Prospective Study
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Apr 21, 2016; 22(15): 4049-4056
Published online Apr 21, 2016. doi: 10.3748/wjg.v22.i15.4049
Extensively drug-resistant bacteria are an independent predictive factor of mortality in 130 patients with spontaneous bacterial peritonitis or spontaneous bacteremia
Alexandra Alexopoulou, Larisa Vasilieva, Danai Agiasotelli, Kyriaki Siranidi, Sophia Pouriki, Athanasia Tsiriga, Marina Toutouza, Spyridon P Dourakis
Alexandra Alexopoulou, Larisa Vasilieva, Danai Agiasotelli, Kyriaki Siranidi, Sophia Pouriki, Spyridon P Dourakis, 2nd Department of Internal Μedicine, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
Athanasia Tsiriga, Marina Toutouza, Department of Microbiology, Hippokration Hospital, 11527 Athens, Greece
Author contributions: Alexopoulou A, Vasilieva L and Agiasotelli D participated in design of the study, assembly, analysis, interpretation of the data and drafting the paper; Pouriki S, Tsiriga A, Siranidi K and Toutouza M participated in acquisition, analysis and interpretation of the data; Dourakis SP participated in conception, design, interpretation, approval and revising of the paper; all authors approved the final version of the article.
Institutional review board statement: The study was reviewed and approved by the Hippokration Hospital Review Board.
Informed consent statement: All study participants or their legal guardians provided written consent prior to study enrollment.
Conflict-of-interest statement: The authors disclose no conflicts.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Dr. Alexandra Alexopoulou, MD, Assistant Professor of Medicine, 2nd Department of Internal Μedicine, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, 114 Vas Sophias St, 11527 Athens, Greece. alexopou@ath.forthnet.gr
Telephone: +30-210-7774742 Fax: +30-210-7706871
Received: December 10, 2015
Peer-review started: December 11, 2015
First decision: January 13, 2015
Revised: January 18, 2015
Accepted: February 20, 2016
Article in press: February 22, 2016
Published online: April 21, 2016
Abstract

AIM: To evaluate the epidemiology and outcomes of culture-positive spontaneous bacterial peritonitis (SBP) and spontaneous bacteremia (SB) in decompensated cirrhosis.

METHODS: We prospectively collected clinical, laboratory characteristics, type of administered antibiotic, susceptibility and resistance of bacteria to antibiotics in one hundred thirty cases (68.5% males) with positive ascitic fluid and/or blood cultures during the period from January 1, 2012 to May 30, 2014. All patients with SBP had polymorphonuclear cell count in ascitic fluid > 250/mm3. In patients with SB a thorough study did not reveal any other cause of bacteremia. The patients were followed-up for a 30-d period following diagnosis of the infection. The final outcome of the patients was recorded in the end of follow-up and comparison among 3 groups of patients according to the pattern of drug resistance was performed.

RESULTS: Gram-positive-cocci (GPC) were found in half of the cases. The most prevalent organisms in a descending order were Escherichia coli (33), Enterococcus spp (30), Streptococcus spp (25), Klebsiella pneumonia (16), S. aureus (8), Pseudomanas aeruginosa (5), other Gram-negative-bacteria (GNB) (11) and anaerobes (2). Overall, 20.8% of isolates were multidrug-resistant (MDR) and 10% extensively drug-resistant (XDR). Health-care-associated (HCA) and/or nosocomial infections were present in 100% of MDR/XDR and in 65.5% of non-DR cases. Meropenem was the empirically prescribed antibiotic in HCA/nosocomial infections showing a drug-resistance rate of 30.7% while third generation cephalosporins of 43.8%. Meropenem was ineffective on both XDR bacteria and Enterococcus faecium (E. faecium). All but one XDR were susceptible to colistin while all GPC (including E. faecium) and the 86% of GNB to tigecycline. Overall 30-d mortality was 37.7% (69.2% for XDR and 34.2% for the rest of the patients) (log rank, P = 0.015). In multivariate analysis, factors adversely affecting outcome included XDR infection (HR = 2.263, 95%CI: 1.005-5.095, P = 0.049), creatinine (HR = 1.125, 95%CI: 1.024-1.236, P = 0.015) and INR (HR =1.553, 95%CI: 1.106-2.180, P = 0.011).

CONCLUSION: XDR bacteria are an independent life-threatening factor in SBP/SB. Strategies aiming at restricting antibiotic overuse and rapid identification of the responsible bacteria could help improve survival.

Keywords: Spontaneous bacterial peritonitis, Spontaneous bacteremia, Multidrug-resistant bacteria, Extensively drug-resistant bacteria, Susceptibility to antibiotics

Core tip: This is a prospective, observational, single Center study seeking to evaluate the epidemiology and outcomes of 130 patients with decompensated cirrhosis and culture-positive spontaneous bacterial peritonitis or spontaneous bacteremia. Both multidrug-resistant (MDR) and extensively drug-resistant (XDR) bacteria were isolated in about one third of the cases. Patients with XDR demonstrated high mortality compared to the rest of the patients. All MDR/XDR associated infections were health-care associated and/or nosocomial. Independent factors adversely affected survival included XDR infection, renal dysfunction and coagulation disorder.