Multidrug-resistant bacterial infections in patients with decompensated cirrhosis and with acute-on-chronic liver failure in Europe.

BACKGROUND

Antibiotic resistance has been increasingly reported in decompensated cirrhosis in single-center studies. Prospective investigations reporting broad epidemiological data are scarce.

AIMS AND METHODS

Prospective evaluation in 2 series of patients hospitalized with decompensated cirrhosis. The Canonic series included 1146 patients from Northern, Southern and Western Europe in 2011. Data on epidemiology, clinical characteristics of bacterial infections, microbiology and empirical antibiotic schedules were assessed. A second series of 883 patients from Eastern, Southern and Western Europe was investigated to evaluate potential epidemiological changes (2017-2018).

RESULTS

455 patients developed 520 infections (39.7%) in the first series. Spontaneous bacterial peritonitis, urinary tract infections and pneumonia were the most frequent infections. Nosocomial episodes predominated in this series. Nearly half of the infections were culture-positive; 29.2% of them were caused by multidrug-resistant organisms (MDROs). MDR strains were more frequently isolated in Northern and Western Europe. ESBL-producing Enterobacteriaceae were the most frequent MDROs isolated in this series although prevalence and type of MDROs differed markedly among countries and centers. Antibiotic resistance was associated to poor prognosis and to failure of antibiotic strategies based on third-generation cephalosporins or quinolones. Nosocomial infection (OR: 2.74; p<0.001), ICU admission (OR: 2.09; p=0.02), and recent hospitalization (OR: 1.93; p=0.04) were identified as independent predictors of MDR infection. Prevalence of MDROs in the second series (392 infections/284 patients) was 23%; 38% in culture-positive infections. A mild increase in the rate of carbapenem-resistant Enterobacteriaceae was observed in this series.

CONCLUSIONS

MDR bacterial infections constitute a prevalent, growing and complex healthcare problem in decompensated cirrhosis and ACLF across all Europe and negatively impact prognosis. Strategies aimed at preventing the spread of antibiotic resistance in cirrhosis should be urgently evaluated.

LAY SUMMARY

Infections caused by bacteria resistant to the main antibiotic families are prevalent in patients with cirrhosis. This study demonstrates that this healthcare problem is increasing and extends through all European regions. Infections caused by these difficult to treat bacteria solve less frequently and often cause the death of the patient. Type of resistant bacteria varies markedly among different hospitals.