The spread of multi drug resistant infections is leading to an increase in the empirical antibiotic treatment failure in cirrhosis: a prospective survey

Manuela Merli, Cristina Lucidi, Vincenza Di Gregorio, Marco Falcone, Valerio Giannelli, Barbara Lattanzi, Michela Giusto, Giancarlo Ceccarelli, Alessio Farcomeni, Oliviero Riggio, Mario Venditti, Manuela Merli, Cristina Lucidi, Vincenza Di Gregorio, Marco Falcone, Valerio Giannelli, Barbara Lattanzi, Michela Giusto, Giancarlo Ceccarelli, Alessio Farcomeni, Oliviero Riggio, Mario Venditti

Abstract

Background: The spread of multi-resistant infections represents a continuously growing problem in cirrhosis, particularly in patients in contact with the healthcare environment.

Aim: Our prospective study aimed to analyze epidemiology, prevalence and risk factors of multi-resistant infections, as well as the rate of failure of empirical antibiotic therapy in cirrhotic patients.

Methods: All consecutive cirrhotic patients hospitalized between 2008 and 2013 with a microbiologically-documented infection (MDI) were enrolled. Infections were classified as Community-Acquired (CA), Hospital-Acquired (HA) and Healthcare-Associated (HCA). Bacteria were classified as Multidrug-Resistant (MDR) if resistant to at least three antimicrobial classes, Extensively-Drug-Resistant (XDR) if only sensitive to one/two classes and Pandrug-Resistant (PDR) if resistant to all classes.

Results: One-hundred-twenty-four infections (15% CA, 52% HA, 33% HCA) were observed in 111 patients. Urinary tract infections, pneumonia and spontaneous bacterial peritonitis were the more frequent. Forty-seven percent of infections were caused by Gram-negative bacteria. Fifty-one percent of the isolates were multi-resistant to antibiotic therapy (76% MDR, 21% XDR, 3% PDR): the use of antibiotic prophylaxis (OR = 8.4; 95%CI = 1.03-76; P = 0,05) and current/recent contact with the healthcare-system (OR = 3.7; 95%CI = 1.05-13; P = 0.04) were selected as independent predictors. The failure of the empirical antibiotic therapy was progressively more frequent according to the degree of resistance. The therapy was inappropriate in the majority of HA and HCA infections.

Conclusions: Multi-resistant infections are increasing in hospitalized cirrhotic patients. A better knowledge of the epidemiological characteristics is important to improve the efficacy of empirical antibiotic therapy. The use of preventive measures aimed at reducing the spread of multi-resistant bacteria is also essential.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

References

    1. Harbarth S, Albrich W, Goldmann DA, Huebner J. Lancet Infect Dis 2001;1:251–261.
    1. Zinn CS, Westh H, Rosdahl VT. Microb Drug Resist 2004;10:160–168.
    1. Merli M, Lucidi C, Giannelli V, Giusto M, Riggio O, Falcone M, et al. Cirrhotic patients are at risk for health care-associated bacterial infections. Clin Gastroenterol Hepatol. 2010;8:979–85. 10.1016/j.cgh.2010.06.024
    1. Ariza X, Castellote J, Lora-Tamayo J, Girbau A, Salord S, Rota R, et al. Risk factors for resistance to ceftriaxone and its impact on mortality in community, healthcare and nosocomial spontaneous bacterial peritonitis. J Hepatol 2012;56:825–32. 10.1016/j.jhep.2011.11.010
    1. Fernández J, Acevedo J, Castro M, Garcia O, de Lope CR, Roca D, et al. Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study. Hepatology 2012;55:1551–61. 10.1002/hep.25532
    1. Harrison PF, Lederberg J. IOM eds 1998 (National Academy Press, Washington, DC), pp. 8–74.
    1. Shlaes DM, Gerding DN, John JF, Craig WA, Bornstein DL, Duncan RA, et al. Infect Control Hosp Epidemiol 1997;18:275–291.
    1. Magiorakos AP, Srinivasan A, Carey RB, Carmeli Y, Falagas ME, Giske CG, et al. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect 2012;18:268–81. 10.1111/j.1469-0691.2011.03570.x
    1. Di Gregorio V, Lucidi C, Giannelli V, Lattanzi B, Iacovone G, Giusto M, et al. Bacterial infections in cirrhotic patients: risk factors and rate of failure of the empirical antibiotic therapy. J of Hep 2014;60:S215–S359.
    1. Bartoletti M, Giannella M, Caraceni P, Domenicali M, Ambretti S, Tedeschi S, et al. Epidemiology and outcomes of bloodstream infection in patients with cirrhosis. J of Hep 2014; 61:51–58.
    1. Friedman ND, Kaye KS, Stout JE, McGarry SA, Trivette SL, Briggs JP, et al. Health care-associated bloodstream infections in adults: a reason to change the accepted definition of community-acquired infections. Ann Intern Med 2002;137:791–7.
    1. Venditti M, Falcone M, Corrao S, Licata G, Serra P, Study Group of the Italian Society of Internal Medicine. Outcomes of patients hospitalized with community-acquired, health care-associated, and hospital-acquired pneumonia. Ann Intern Med 2009; 150:19–26.
    1. European Association for the Study of the Liver EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol 2010;53:397–417. 10.1016/j.jhep.2010.05.004
    1. Merli M, Lucidi C. Bacterial resistance in cirrhotic patients: an emerging reality. J Hepatol 2012;56:756–7. 10.1016/j.jhep.2011.12.004
    1. Fernandez J, Navasa M, Gomez J, Colmenero J, Vila J, Arroyo V, et al. Bacterial infections in cirrhosis: epidemiological changes with invasive procedures and norfloxacin prophylaxis. Hepatology 2002;35:140–148.
    1. Bajaj JS, O'Leary JG, Reddy KR, Wong F, Olson JC, Subramanian RM, et al. Second infections independently increase mortality in hospitalized patients with cirrhosis: the North American consortium for the study of end-stage liver disease (NACSELD) experience. Hepatology 2012;56(6):2328–35. 10.1002/hep.25947
    1. Boucher HW, Talbot GH, Bradley JS, Edwards JE, Gilbert D, Rice LB, et al. Bad bugs, no drugs: no ESKAPE! An update from the Infectious Diseases Society of America. Clin Infect Dis. 2009;48:1–12. 10.1086/595011

Source: PubMed

Sponsorit ja yhteistyökumppanit

Sairaudet

Huumeiden interventiot

3
Tilaa