Infections In Cirrhotic Patients Research Articles

Hospital-acquired bloodstream infections in critically ill cirrhotic patients: a post-hoc analysis of the EUROBACT-2 international cohort study

BackgroundHospital-acquired bloodstream infections are common in the intensive care unit (ICU) and have a high mortality rate. Patients with cirrhosis are especially susceptible to infections, yet there is a knowledge gap in the epidemiological distinctions in hospital-acquired bloodstream infections between cirrhotic and non-cirrhotic patients in the ICU. It has been suggested that cirrhotic patients, present a trend towards more gram-positive infections, and especially enterococcal infections. This study aims to describe epidemiological differences in hospital-acquired bloodstream infections between cirrhotic and non-cirrhotic patients hospitalized in the ICU regarding infection sources, microorganisms and mortality.MethodsUsing prospective Eurobact-2 international cohort study data, we compared hospital-acquired bloodstream infections sources and microorganisms in cirrhotic and non-cirrhotic patients. The association between Enterococcus faecium and cirrhosis was studied using a multivariable mixed logistic regression. The association between cirrhosis and mortality was assessed by a multivariable frailty Cox model.ResultsAmong the 1059 hospital-acquired bloodstream infections patients included from 101 centers, 160 had cirrhosis. Hospital-acquired bloodstream infection source in cirrhotic patients was primarily abdominal (35.6%), while it was pulmonary (18.9%) for non-cirrhotic (p < 0.01). Gram-positive hospital-acquired bloodstream infections accounted for 42.3% in cirrhotic patients compared to 33.2% in non-cirrhotic patients (p = 0.02). Hospital-acquired bloodstream infections in cirrhotic patients were most frequently caused by Klebsiella spp (16.5%), coagulase-negative Staphylococci (13.7%) and E. faecium (11.5%). E. faecium bacteremia was more frequent in cirrhotic patients (11.5% versus 4.5%, p < 0.01). After adjusting for possible confounding factors, cirrhosis was associated with higher E. faecium hospital-acquired bloodstream infections risk (Odds ratio 2.5, 95% CI 1.3–4.5, p < 0.01). Cirrhotic patients had increased mortality compared to non-cirrhotic patients (Hazard Ratio 1.3, 95% CI 1.01–1.7, p = 0.045).ConclusionsCritically ill cirrhotic patients with hospital-acquired bloodstream infections exhibit distinct epidemiology, with more Gram-positive infections and particularly Enterococcus faecium.

Pulmonary Bacterial Infection and Liver Cirrhosis: Current Status and Treatment

Abstract Liver cirrhosis has a higher incidence rate and mortality when complicated with bacterial infections. Concomitant bacterial infections, especially bacterial pneumonia, increase the susceptibility of cirrhotic patients to decompensation, with a higher likelihood of mortality. Bacterial pneumonia is often overlooked in patients with liver cirrhosis, although it can impact the clinical progress and outcomes. Untimely diagnosis and inappropriate antibiotic treatments are associated with poor prognosis and increased mortality. Current understanding of mechanisms and appropriate antibiotic treatments for cirrhosis-related bacterial pneumonia remain inadequate. Herein, we reviewed the epidemiology, clinical characteristics and treatment of pulmonary bacterial infections in cirrhotic patients to provide suggestions for clinical practice.

Spontaneous fungal peritonitis is not a rare infection in cirrhotic patients with ascites: A cross-sectional Study

Spontaneous fungal peritonitis is not a rare infection in cirrhotic patients with ascites: A cross-sectional Study

Proton Pump Inhibitors Increases Longitudinal Risk of Mortality, Decompensation, and Infection in Cirrhosis: A Meta-Analysis.

Proton pump inhibitors (PPIs) are frequently prescribed to cirrhotic patients, but there is limited longitudinal evidence regarding their effects. This study aimed to assess the impact of PPIs on adverse events in cirrhotic patients. A comprehensive search was conducted using the Medline and Embase databases to identify relevant articles. Pooled hazard ratios (HRs) using DerSimonian and Laird random-effects model were calculated to evaluate the risk of adverse events such as long-term mortality, hepatic decompensation, hepatic encephalopathy (HE), spontaneous bacterial peritonitis (SBP), and overall infection in cirrhotic patients with PPI use. The analysis included 28 studies with 260,854 cirrhotic patients. The prevalence of PPI use among cirrhotic patients was 55.93%. The use of PPIs was not significantly associated with short-term mortality in cirrhotic patients. However, long-term mortality (HR 1.321, 95% CI 1.103-1.581, P = 0.002), decompensation (HR 1.646, 95% CI 1.477-1.835, P < 0.001), HE (HR 1.968, 95% CI 1.372-2.822, P < 0.001), SBP (HR 1.751, 95% CI 1.649-1.859, P < 0.001), and infection (HR 1.370, 95% CI 1.148-1.634, P < 0.001) were significantly associated with PPI use. Sensitivity analysis with prospective studies yielded similar results. PPIs should be reserved for appropriate indications at lowest effective dose for cirrhotic patients due to the potential harm.

Serum D-dimer and risk factors for nosocomial infections in cirrhotic patients presenting with upper gastrointestinal bleeding.

Serum D-dimer and risk factors for nosocomial infections in cirrhotic patients presenting with upper gastrointestinal bleeding.

PREDICTIVE FACTORS OF MORBIDITY ASSOCIATED WITH ESOPHAGEAL VARICEAL BLEEDING IN CHILDREN WITH PORTAL HYPERTENSION.

•Most data on the natural history of portal hypertension come from studies in adults. •The morbidity rate of upper gastrointestinal bleeding in children with portal hypertension tend to be underestimated. •This study showed the relevance of morbidity rates after variceal hemorrhage in pediatric patients, especially those with cirrhosis. •Patients with hemodynamic instability requiring blood transfusion or expansion on admission are at increased risk of complications secondary to upper gastrointestinal bleeding and should be closely monitored. Background - Most data on the natural history of portal hypertension come from studies in adults. The morbidity rate of upper gastrointestinal bleeding (UGIB) in children with portal hypertension has not been systematically characterized. Objective - To describe the morbidity and mortality of UGIB in pediatric patients with portal hypertension and identify predictive factors for the occurrence of its main complications. Methods - This retrospective study included pediatric patients with cirrhotic portal hypertension or with extrahepatic portal vein obstruction (EHPVO). Mortality and UGIB complications within a period of up to 6 weeks of the bleeding were investigated. To determine the predictive factors of morbidity, a multivariate analysis was performed using logistic regression; all results were considered significant at P<0.05. Results - A total of 86 patients (51.2% with EHPVO and 48.8% with cirrhosis) had 174 bleeding events. Ascites was the most common complication (43.1% of all cases), being more prevalent in patients with cirrhosis (P<0.001). Cirrhosis was a predictor of the occurrence of any morbidity (OR 20.3). The need for blood transfusion was predictor of at least one complication (OR 5.8), ascites (OR 7.2) and infections (OR 3.8) in the general group and at least one complication (OR 11.3) and ascites (OR 5.8) in cirrhotic patients. The need for expansion was a predictor of any morbidity (OR 4.6) and infections (OR 3.9) in the general group, in addition to being predictor of infection in cirrhotic patients (OR 5.4). There were no deaths from UGIB in the six weeks post-bleeding. Conclusion - The study showed the relevance of morbidity after UGIB in pediatric patients with portal hypertension, especially in those with cirrhosis. The patients with hemodynamic instability requiring blood transfusion or expansion on admission are at increased risk of complications related to upper gastrointestinal bleeding and should be closely monitored.

WED-368 - Impact of allelic HLA divergence on the risk of bacterial infections in cirrhotic patients awaiting liver transplantation

WED-368 - Impact of allelic HLA divergence on the risk of bacterial infections in cirrhotic patients awaiting liver transplantation

Transjugular intrahepatic Porto-systemic shunt positively influences the composition and metabolic functions of the gut microbiota in cirrhotic patients.

Cirrhosis and its complications may affect gut microbiota (GM) composition. Transjugular intrahepatic portosystemic shunt (TIPS) represents the most effective treatment for portal hypertension (PH). We aimed to evaluate whether TIPS placement modifies GM composition and metabolic function. A compositional and functional GM analysis was prospectively performed in 13 cirrhotic patients receiving TIPS. Patients receiving systemic or non-absorbable antibiotics for any indications were excluded. Fecal samples were collected before and three months after TIPS. GM was analyzed by 16S ribosomal RNA sequencing. Small- and medium-chain fatty acids (SCFAs and MCFAs, respectively) were measured by gas chromatography/mass spectrometry. TIPS placement resulted in a mean 48% reduction in portal-caval pressure gradient. No recurrence of PH related complications was observed. After TIPS, increased levels of Flavonifractor spp. (p=0.049), and decreased levels of Clostridiaceae (p=0.024), these latter linked to abdominal infections in cirrhotic patients, were observed. No differences were found in the SCFAs signature while analysis of MCFA profiles showed a decreased abundance of pro-inflammatory isohexanoic (p<0.01), 2-ethylhexanoic (p<0.01) and octanoic acids (p<0.01) after TIPS. Correction of PH following TIPS results in modifications of GM composition which could be potentially beneficial and reduces the levels of fecal pro-inflammatory MCFAs.

Incidence of Bacterial Infections Following Elective Endoscopic Variceal Ligation of Cirrhotic Patients in a Tertiary Care Hospital

Background: Esophageal varices are the consequence of portal hypertension which occurs mostly due to chronic liver disease and bleeding from rupture of this is one of the modes of death. Endoscopic variceal ligation (EVL) till date is recommended and most accepted method of treatment for prevention of both acute and chronic variceal bleeding of cirrhotic patients. Cirrhotic patients are vulnerable to have infection and it is expected to be augmented by any kind of intervention. Endoscopic variceal ligation being used as a modality of treatment, have the potentiality to cause infection in cirrhotic patients and empirical antibiotic prophylaxis is widely practiced in elective EVL but data regarding this is scanty and hence this study was undertaken in the Dept of Gastroenterology from January,2019 to December, 2019. Aims: To see the incidence of bacterial infection in cirrhotic patients following elective EVL. Methods: Fifty four patients were enrolled fulfilling the inclusion and exclusion criteria. Clinical evaluation and biochemical parameters including CBC, CRP, Blood culture, serum billirubin, serum albumin and PT were done. Fifty four EVL sessions were done and in each session, two to six bands were applied. Patients were followed up for 24 hrs to see any clinical signs of infection and CBC, CRP, Blood culture were done at 24 hrs of EVL. Results: Among fifty four subjects, male were 39(72.2%), and female were 15(27.8%) with mean age 46.62 ± 1.34. Eight patients were in Child Pugh A, 43 in Child B and 3 in Child C class ( Child Pugh classification is used to see prognosis in Cirrhosis comprising Encephalopathy, serum billirubin, serum albumin, PT and ascites) . Hepatitis B virus was found to be the most common etiology. Only one subject of Child B class had neutrophilllic leukocytosis with normal other parameters of infection. All other patients did not show any features of infection both clinically and biochemically. Conclusions: The incidence of bacterial infection was found to be an uncommon event following elective EVL in this study J Shaheed Suhrawardy Med Coll 2021; 13(2): 113-116

The multi-drug resistant organisms infections decrease during the antimicrobial stewardship era in cirrhotic patients: An Italian cohort study.

Bacterial infections represent a major cause of morbidity and mortality in cirrhotic patients. Our aim was to assess the incidence of bacterial infections, in particular due to multidrug-resistant organisms (MDROs) before and after the introduction of the antimicrobial stewardship program, "Stewardship Antimicrobial in VErona" (SAVE). In addition, we also analysed the liver complications and the crude mortality during the whole follow up. We analysed 229 cirrhotic subjects without previous hospitalization for infections enrolled at the University Verona Hospital from 2017 to 2019 and followed up until December 2021 (mean follow-up 42.7 months). 101 infections were recorded and 31.7% were recurrent. The most frequent were sepsis (24.7%), pneumonia (19.8%), spontaneous bacterial peritonitis (17.8%). 14.9% of infections were sustained by MDROs. Liver complications occurred more frequently in infected patients, and in case of MDROs infections with a significantly higher MELD and Child-Pugh score. In Cox regression analysis, mortality was associated with age, diabetes and bacterial infections episodes (OR 3.30, CI 95%: (1.63-6.70). Despite an increase in total infections over the past three years, a decrease in the incidence rate in MDROs infections was documented concurrently with the introduction of SAVE (IRD 28.6; 95% CI: 4.6-52.5, p = 0.02). Our study confirms the burden of bacterial infections in cirrhotic patients, especially MDROs, and the strong interconnection with liver complications. The introduction of SAVE decreased MDROs infections. Cirrhotic patients require a closer clinical surveillance to identify colonized patients and avoid the horizontal spread of MDROs in this setting.

Impact of multidrug resistance on the management of bacterial infections in cirrhosis.

Patients with cirrhosis have an increased risk of infection and differently from other complications, that over the years are improving in their outcomes, infections in cirrhotic patients are still a major cause of hospitalization and death (up to 50% in-hospital mortality). Infections by multidrug-resistant organisms (MDRO) have become a major challenge in the management of cirrhotic patients with significant prognostic and cost-related impact. About one third of cirrhotic patients with bacterial infections is infected with MDR bacteria and their prevalence has increased in recent years. MDR infections have a worse prognosis compared to infections by non-resistant bacteria because they are associated with lower rate of infection resolution. An adequate management of cirrhotic patients with infections caused by MDR bacteria depends on the knowledge of some epidemiological aspects, such as the type of infection (spontaneous bacterial peritonitis, pneumonia, urinary tract infection and spontaneous bacteremia), bacteriological profile of antibiotic resistance at each health care unit and site of infection acquisition (community acquired, healthcare associated or nosocomial). Furthermore, regional variations in the prevalence of MDR infections determine that the choice of empirical antibiotic therapy must be adapted to the local microbiological epidemiology. Antibiotic treatment is the most effective measure to treat infections caused by MDRO. Therefore, optimizing antibiotic prescribing is critical to effectively treat these infections. Identification of risk factors for multidrug resistance is essential to define the best antibiotic treatment strategy in each case and the choice of an effective empirical antibiotic therapy and its early administration is cardinal to reduce mortality. On the other hand, the supply of new agents to treat these infections is very limited. Thus, specific protocols that include preventive measures must be implemented in order to limit the negative impact of this severe complication in cirrhotic patients.

O03 Rapid Infection Diagnostics in Cirrhosis (RIDiC): a novel molecular-based approach to address the ever increasing challenge of antimicrobial resistant infections in decompensated cirrhosis and acute-on-chronic liver failure

Abstract Background Global prevalence of MDR infections in cirrhotic patients has risen to 34% and associates with worsening clinical trajectory and mortality (Fernandez J et al. 2019). A major unmet need in addressing the challenge of antimicrobial resistance (AMR) in cirrhosis is rapid pathogen diagnosis and antimicrobial resistance (AMR) (Patel VC et al. 2019). These can facilitate selection of more effective antibiotic therapy, reducing selection for MDR organisms. The Curetis Unyvero™ platform (CUp) employs multiplex PCR technology for pathogen and AMR gene detection from multiple bodily tissues and fluids requiring minimal pre- processing. The investigator-initiated pilot study aimed to assess the utility of this platform for hospitalized cirrhotic patients. Methods Ascitic fluid, bronchoalveolar lavage (BAL) and blood culture samples were obtained from hospitalized cirrhotic patients with acute decompensation (AD) or acute-on-chronic liver failure (ACLF), in whom there was clinical suspicion of infection. Samples were tested using the IAI (intra-abdominal infection) panel, HPN (hospital pneumonia) panel and BCU (blood culture) panel based on sample type available. Results were not shared with clinicians for decision-making. Data were compared with standard microbiology diagnostics. Results 31 samples from 21 patients were tested: ascites (25), BAL (4), blood culture (2). Time to positive culture result of all samples was reduced with CUp compared with standard microbiology (4.59 versus 73.5 h). CUp showed 100% specificity (12/12) and detected the same organism in 100% of cases (10/12). In 6 samples, CUp identified pathogens which were consistent with clinical evidence of spontaneous bacterial peritonitis and previous positive isolates which standard microbiological diagnostics failed to identify. AMR genes identified by the CUp correlated with AMR patterns reported by standard diagnostics in 100% (5/5) of cases. In 2 patients, broad-spectrum antibiotic therapy continued although the CUp supported infection resolution. Four patients in whom CUp screening was negative continued to receive antibiotics whilst awaiting negative standard cultures that arrived 72 h later. CUp did not identify an Aspergillus species in one BAL sample as this is not part of the BAL panel. Conclusions These preliminary data suggest CUp results are compatible with standard laboratory diagnostics. The CUp may be utilized for earlier infection diagnosis and improve the targeting and de-escalation of antimicrobial therapy in AD and ACLF. These are crucial components in enhancing antibiotic stewardship strategies and to reduce MDR infections (Figure 1). Further work is however required to evaluate cost implications, validation and impact on clinical outcomes and mortality in cirrhosis.

Učestalost Helicobacter pylori infekcije i antibiotska rezistencija kod bolesnika sa akutnim dekompenzacijama jetre

Introduction: Helicobacter pylori (H. pylori) infection is a global healthcare challenge. In its course of infection, Helicobacter pylori infection leads to a systemic increase of post-inflammatory cytokines and can have extra gastric manifestations, affecting the worsening of metabolic and cardiovascular diseases and endangering normal liver function, especially when liver cirrhosis is present. Aim: The aim of this study was to examine the frequency of H. pylori infection in patients with cirrhosis of the liver in stage AD or ACLF. The frequency of antibiotic resistance to clarithromycin and fluoroquinolones was also investigated. Material and methods: A prospective study with 45 patients was conducted which included both sexes. Samples of gastric mucosa were taken from all patients included in the study during the upper endoscopy and were sent to the Institute of Microbiology of the Faculty of Medicine University of Belgrade. A molecular method, Polymerase chain reaction (PCR) was used to detect H. pylori and mutations responsible for resistance to clarithromycin and fluoroquinolones. Results: The presence of H. pylori infection was registered in 15 decompensated patients (33.33%), while 30 (66.67%) were negative. In H. pylori positive patients, PCR detection of genotypes responsible for antibiotic resistance revealed clarithromycin resistance in 11 patients (73.33%), while fluoroquinolone resistance was detected in 7 patients (46.66%). In 6 patients (40.0%), an associated resistance to clarithromycin and fluoroquinolones was found. Conclusion: The H. pylori infection in cirrhotic patients with acute decompensation or ACLF has no significant effect on the severity of the clinical condition, elevated laboratory parameters and survival. Resistance rates to fluoroquinolones and clarithromycin or both antibiotics are high in decompensated patients with cirrhosis. There is a need to increase awareness of the rational use of antibiotics based on further investigations.

Evaluation of the early response to empirical treatment and its association with cultures in patients with spontaneous bacterial peritonitis (SBP)

Spontaneous bacterial peritonitis (SBP) is a frequent complication in cirrhotic patients; the start of treatment is empirical and is adjusted with cultures. The antibiotic of choice is cephalosporins, which have reported high resistance. Improving SBP conditions has an impact on the evolution of patients. This study aimed to assess the early treatment response of SBP treated with empiric antibiotics. Patients with a diagnosis of cirrhosis and SBP were included who underwent diagnostic paracentesis and paracentesis thee days after starting treatment; a decrease in ascites cellularity was evaluated as a criterion of response to treatment and the culture report. Descriptive and inferential statistics were performed. The trial was approved by the research ethics committee, and informed consent was obtained. Six hundred twenty-one patients diagnosed with liver cirrhosis were included. Forty-seven met the criteria for SBP. Thirty men (63%) and 17 women (36%); the causes of cirrhosis were: Alcohol 25 (53%), MAFLD 9 (19%), autoimmune 2 (4%) and unknown 10 (21%) By Child-Pugh B 12 (25%) and 35 (74%) C. 89% (42) received cephalosporins, of which 78% (33) responded to treatment (figure 1), of which 66% (23) did not isolated agent in culture, only 31% (10) developed bacterial agent, mainly E. coli (60%). SBP is the most common cause of infections in cirrhotic patients, with a high impact on morbidity and mortality. Despite reports of resistance to cephalosporins in our population, the response to empirical treatment with cephalosporins is still optimal. The resources used in this study were from the hospital without any additional financing The authors declare no potential conflicts of interest.

Is There an Association between Variceal Bleed and Helicobacter pylori Infection in Cirrhotic Patients with Portal Hypertension?: A prospective cohort study.

This study aimed to determine the association between Helicobacter pylori infection and variceal bleeding as well as rebleeding in cases of cirrhosis with portal hypertension. This prospective cohort study included patients with bleeding oesophageal varices and was conducted at the Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India, from August 2016 to July 2018. A total of 190 patients were assessed for eligibility, of which 159 patients were included in this study. Among the 159 patients, 124 (78.0%) had alcohol-related liver disease and eight had hepatitis B virus-related liver disease. Seven patients with varices had bled neither at presentation nor during the follow-up period. A total of 78 (49.1%) patients were H. pylori infected. The primary outcome, which was correlation between prevalence of H. pylori and the incidence of bleeding/rebleeding from varices as well as encephalopathy found that patients with oesophageal varices (adjusted risk [AR] = 0.714) and H. pylori infection (AR = 0.682) had a lower risk of variceal rebleeding. Among H. pylori-negative patients, pepsinogen I was higher in patients with rebleeding (30.7 versus 14.4 ng/mL; P <0.001). The secondary outcome, which was correlation of the site of bleeding with H. pylori infection and the association of the ratio of pepsinogen I/II with bleeding showed that among H. pylori-positive patients, the ratio of pepsinogen I/II was higher in patients with rebleeding (2.9 versus 1.3 ng/mL; P = 0.023). H. pylori infection was associated with a lower risk of rebleeding in cases of cirrhosis with portal hypertension. Irrespective of the status of the H. pylori infection, rebleeding was associated with increased levels of gastric acid output, as demonstrated by the level of pepsinogen.

Ascitic calprotectin and lactoferrin for detection of spontaneous bacterial peritonitis: a systematic review and meta-analysis.

BackgroundSpontaneous bacterial peritonitis (SBP) is a common bacterial infection in cirrhotic patients associated with a high mortality rate. Prompt diagnosis and early antibiotic administration are crucial in minimizing adverse outcomes. Although detection of ≥250 polymorphonuclear leukocytes (PMN) in ascitic fluid is the current gold standard to diagnose SBP, consideration for rapid detection with biomarkers is warranted.MethodsA literature search for studies evaluating ascitic calprotectin and lactoferrin for detection of SBP was performed using PubMed, Embase, Scopus, Google Scholar, Cochrane library, and Clinical Trial Registries. Summary sensitivity, specificity, log diagnostic odds ratio (LDOR), and area under the summary receiver operating curve (AUC) were calculated.ResultsIn total, 12 and 13 studies evaluated ascitic calprotectin and lactoferrin, respectively, for detection of SBP. Summary sensitivity, specificity, and LDOR for calprotectin were 0.942 (95% CI, 0.916, 0.967), 0.860 (95% CI, 0.799, 0.935), and 4.250 (95% CI, 3.504, 4.990), respectively. AUC for calprotectin was 0.91. Summary sensitivity, specificity, and LDOR for lactoferrin were 0.954 (95% CI, 0.930, 0.979), 0.890 (95% CI, 0.836, 0.945), and 4.630 (95% CI, 3.800, 5.452), respectively. AUC for lactoferrin was 0.958.ConclusionsThe overall performance of ascitic calprotectin and lactoferrin was substantial, potentially serving as a screening tool or an alternative to manual cell count. However, a variety of manufacturers, cut-off values, and significant heterogeneity between studies should be noted. Point-of-care testing for calprotectin and lactoferrin may resolve disadvantages associated with the current methods. Future studies on this topic are, therefore, needed.

The Role of Presepsin and Procalcitonin in Early Diagnosis of Bacterial Infections in Cirrhotic Patients with Acute-on-Chronic Liver Failure.

Background and Objectives: Bacterial infections represent one of the most frequent precipitating events of acute-on-chronic liver failure (ACLF) in a patient with liver cirrhosis (LC). Early diagnosis and treatment could influence the ACLF reversal rate and decrease the mortality rate in these patients. The study aimed to evaluate the role of presepsin, C-reactive protein (CRP), and procalcitonin (PCT) in the early diagnosis of bacterial infections in patients with LC and ACLF, defined according to the European Association for the Study of the Liver-Chronic Liver Failure Consortium (EASL-CLIF) criteria. Material and Methods: We performed a prospective observational study including all consecutive cirrhotic patients with ACLF admitted to our tertiary university center. The patients were follow-up until discharge. All patients were screened for infection at admission, and we included patients with community-acquired or healthcare-associated bacterial infections. Results: In this study, we included 153 patients with a median age of 60 years, of whom 65.4% were male. Infections were diagnosed in 71 patients (46.4%). The presepsin, CRP, and PCT levels were higher in patients with infections than in those without infections (p < 0.001, p = 0.023, and p < 0.001, respectively). The ROC analysis results demonstrated that the best cut-offs values for infections diagnosis were for presepsin 2300 pg/mL (sensitivity of 81.7%, specificity of 92.7%, AUROC 0.959, p < 0.001), CRP 5.3 mg/dL (sensitivity of 54.9%, specificity of 69.6%, AUROC 0.648, p = 0.023), and PCT 0.9 ng/mL (sensitivity of 80.3%, specificity of 86.6%, AUROC 0.909, p < 0.001). Presepsin (OR 3.65, 95%CI 1.394–9.588, p = 0.008), PCT (OR 9.79, 95%CI 6.168–25.736, p < 0.001), and MELD score (OR 7.37, 95%CI 1.416–18.430, p = 0.018) were associated with bacterial infections in patients with ACLF. Conclusion: Presepsin level ≥2300 pg/mL and PCT level ≥0.9 ng/mL may be adequate non-invasive tools for the early diagnosis of infections in cirrhotics with ACLF.

Alterations of gut microbiota in cirrhotic patients with spontaneous bacterial peritonitis: A distinctive diagnostic feature.

BackgroundSpontaneous bacterial peritonitis (SBP) is a severe infection in cirrhotic patients that requires early diagnosis to improve the long-term outcome. Alterations in the gut microbiota have been shown to correlate with the development and progression of liver cirrhosis. However, the relationship between SBP and gut microbiota remains unknown.MethodsIn this study, we applied 16S rRNA pyrosequencing of feces to ascertain possible links between the gut microbiota and SBP. We recruited 30 SBP patients, 30 decompensated cirrhotic patients without SBP (NSBP) and 30 healthy controls. Metagenomic functional prediction of bacterial taxa was achieved using PICRUSt. ResultsThe composition of the gut microbiota in the SBP patients differed remarkably from that in the NSBP patients and healthy individuals. The microbial richness was significantly decreased, while the diversity was increased in the SBP patients. Thirty-four bacterial taxa containing 15 species, mainly pathogens such as Klebsiella pneumoniae, Serratia marcescens and Prevotella oris, were dominant in the SBP group, while 42 bacterial taxa containing 16 species, especially beneficial species such as Faecalibacterium prausnitzii, Methanobrevibacter smithii and Lactobacillus reuteri, were enriched in the NSBP group. Notably, we found that 18 gene functions of gut microbiota were different between SBP patients and NSBP patients, which were associated with energy metabolism and functional substance metabolism. Five optimal microbial markers were determined using a random forest model, and the combination of Lactobacillus reuteri, Rothia mucilaginosa, Serratia marcescens, Ruminococcus callidus and Neisseria mucosa achieved an area under the curve (AUC) value of 0.8383 to distinguish SBP from decompensated cirrhosis.ConclusionsWe described the obvious dysbiosis of gut microbiota in SBP patients and demonstrated the potential of microbial markers as noninvasive diagnostic tools for SBP at an early stage.

Increased rate of enteric bacteria as cause of periprosthetic joint infections in patients with liver cirrhosis

IntroductionPeriprosthetic joint infections (PJI) are a major complication in joint-arthroplasty. Rifampicin is often used as an additional agent to treat PJI, because it penetrates bacterial biofilms. However, rifaximin, belonging to the same antibiotic class as rifampicin, is frequently used to prevent episodes of hepatic encephalopathy in patients with cirrhosis and may induce resistance to rifampicin. The aim of this study was to examine the microbial pattern of periprosthetic joint infections in cirrhotic patients and to test the hypothesis that intake of rifaximin increases the rate of resistance to rifampicin in periprosthetic joint infections.MethodsA cohort of cirrhotic patients and PJI (n = 25) was analysed on the characteristics of bacterial isolates from sonication and tissue analysis. In a second step a subgroup analysis on the development of rifampicin resistant bacterial specimens, depending on the intake of rifaximin (8 rifaximin intake patients vs. 13 non rifaximin intake patients) was performed.ResultsIntestinal bacteria were found in 50% of the specimens, which was significantly more frequent than in a control cohort. By comparison of the single bacterial isolates, rifampicin resistance was detected in 69.2% (9/13) of the rifaximin-intake samples. In contrast, the non-rifaximin-intake isolates only were resistant to rifampicin in 22.2% (4/18) of the cases (p = 0.01). The odds ratio for developing a rifampicin-resistance through rifaximin intake was calculated as OR = 13.5.ConclusionPeriprosthetic joint infections have a high incidence of being caused by enteric bacteria in cirrhotic patients. Due to this change in microbial pattern and the innate resistance to rifampicin of most of gram-negative bacteria, the therapy with rifampicin should be carefully considered. The association between the use of rifaximin and developed resistance to rifampicin has a major impact on the treatment of PJI.

ANALYSIS OF HEALTHCARE ASSOCIATED AND HOSPITAL ACQUIRED INFECTIONS IN CRITICALLY ILL PATIENTS WITH CIRRHOSIS.

Bacterial infections occur in 43-59% of cirrhotic patients admitted to the intensive care unit with impact in morbidity and mortality. An increase in the frequency of multidrug-resistant (MDRO) and extensively drug-resistant (XDRO) organisms has been described in bacterial infections in cirrhotic patients with an adverse impact on survival. To characterize community-acquired (CA), healthcare-associated (HCA), and hospital-acquired (HA) infections in cirrhotic patients and their impact in the occurrence of adverse outcomes. This study included all cirrhotic patients admitted in an intensive care unit specialized in liver and gastrointestinal diseases in Brazil between January 2012 and June 2018. Frequency and topography of infections were retrospectively evaluated, as well as the frequency of MDRO and XDRO organisms, and their impact in occurrence of acute kidney injury, hepatorenal syndrome, acute-on-chronic liver failure, sepsis and mortality. A total of 374 infections were observed and classified as CA (22%), HCA (34%) and hospital-acquired (44%). Eighty-nine (54%) episodes of hospital-acquired infections were second infections. Spontaneous bacterial peritonitis (32%) and urinary tract infection (23%) were the most common infections. Culture-proven infections were positive in 61% of the cases, mainly gram-negative bacteria (73%). Acute kidney injury, hepatorenal syndrome and sepsis were observed, respectively, in 48%, 15% and 53% of the cases. MDRO and XDRO were seen, respectively, in 35% and 16%, mainly in HCA (48% vs 26% in CA infections, P=0.02) and hospital-acquired (58% vs 26% in CA infections, P=0.0009). Adverse outcomes were more frequently observed in subjects with hospital-acquired infections when compared to HCA and CA infections. Hospital-acquired, HCA and second infections were independently associated with in-hospital mortality. Hospital-acquired, HCA and second infections are increasingly associated with either MDRO and/or XDRO and are independent predictors of in-hospital mortality. Their recognition and proper selection of appropriate empiric antibiotic regimens are important measures to reduce in-hospital mortality.