Retrospective study of the incidence, risk factors, treatment outcomes of bacterial infections at uncommon sites in cirrhotic patients

Table 1 Comparing common and non-common bacterial infections

	Atypical BI (n = 74)	Common BI (n = 225)	No BI (n = 640)	P value1	P value2	P value3
Sex (female)	20 (27.0)	80 (35.6)	218 (34.1)	0.20	0.243	0.88
Age (yr)	61.14 ± 12.61	61.34 ± 11.95	60.45 ± 10.76	0.901	0.61
Diabetes (yes)	28 (37.8)	69 (30.7)	199 (31.1)	0.26	0.238	0.706
Etiology of cirrhosis
Alcoholic	35 (47.3)	147 (65.3)	317 (49.5)
Hepatitis C	2 (2.7)	29 (12.9)	101 (15.8)
Hepatitis B	1 (1.4)	3 (1.3)	21 (3.3)
NASH	5 (6.8)	7 (3.1)	60 (9.4)
Cryptogenic	6 (8.1)	19 (8.4)	72 (11.3)
PSC	7 (9.5)	2 (0.9)	6 (0.9)
Others	11 (14.9)	10 (4.4)	48 (7.5)
Hemochromatosis	3 (4.1)	1 (0.4)	10 (1.6)
PBC	4 (5.4)	2 (0.9)	5 (0.8)
Medication
Beta blocker	33 (45.8)	115 (51.8)	297 (47.1)	0.42	0.901	0.359
Long term ATBx	13 (18.1)	74 (33.1)	73 (11.6)	0.017	0.128	< 0.001
Lactulose	24 (33.3)	108 (48.6)	196 (31.1)	0.029	0.689	< 0.001
PPI	49 (68.1)	183 (82.4)	419 (66.3)	0.013	0.794	< 0.001
Laboratory parameters
Serum sodium (mmol/L)	137.62 ± 4.04	136.56 ± 5.03	138.10 ± 4.61	0.10	0.346	< 0.001
Creatinine (mg/dL)	1.14 ± 0.60	1.38 ± 1.17	1.029 ± 0.52	0.018	0.106	< 0.001
Total bilirubin (mg/dL)	2.83 ± 4.00	3.73 ± 5.88	2.21 ± 3.96	0.14	0.205	< 0.001
Albumin (g/dL)	33.24 ± 6.73	32.95 ± 6.91	36.64 ± 7.14	0.75	< 0.001	< 0.001
Hemoglobin (g/dL)	11.98 ± 2.21	11.19 ± 2.34	12.66 ± 2.48	0.009	0.025	< 0.001
INR	1.27 ± 0.34	1.37 ± 58	1.25 ± 0.32	0.15	0.639	0.001
ASAT	108.69 ± 257.76	80.55 ± 104.89	84.75 ± 185.15	0.31	0.475	0.930
ALAT	71.46 ± 219.92	53.63 ± 121.43	69.08 ± 164.11	0.39	0.911	0.327
Platelets	164.93 ± 110.00	150.74 ± 88.46	150.27 ± 79.27	0.26	0.151	0.527
MELD	12.86 ± 5.13	15.10 ± 7.44	11.60 ± 5.13	0.005	0.049	< 0.001
CPS	7.99 ± 2.15	8.61 ± 2.50	7.19 ± 5.44	0.05	0.003	< 0.001
Fibroscan (kPa)	41.96 ± 21.94	46 ± 21.90	37.06 ± 21.44	0.22	0.106	< 0.001

¹Uncommon bacterial infections (BI) versus common BI.

²Uncommon BI versus no BI.

³Any BI versus no BI.

Data is presented as frequency and percentage or median and standard deviation. Significant P values are marked in bold. ALAT: Alanine aminotransferase; ASAT: Aspartate aminotransferase; ATBx: Antibiotic therapy; BI: Bacterial infection; CPS: Child-Pugh-Score; CRP: C-reactive-protein; INR: International normalized ratio; MELD: Model of End Stage Liver Disease; WBC: White blood cells; UTI: Urinary tract infections; SBP: Spontaneous-bacterial peritonitis. Long term ATBx = minimum 28 d, in the case of hepatic encephalopathy or prophylaxis of SBP.

Table 2 Characteristics of patients with atypical bacterial infection (at the time of bacterial infection diagnosis)

	Atypical BI (n = 74)
Outcome
Dead within 30 d	7 (9.5)
Sepsis	9 (12.7)
Laboratory parameters (at BI)
Serum sodium (mmol/L)	137 ± 5.5
Creatinine (mg/dL)	1.13 ± 13.5
Total bilirubin (mg/dL)	1.9 ± 6.67
Albumin (g/dL)	30.0 ± 6.25
Hemoglobin (g/dL)	11.8 ± 3.00
INR	1.20 ± 0.48
ASAT (U/l)	67.0 ± 42.47
ALAT (U/l)	44 ± 30.92
Platelets	154 ± 103
MELD	14.5 ± 6.23
CPS	8 ± 1.86
WBC (×109)	8.2 ± 5.05
CRP (mg/dL)	43.1 ± 61.77

Data are presented as frequency and percentage or median and standard deviation. Significant P values are marked in bold. ALAT: Alanine aminotransferase; ASAT: Aspartate aminotransferase; BI: Bacterial infection; CPS: Child-Pugh-Score; CRP: C-reactive-protein; INR: International normalized ratio; MELD: Model of End Stage Liver Disease; WBC: White blood cells.

Table 3 Microbiological characteristics of selected infections

Pathogen	Organs frequently affected (n)	% MDR1
Gram positive (n = 17)
Staphylococcus aureus (n = 10)	Soft tissue infection[3], abscess[3], discitis/osteomyelitis[2], endocarditis[2]	1/10
Streptococcus spp. (n = 4)	Cholangitis/cholecystitis[1], endocarditis[1], meningitis[1], epididymitis[1]	NU
Enterococcus faecium (n = 3)	Cholangitis/cholecystitis[3]	NA
Gram negative (n = 20)
Escherichia coli (n = 7)	Cholangitis[5], soft tissue infection[2]	6/7
Klebsiella spp. (n = 3)	Cholangitis[1], soft tissue infection[1], appendicitis[1]	1/3
Enterobacter spp. (n = 2)	Cholangitis[1], periprothetic infection of hip joint[1]	1/2
Pseudomonas spp. (n = 4)	Soft tissue infection[2], cholangitis[1], abscess[1]	0/4
Campylobacter spp. (n = 3)	Colitis[3]	0/3
Acinetobacter baumanii (n = 1)	Soft tissue infection[1]	0/1

¹Multi-drug classification used by[8]. NU: No MDR classification; NA: Not available.

Table 4 Characteristics of antibiotic therapy

Variable	Number (n = 73)1
Empirical antibiotic treatment
Monotherapy	40 (54.8)
Combination therapy with > 2 antibiotics (n)	24 (32.9)
Combination therapy with > 3 antibiotics (n)	6 (8.2)
Unspecific antibiotic information	3 (4,1)
Antibiotic classes1
Penicillins	25 (34.2)
Cephalosporins	14 (19.2)
Metronidazole	14 (19.2)
Carbapenems	13 (17.8)
Other	13 (17.8)
Quinolones	11 (15.1)
Glycopeptides	6 (8,2)
Not assessable	4 (5.5)
Most frequent antibiotic combinations
Cephalosporins with Metronidazole	8 (11)
Carbapenems with others	4 (5.5)
Quinolones with Metronidazole	3 (4.1)
Coverage
Gram positive	26 (35.6)
Gram negative	17 (23.3)
Gram positive and negative	12 (16.4)
Gram negative and anaerobic	12 (16.4)
Non-rankable/gram positive. Negative and anaerobic	6 (8.2)
Duration of therapy
One week	18 (24.7)
Up to two weeks	28 (38.4)
More than two weeks	10 (13.7)
No data	18 (24.7)
Efficacy of empirical antibiotic therapy
No sufficient data	17 (23.3)
No resistance to antibiotics being used	19 (26)
Change in multi-resistant germ under antibiotic therapy	2 (2.7)
Antibiotic therapy not adequate	7 (9.6)
No germ detection with adequate diagnostics. Effectiveness of antibiotic therapy cannot be assessed	5 (6.8)
No germ detection in the absence of microbiological diagnostics	24 (32.9)

¹n = 73 because of one patient without specific treatment.