyzed by polymerase chain reaction (PCR). Seventeen CRE strains were detected, among which the most common was Klebsiella pneumoniae. The CRE colonization rate was 5.5%. Artificial liver support was an independent risk factor for CRE colonization. Compared to the non-CRE colonization group, the colonization group had a higher incidence of CRE infection and a worse prognosis. Furthermore, these strains were not closely related, and all were sensitive to polymyxin and tigecycline. There was a high colonization rate in ESLD patients, and colonization strains were highly diverse. CRE colonization deserves attention in these patients, especially when treated with artificial liver support.

Bacteraemia, sepsis and antibiotic resistance in Australian patients with cirrhosis: a population-based study

Objective

Multiple factors predispose patients with cirrhosis to sepsis and/or bacteraemia and this has a high mortality rate. Within different geographical regions there are marked differences in the prevalence of infection with multidrug-resistant organisms (MDR). This study examined risk factors for and outcomes of sepsis/bacteraemia in public hospital admissions with cirrhosis in the state of Queensland, Australia, over the last decade, along with the bacterial pathogens responsible and their antibiotic susceptibility profiles.

Design

A population-based retrospective cohort study of public hospital admissions was conducted from 1 January 2008 to 31 December 2017. Hospital admissions for patients with a diagnosis of cirrhosis were categorised by the presence or absence of sepsis/bacteraemia. Clinical and sociodemographic information including cirrhosis aetiology, complications and comorbidities, and in-hospital mortality were examined using bivariate and multivariate analyses. In patients with bacteraemia, the type and prevalence of bacteria and antibiotic resistance was assessed.

Results

Sepsis/bacteraemia was present in 3951 of 103 165 hospital admissions with a diagnosis of cirrhosis. Factors associated with sepsis/bacteraemia included disease aetiology, particularly primary sclerosing cholangitis (adj-OR 15.09, 95% CI 12.24 to 18.60), alcohol (adj-OR 2.90, 95% CI 2.71 to 3.09), Charlson Comorbidity Index ≥3 (adj-OR 3.54, 95% CI 3.19 to 3.93) and diabetes (adj-OR 1.87, 95% CI 1.74 to 2.01). Overall case-fatality rate among admissions with sepsis/bacteraemia was 27.7% (95% CI 26.3% to 29.1%) vs 3.7% (95% CI 3.6% to 3.8%) without sepsis/bacteraemia. In-hospital death was significantly associated with sepsis/bacteraemia (adj-OR 6.50, 95% CI 5.95 to 7.11). The most common organisms identified were Escherichia coli and Staphylococcus aureus, present in 22.9% and 18.1%, respectively, of the 2265 admissions with a positive blood culture. The prevalence of MDR bacteria was low (5.6%)

Conclusion

Morbidity and mortality related to sepsis/bacteraemia in patients with cirrhosis remains a critical clinical problem.

Risk factors for the emergence of multidrug-resistant organisms in liver cirrhosis

BACKGROUND

Multidrug-resistant organisms (MDROs) are a reality that can alter the paradigm of treatment and prevention of infection in patients with liver cirrhosis (LC).

OBJECTIVE

Identify risk factors for the occurrence of MDROs in patients with LC.

PATIENTS AND METHODS

Prospective study from October 2017 to March 2018 in consecutively hospitalized patients with decompensated LC with infection. Blood, urine and ascitic fluid cultures were analyzed. A p-value ≤0.05 was considered statistically significant.

RESULTS

MDROs isolated in 18 of 52 episodes of infection. MDROs were associated with the use of proton pump inhibitors (PPIs) (p=0.0312), antibiotic therapy in the last 90 days (p=0.0033) and discharge within preceding 30 days or current hospitalization above 48h (p=0.0082). There was higher 90-day mortality in patients with MDROs infection (71.4% versus 35.7%, p=0.0316).

CONCLUSION

MDROs infections were prevalent in this cohort and associated with 90-day mortality. Use of PPIs and antibiotics increased the risk of MDROs infections, suggesting that its prescription should be restricted to formal indication. Hospitalization was associated with the onset of MDROs, so LC patients should stay at the hospital the least possible. It is relevant to investigate other factors predisposing to the emergence of these microorganisms, in order to prevent it.