The characteristics of and prognosis for nosocomial spontaneous bacterial peritonitis (SBP) and bacteremia were examined in a prospective study that included data from 194 consecutive episodes of SBP and 119 episodes of bacteremia, 93.3% of which were nosocomial, in 200 hospitalized cirrhotic patients. Gram-positive pathogens were predominant (70% of the total) among isolates from nosocomial infections; the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) was 24.8%. Nosocomial and staphylococcal infections were associated with a higher mortality rate than were community-acquired infections (P=.0255) and nonstaphylococcal infections (P<.001), respectively. In comparison with non-MRSA infections, MRSA infections were more likely to recur and occurred in a greater number of sites other than ascitic fluid and blood (P=.0004). Older age (P=.0048), higher Child-Pugh score (P=.0011), and infection with staphylococci (P=.0031) were independently associated with a higher mortality rate. The emergence of MRSA is important because of the recurrence and poor outcome associated with infection with such organisms.

We performed a 5-year retrospective study to evaluate the effect of long-term administration of norfloxacin on the epidemiology of severe hospital-acquired infections in patients with advanced cirrhosis. Sixty-seven episodes of spontaneous bacterial peritonitis and 60 episodes of bacteremia occurred in, respectively, 46 patients (group 1a) and 52 patients (group 1b) who did not receive norfloxacin, while 23 and 17 episodes occurred in 21 patients (group 2a) and 17 patients (group 2b) during or within 10 days after long-term administration of norfloxacin. Enterobacteriaceae were more prevalent in groups 1a and 1b than in the other two groups (P < .001 and P < .01, respectively); conversely, staphylococci were more prevalent in groups 2a and 2b (P < .001 and P < .05, respectively). The rate of staphylococcal resistance to methicillin was 53.6% in groups 1a and 1b and 77.3% in groups 2a and 2b. We conclude that long-term norfloxacin administration to cirrhotic patients reduces the risk of gram-negative infections but increases the risk of severe hospital-acquired staphylococcal infections and of high-level resistance to antibiotics.

The prevalence of oral candidiasis and its association with malnutrition in terms of protein-energy malnutrition and mineral and vitamin depletion were evaluated in ninety-seven hospitalised older adults aged 82·1 (SD 8·6) years. Patients underwent a complete oral examination with microbiological investigation on admission to our geriatric rehabilitation unit. Patients were assessed nutritionally by evaluation of dietary intake and measurement of anthropometric variables, serum nutritional proteins, ferritin, Zn, folate, vitamins B 12 and C. The prevalence of oral candidiasis was 37 % (n 36); the proportion of patients with BMI , 20 kg/m 2 was 32 % (n 31). The nutritional status of the population was studied by comparing two groups defined according to the absence (group I; n 61) or presence (group II; n 36) of oral candidiasis. The two groups did not differ on the basis of BMI and mid-arm circumference. However, group II had a smaller leg circumference, lower daily energy and protein intakes, lower albumin and transthyretin levels. Patients successfully treated with fluconazole increased their intake on day 30. The proportion of patients with hypozincaemia (,12·5 mmol/l) and vitamin C deficiency (, 0·7 mg/l) was higher in group II. Treatment with antibiotics, poor oral hygiene, denture wearing, and vitamin C deficiency appeared as the most significant independent risk factors associated with oral candidiasis. The present findings show that oral candidiasis appears to be related to malnutrition and results in mucosal lesions that have a negative impact on energy intake, which may subsequently worsen nutritional status.

We carried out quantitative culturing of stools from 31 hospitalized alcoholic patients with cirrhosis and ascites, before treatment with 400 mg of norfloxacin per day, weekly for the first month, and then every 2 weeks thereafter for 15 to 229 days (median, 54 days). Members of the family Enterobacteriaceae virtually disappeared from the stools (<102/g), but treatment had little effect on enterococci. No selection of resistant organisms occurred in 15 patients, but the remaining 16 patients developed fecal organisms resistant to fluoroquinolones between days 14 and 43 of treatment (median, 25 days). Staphylococcus aureus was isolated four times, coagulase-negative Staphylococcus spp. were isolated six times, Citrobacter freundii was isolated four times, Enterobacter cloacae was isolated three times, KlebsieUla oxytoca was isolated twice, Proteus rettgeri was isolated once, and untypeable streptococci were isolated six times. Some isolates persisted, while others were transient (one to seven consecutively positive cultures). The MICs of four quinolones (nalidixic acid, norfloxacin, ofloxacin, and ciprofloxacin) were determined by use of experimental microwell strips (ATB CMI; Biomerieux S.A.). All the strains isolated before treatment were susceptible to the four quinolones, with low MICs, whereas those isolated during norfloxacin treatment were highly resistant. Long-term norfloxacin administration thus carries a risk of disturbing the bacterial ecology in these patients, suggesting that digestive decontamination should no longer be prescribed routinely to cirrhotic patients with ascites.

We assessed the prevalence of carriage of methicillin-resistant Staphylococcus aureus (MRSA) in anterior nares and stools, and of third-generation cephalosporin resistant enterobacteriaceae and non-fermenting gram-negative bacilli (RE/RNF) in stools of 748 hospitalized long-stay cirrhotic patients. We also evaluated the consequences of carriage on the epidemiology of hospital-acquired spontaneous bacterial peritonitis, bacteraemia and urinary tract infection (UTI) in these patients. The prevalence of carriage of MRSA and RE/RNF was 16.7% and 14.7% respectively. Whereas RE/RNF carriage did not lead to an increased risk of infection due to RE/RNF, the overall risk of infections caused by MRSA was more than tenfold higher in MRSA carriers. MRSA and RE/RNF carriers had received prior antibiotic therapy to a greater extent than non-carriers (P < 0.001) and MRSA carriers had received prior norfloxacin prophylaxis to a greater extent than the two other groups (P < 0.02). The mortality rate during hospital stay was higher in MRSA and RE/RNF carriers than in non-carriers (P < 0.001). Pugh score (P < 0.0001), age (P < 0.0001), MRSA carriage (P = 0.0018) and bacteraemia (P = 0.0017) were associated independently with mortality. MRSA carriage in hospitalized cirrhotic patients leads to the emergence of infections due to this strain, mainly SBP and bacteraemia. Prior antibiotic therapy and norfloxacin prophylaxis increase the risk of carriage of MRSA.