'Alarming' New Numbers on Bacterial Infection in Cirrhosis

Neil Osterweil

April 12, 2018

PARIS — Infections caused by multidrug-resistant bacteria, which are common in patients with cirrhosis, are associated with a significant elevation in risk for in-hospital mortality, results from a global study show.

"The efficacy of first-line treatment is crucial to improve the survival of cirrhotic patients with bacterial infections," said Paolo Angeli, MD, PhD, from the University of Padova in Italy.

For their study, Angeli and his colleagues followed 1302 patients with cirrhosis and bacterial or fungal infections until death, liver transplantation, or discharge. All were treated at one of 46 centers in North and South America, Europe, Africa, and Asia, and bacteria were considered multidrug-resistant if they were impervious to at least one agent in three or more antibiotic classes.

Angeli presented the results here at the International Liver Congress 2018.

In the study cohort, mean Model for End Stage Liver Disease (MELD) score was 21, 77% of the patients had ascites, and 35% had acute-on-chronic liver failure. Cirrhosis was caused by alcohol in 52% of patients, by hepatitis C virus in 20%, by hepatitis B virus in 8%, and by nonalcoholic steatohepatitis in 10%; the remaining 10% of patients had cirrhosis of unspecified origin.

Of the infections, 48% were deemed to be community-acquired, 26% were nonhospital healthcare-associated, and 26% were nosocomial.

The most common infections were spontaneous bacterial peritonitis (27%), urinary tract infections (22%), and pneumonia (19%). The most prevalent infectious organisms were Escherichia coli, Klebsiella pneumonia, Enterococcus, Staphylococcus aureus, and Pseudomnoas areuginosa.

Of the 959 micro-organisms isolated from the 740 patients with at least one positive culture, 58% were Gram-negative, 38% were Gram-positive, and 4% were fungi.

The global prevalence of multidrug-resistant bacteria was 34%, and the prevalence of extensively drug-resistant bacteria — Gram-negative bacteria resistant to nearly all available agents — was 8%.

The risk for infection with multidrug-resistant bacteria was especially high in India (odds ratio [OR], 7.94; < .001), Asia (OR, 2.79; P = .017), and South America (OR, 2.23; = .053).

Table. Factors Associated With Multidrug-Resistant Bacteria in Cirrhotic Patients

Risk Factor Odds Ratio P Value
Antibiotics in the 3 months before hospitalization 1.92 .001
Nosocomial infection 2.65 <.001
Healthcare-associated infection 1.62 .032
Pneumonia 3.20 <.001
Urinary tract infection 2.48 <.001
Skin and soft tissue infection 2.92 .004


Multidrug-resistant bacterial infections were less likely than other bacteria to respond to empiric antibiotic therapy (40% vs 68%; < .001). And patients with multidrug-resistant infections were significantly more likely to experience septic shock (27% vs15%; P < .001) and new organ failure (42% vs 31%; = .001).

Additionally, multidrug-resistant infections were less likely to be resolved and were associated with a significantly higher rate of in-hospital death (31% vs 21%; P = .004).

Distressing Data

"These are very alarming data: more than 30% of multidrug resistance anywhere, more or less, in the world is really alarming," said Annalisa Berzigotti, MD, PhD, from the University of Bern in Switzerland, who was not involved in the study.

"At the moment, we are awaiting new antibiotic therapy that could overcome these bugs, but meanwhile, we should all be aware of the measures to prevent infectious disease," she said during a briefing held in advance of the presentation.

Isolation of these patients could have reduced the number of infections, she said.

"As Angeli suggested, there must be active screening of patients who might have been in contact with these bacteria," Berzigotti told Medscape Medical News.

"Whenever they are admitted to the hospital from another hospital or from the intensive care unit, where there is a much greater distribution of these bacteria, they should be actively screened, and as soon as they are identified, they should be isolated," she said.

This study was supported by the International Club of Ascites. Angeli and Berzigotti have disclosed no relevant financial relationships.

International Liver Congress (ILC) 2018: Abstract GS-001. Presented April 12, 2018.

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