• SIRS
• antibiotic resistance
• bacterial infections
• cirrhosis
• immuno-modulation
• immunotherapy
• sepsis

• Cirrhosis
• Infection (gastroenterology)
• Infectious diseases

• Ascites/complications
• Ascitic Fluid/microbiology
• Bacterial Infections/complications
• Female
• Humans
• Liver Cirrhosis/complications
• Peritonitis/etiology
• Salmonella typhimurium

• Antibiotic treatment
• Liver cirrhosis
• Piperacillin/tazobactam
• Spontaneous bacterial peritonitis

Background and aims

Spontaneous bacterial peritonitis (SBP) is an important cause of morbidity and mortality in patients with cirrhosis. This study aimed to identify the factors impacting morbidity and short-term mortality in a cohort of patients with cirrhosis following an index episode of SBP.

Methods

In a retrospective study of hospitalized cirrhotic cohort, 333 patient records were reviewed. Demographic, clinical, and laboratory, as well as radiological characteristics of the patient population were analyzed on day 1 of admission. The diagnosis of cirrhosis was based on the combination of laboratory, clinical, and radiological features. The diagnosis of SBP was established by abdominal paracentesis in the presence of cellular, biochemical, and microbiological features consistent with SBP. All independent variables were analyzed to generate a predictive model of mortality by using the Cox proportional hazards regression analysis (adjusted for age and gender).

Results

A total of 61 cirrhotic patients with ascites and a first episode of SBP were identified. The overall mortality among hospitalized patients was 19.7% and was associated with longer length of stay (12.6 vs. 7.6 days; p=0.01). Patient cohorts with multiple antibiotic resistant bacteria as a cause of SBP had a significantly higher mortality compared to those with other bacterial phenotypes (p=0.03). Multivariate analyses showed that a model for end-stage liver disease (MELD) score (hazard ratio [HR]=1.29; 95% CI: 1.10 to 1.92; p=0.023), Child-Turcotte-Pugh score (HR=1.23; 95% CI: 1.05 to 1.82; p=0.027), and acute kidney injury (HR=2.09; 95% CI: 1.41 to 3.47; p=0.01) were the predictors of mortality from SBP.

Conclusion

SBP predicts in-hospital mortality in cirrhotic patients. In addition to multiple antibiotic resistant bacteria, thresholds of both hepatic and renal injury independently predict adverse outcomes.

• cirrhosis
• infection
• mortality
• peritonitis
• sepsis
• spontaneous bacterial peritonitis

Bacterial infections are common in patients with decompensated liver cirrhosis and a leading cause of death. Reliable data on antibiotic resistance are required to initiate effective empiric therapy. We here aim to assess the antimicrobial resistance profile of bacteria among patients with liver cirrhosis and infection.

Overall, 666 cirrhotic patients admitted to Hannover Medical School between January 2012 and April 2018 with ascites were assessed for bacterial infection. In case of infection, bacteria cultured from microbiological specimens of ascites, blood or urine were identified and analyzed for resistances against common antibiotic agents. Furthermore, analyses compared two periods of time and community-acquired vs. nosocomial infections.

In 281 patients with infection, microbiological sampling was performed and culture-positive results were obtained in 56.9%. Multidrug-resistant (MDR)-bacteria were found in 54 patients (19.2%). Gram-positive organisms were more common (n = 141/261, 54.0%) and detected in 116/192 culture-positive infections (60.4%). Comparing infections before and after 2015, a numerical decline for MDR-bacteria (23.8% vs. 15.6%, p = 0.08) was observed with a significant decline in meropenem resistance (34.9% vs. 19.5%, p = 0.03). MDR-bacteria were more frequent in the case of nosocomial infections. Of note, in ascites the majority of the tested bacteria were resistant against ceftriaxone (73.8%) whereas significantly less were resistant against meropenem (27.0%) and vancomycin (25.9%).

In our tertiary center, distinct ratios of gram-positive infection with overall low ratios of MDR-bacteria were found. Adequate gram-positive coverage in the empiric therapy should be considered. Carbapenem treatment may be omitted even in nosocomial infection. In contrast, 3rd generation cephalosporins cannot be recommended even in community-acquired infection in our cirrhotic population.

The online version contains supplementary material available at 10.1186/s12876-021-01871-w.

• Antibiotic resistance
• Ascites
• Bacterial infection
• Liver cirrhosis
• Multiresistant bacteria

• Ascites
• Cirrhosis
• Risk of Death
• Therapy

• Antibiotic selection
• MELD
• Mortality
• Multi drug resistant
• Nosocomial

• cirrhosis
• platelet count
• recurrence
• serum albumin
• serum potassium
• spontaneous bacterial peritonitis

• Adult
• Anti-Bacterial Agents/therapeutic use
• Anti-Infective Agents/therapeutic use
• Bacterial Infections/diagnosis
• Bacterial Infections/etiology
• Female
• Humans
• Liver Cirrhosis/complications
• Liver Cirrhosis/drug therapy
• Male
• Middle Aged
• Peritonitis/diagnosis
• Peritonitis/etiology
• Prognosis
• Recurrence
• Retrospective Studies
• Severity of Illness Index

Spontaneous bacterial peritonitis (SBP) is a commonly encountered infection seen in the setting of ascites secondary to advanced liver disease. Recurrence of SBP is common and is associated with high mortality. This study was designed to recognize a better initial choice of antibiotic in case of recurrent SBP – a third-generation cephalosporin or a carbapenem.

This study aims to determine a better initial choice of antibiotic in case of recurrent SBP and to compare the all-cause mortality among two different groups of patients treated with a third-generation cephalosporin and a carbapenem.

This study was conducted among fifty patients presenting with recurrent SBP visiting the emergency department (ED) at a tertiary care center and who were subsequently admitted in a gastroenterology intensive care unit, during a period of 1 year.

This is a retrospective, observational study conducted among patients with chronic liver disease and diagnosed with recurrent SBP visiting the ED at a tertiary care center in South India treated with either of two classes of antibiotics – third-generation cephalosporins or carbapenems, and their outcomes were compared. Recurrence is defined as an episode of SBP after resolution of the first index case of SBP within 1 year.

Statistical analysis was done using IBM SPSS version 23.0 (SPSS Inc., Chicago, IL, USA). All categorical variables were represented as percentages, and all continuous variables were represented as mean ± standard deviation. To test the statistical significance of the association of categorical variables with the outcome, Chi-square test was used. P <0.05 was considered statistically significant.

A total of fifty patients with recurrent SBP were included in the study, of which 44 (88%) patients were male and 6 patients were female (12%). Twenty-nine (58%) patients survived and 21 (42%) patients expired within 28 days. Twenty-seven (54%) patients were treated with third-generation cephalosporins and 23 (46%) were treated with carbapenems. It was observed that mortality was statistically significantly lower among patients treated with carbapenem (P = 0.001). The incidence of acute kidney injury was also lower among patients treated with a carbapenem than patients treated with a third-generation cephalosporin (40.7% vs. 59.25%, respectively).

Initiation of a carbapenem significantly reduced the all-cause mortality when compared to a third-generation cephalosporin as an initial antibiotic of choice in recurrent SBP.

• Carbapenem
• initial antibiotic
• recurrent spontaneous bacterial peritonitis
• third-generation cephalosporin

• Academic Medical Centers
• Adult
• Aged
• Aged, 80 and over
• Cephalosporin Resistance
• Cephalosporins/pharmacology
• Cephalosporins/therapeutic use
• Databases, Factual
• Female
• Follow-Up Studies
• Gram-Positive Bacterial Infections/diagnosis
• Gram-Positive Bacterial Infections/drug therapy
• Gram-Positive Bacterial Infections/epidemiology
• Humans
• Kaplan-Meier Estimate
• Male
• Microbial Sensitivity Tests
• Middle Aged
• Minnesota
• Peritonitis/diagnosis
• Peritonitis/drug therapy
• Peritonitis/epidemiology
• Peritonitis/microbiology
• Predictive Value of Tests
• Prevalence
• Retrospective Studies
• Risk Assessment
• Survival Rate
• Time Factors
• Treatment Outcome
• Young Adult

• nosocomial
• predictors
• spontaneous bacterial peritonitis
• survival

• Antibiotic therapy
• Gram-negative
• antibiotic resistance
• infection
• spontaneous bacterial peritonitis

• Ascites
• Spontaneous bacterial peritonitis
• Therapy

• Global
• Resistance
• Sepsis
• Stewardship

• Antibiotic resistance
• Antibiotic strategies
• Epidemiology
• Prevalence
• Prognosis

Cirrhosis-associated immune dysfunction syndrome (CAIDS) has been identified in patients with liver cirrhosis (LC), predisposing them to a wide variety of infections. In patients with LC, healthcare-associated infections involving multi-drug resistant (MDR) bacteria have increased significantly over the last decades. Among them, hospital-acquired urinary tract infections (HA-UTI) are the most common. This study aimed to investigate the rates of antimicrobial resistance among patients with LC and HA-UTI and to determine risk factors associated with their development among patients hospitalized in tertiary care facility in Serbia.

This retrospective study included 65 hospitalized patients with LC who had developed HA-UTI. We examined the epidemiology of these infections concerning resistance to the most commonly used antimicrobials and patient-specific risk factors associated with HA-UTI development by MDR pathogens.

The most frequently isolated organisms were Enterococcus spp. (n = 34, 52.3%), Klebsiella spp. (n = 10, 15.4%), and E.coli (n = 6, 9.2%). Thirty-five isolates (53.8%) were identified as MDR, and 30 (46.2%) were non-MDR.We found a statistically significant difference in the distribution of MDR and non-MDR strains, based on Gram staining, with the majority of Gram-negative pathogens being MDR (p = 0.005). We identified age ≥ 65 years (p = 0.007), previous use of cephalosporins as empiric therapy (p = 0.042), and the presence of hepatic encephalopathy (p = 0.011) as independent risk factors for the development of MDR UTIs.

This is the first study from Serbia and the Balkans concerning the changing epidemiology of MDR UTI in patients with LC. Our study showed that more than half of HA-UTI was caused by MDR and the most common pathogen was Enterococcus spp. The overall resistance to ceftriaxone was 92%. Our findings underscore the need for institutions to individualize protocols for treatment of hospital-acquired infections, particularly in immunocompromised populations.

• Immune dysfunction
• Liver cirrhosis
• Multi-drug resistant organism
• Urinary tract infection

Spontaneous bacterial peritonitis (SBP) is a severe complication of decompensated cirrhosis. The prevalence of multidrug-resistant organisms (MDROs) in patients with cirrhosis is increasing. Identification of patients at risk for SBP due to MDROs (ie, SBP with the evidence of MDROs or Stenotrophomonas maltophilia in ascitic culture, MDRO-SBP) is crucial to the early adaptation of antibiotic treatment in such patients. We therefore investigated whether MDROs found in ascitic cultures can also be found in specimens determined by noninvasive screening procedures.

This retrospective study was conducted at the liver center of the University Hospital Frankfurt, Germany. Between 2011 and 2016, patients with cirrhosis were included upon diagnosis of SBP and sample collection of aerobic/anaerobic ascitic cultures. Furthermore, the performance of at least one complete MDRO screening was mandatory for study inclusion.

Of 133 patients diagnosed with SBP, 75 (56.4%) had culture-positive SBP and 22 (16.5%) had MDRO-SBP. Multidrug-resistant Escherichia coli (10/22; 45.5%) and vancomycin-resistant enterococci (7/22; 36.4%) resembled the major causatives of MDRO-SBP. Rectal swabs identified MDROs in 17 of 22 patients (77.3%) who developed MDRO-SBP with a time-dependent sensitivity of 77% and 87% after 30 and 90 days upon testing, while negative predictive value was 83% and 76%, respectively. The majority of patients were included from intensive care unit or intermediate care unit.

MDRO screening may serve as a noninvasive diagnostic tool to identify patients at risk for MDRO-SBP. Patients with decompensated cirrhosis should be screened for MDROs from the first day of inpatient treatment onward.

• antibiotic therapy
• ascites
• liver cirrhosis
• multidrug resistance
• screening routine

• Bacterial infections
• liver cirrhosis
• mortality
• multidrug-resistant bacteria
• prognosis

• Hemodynamic monitoring; Preload; Fluid responsiveness; Stroke volume variation; Pulse pressure variation

• Akaike Information Criterion
• Cirrhosis
• Emergency care
• Infection
• Prognostication

Spontaneous bacterial peritonitis (SBP) and bacterascites (BA) represent frequent and serious complications in cirrhosis patients with ascites. However, few detailed data are available regarding the clinical and bacteriological feature of SBP or BA patients in China.

We retrospectively analyzed bacteriological and clinical characteristics of patients with SBP and BA at Beijing 302 Hospital in China from January 2012 to December 2015.

A total of 600 patients with SBP (n = 408) or BA (n = 192) were enrolled. Patients with BA appeared to have a less severe clinical manifestation and lower mortality rate than patients with SBP. Gram-negative bacteria formed the majority of pathogens in SBP (73.9%) and BA (55.8%) cases. Higher ascitic fluid polymorphonuclear leucocytes (PMN) count and hepatocellular carcinoma were independent risk factors for BA episode progressing to SBP. The concentration of blood urea nitrogen (BUN) was independent risk factor for 30-day mortality of BA patients. For patients with SBP, the independent risk factors for 30-day mortality were age, Model for End-Stage Liver Disease (MELD) score, septic shock and hepatocellular carcinoma. Patients with third-generation cephalosporin or carbapenems resistant infection had a significantly lower survival probability. There were significant differences in clinical characteristics and outcome among the major bacteria. Multivariate analysis showed that patients infected with Klebsiella spp. had higher hazard ratio of 30-day mortality.

Our study reported the bacteriological and clinical characteristics of patients with SBP and BA. Higher ascitic fluid PMN count and hepatocellular carcinoma were found to be independent risk factors for BA episode progressed to SBP. Outcome of ascitic fluid infection in patients with cirrhosis was influenced by the type of bacteria and antimicrobial susceptibility.

The online version of this article (10.1186/s12879-018-3101-1) contains supplementary material, which is available to authorized users.

• Bacterascites
• Causative pathogens
• Cirrhosis
• Mortality
• Risk factor
• Spontaneous bacterial peritonitis

• Antimicrobial resistance
• Chronic liver disease
• Epidemiology

• Wilson disease
• acute liver failure
• ascites
• esophageal varices
• hepatic encephalopathy
• liver cirrhosis

• ALF, Acute Liver Failure
• CA, Community Acquired
• DCLD, Decompensated Chronic Liver Diseases
• GIB, Gastrointestinal Bleeding
• GNB, Gram Negative Bacilli
• GPC, Gram Positive Cocci
• HCA, Healthcare Associated
• HE, Hepatic Encephalopathy
• ICU, Intensive Care Unit
• INR, International Normalized Ratio
• MRB, Multiresistant Bacteria
• NC, Nosocomial
• SBP, Spontaneous Bacterial Peritonitis
• UTI, Urinary Tract Infection
• chronic liver disease
• infections
• liver failure

The critically ill patients with liver disease are vulnerable to infections in both community and hospital settings. The nosocomial infections are often caused by multidrug-resistant (MDR) bacteria. The present observational study was conducted to describe the epidemiology, course, and outcome of MDR bacterial infection and identify the risk factors of such infection in critically ill patients with liver disease.

A retrospective observational study was conducted on 106 consecutive critically patients with liver disease admitted in the Intensive Care Unit between March 2015 and February 2017. The MDR and non-MDR (non-MDR) groups were compared and the risk factors identified by multivariate analysis.

Out of the 106 patients enrolled in the study, 23 patients had infections caused by MDR bacteria. The MDR-infected patients had severe liver disease (Child–Pugh score 11 ± 2.3 vs. 7 ± 3.9; P = 0.04), longer duration of antibiotic usage (6 ± 2.7 days vs. 2 ± 1.5 days; P = 0.04), greater use of total parenteral nutrition (TPN) (73.9% vs. 62.6%; P = 0.04), and more concurrent antifungal administration (60.8% vs. 38.5%; P = 0.04). The mortality was higher in MDR group (hazard ratio = 1.86; P < 0.05). The independent predictors of MDR bacterial infection were Child–Pugh score >10, prior carbapenem use, antibiotic use for more than 10 days, TPN use, and concurrent antifungal administration.

The study demonstrated a high prevalence of MDR bacterial infection in critically ill patients with a higher mortality over non-MDR bacterial infection and also identified the independent predictors of such infections.

• Critically ill
• liver disease
• multidrug-resistant bacteria

• CAI, community-acquired infection
• CPK, carbapenemase producing Klebsiella
• ESBL, beta lactamase producing enterobacteriacae
• ESLD, end stage liver disease
• HAI, hospital acquired infection
• MRSA, methicillin-resistant Staphylococcus aureus
• SBP, spontaneous bacterial peritonitis
• TGC, third generation cephalosporins
• UTI, urinary tract infection
• VRE, vancomycin-resistant Enterococcus
• antibiotics
• cirrhosis liver
• microbial resistance

• Cirrhosis
• Critically ill patient
• End-stage liver disease
• Multi-drug resistant bacteria
• Spontaneous bacterial peritonitis

Spontaneous bacterial peritonitis (SBP) is a common complication of liver cirrhosis. This study was performed to compare the microbiological characteristics of nosocomial and community-acquired episodes of bacterial peritonitis in China. Five hundred and seventy-five strains were isolated from the ascitic fluid of cirrhotic patients from the Beijing 302 Hospital from January 2014 to December 2014. The patients in the community-acquired SBP (n = 311) and the nosocomial SBP (n = 264) groups exhibited significant differences in clinical symptoms (P < 0.01). In both groups, most of the bacteria were Escherichia coli, Klebsiella pneumoniae, coagulase-negative staphylococcus and Enterococcus. There were more frequent gram-positive cocci (G⁺ C) in the nosocomial group (n = 170). Compared with the community-acquired group, the proportion of Enterococcus was significantly increased in the nosocomial group (9.0% vs. 16.6%, P < 0.05). The resistance rate of the main pathogenic bacteria to the recommended first-line drug in the guideline was very high. Community-acquired and nosocomial SBP groups exhibited differences in clinical symptoms and antibiotic susceptibility tests. Optimal treatments should be provided for these patients. We recommend that cefoperazone/sulbactam or piperacillin/tazobactam should be used for the empirical treatment of SBP.

• bacterial resistance
• cirrhosis
• portal hypertension
• survival

• Antibiotic
• ascites
• cirrhosis
• liver
• resistance
• spontaneous bacterial peritonitis

• Antibiotic prescriptions
• Antimicrobial resistance
• De-escalation
• Epidemiological surveillance
• Extensively drug-resistant
• Mortality
• Multi-drug-resistance
• New antibiotics
• Pan-drug-resistance
• Prevention
• Prognosis
• Stewardship programs

• antibiotic strategies
• multidrug resistant bacteria
• prognosis
• survival

Spontaneous bacterial peritonitis is a complication of ascitic patients with end-stage liver disease (ESLD); spontaneous fungal peritonitis (SFP) is a complication of ESLD less known and described. ESLD is associated to immunodepression and the resulting increased susceptibility to infections. Recent perspectives of the management of the critically ill patient with ESLD do not specify the rate of isolation of fungi in critically ill patients, not even the antifungals used for the prophylaxis, neither optimal treatment. We reviewed, in order to focus the epidemiology, characteristics, and, considering the high mortality rate of SFP, the use of optimal empirical antifungal therapy the current literature.

• Cirrhosis
• Critically ill patient
• Spontaneous fungal peritonitis
• Life-threatening infections
• Fungal ascitis
• Nosocomial spontaneous peritonitis

• Antifungal Agents/therapeutic use
• Ascites/microbiology
• Ascitic Fluid/microbiology
• Bacterial Infections/complications
• Bacterial Infections/epidemiology
• Bacterial Infections/microbiology
• Bacterial Infections/therapy
• Critical Illness
• Cross Infection/complications
• End Stage Liver Disease/complications
• Humans
• Liver Cirrhosis/complications
• Mycoses/complications
• Mycoses/epidemiology
• Mycoses/microbiology
• Mycoses/therapy
• Peritonitis/complications
• Peritonitis/epidemiology
• Peritonitis/microbiology
• Peritonitis/therapy
• Risk Factors

• hepatic cirrhosis
• bacterial infections
• multi-drug resistance

• Bacterial Infections/classification
• Bacterial Infections/drug therapy
• Bacterial Infections/epidemiology
• Bacterial Infections/microbiology
• Brazil/epidemiology
• Cross Infection/drug therapy
• Cross Infection/epidemiology
• Cross Infection/microbiology
• Drug Resistance, Bacterial
• Female
• Humans
• Liver Cirrhosis/drug therapy
• Liver Cirrhosis/epidemiology
• Liver Cirrhosis/microbiology
• Male
• Middle Aged
• Prevalence
• Retrospective Studies
• Risk Factors

• acute kidney injury
• ascites
• cirrhosis
• hepatic encephalopathy
• liver transplantation
• multidrug resistance

• Acute kidney injury
• Decompensated cirrhosis
• Model for end-stage liver disease sodium
• Septic shock
• Spontaneous bacterial peritonitis

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.

• Spontaneous bacterial peritonitis
• Spontaneous bacteremia
• Multidrug-resistant bacteria
• Extensively drug-resistant bacteria
• Susceptibility to antibiotics

• Aged
• Anti-Bacterial Agents/therapeutic use
• Bacteremia/diagnosis
• Bacteremia/drug therapy
• Bacteremia/microbiology
• Bacteremia/mortality
• Cross Infection/diagnosis
• Cross Infection/drug therapy
• Cross Infection/microbiology
• Cross Infection/mortality
• Drug Resistance, Multiple, Bacterial
• Female
• Humans
• Kaplan-Meier Estimate
• Liver Cirrhosis/complications
• Liver Cirrhosis/diagnosis
• Liver Cirrhosis/mortality
• Male
• Microbial Sensitivity Tests
• Middle Aged
• Peritonitis/diagnosis
• Peritonitis/drug therapy
• Peritonitis/microbiology
• Peritonitis/mortality
• Predictive Value of Tests
• Prospective Studies
• Risk Assessment
• Risk Factors
• Time Factors
• Treatment Outcome