Bacterial infections in acute variceal hemorrhage despite antibiotics—a multicenter study of predictors and clinical impact

Abstract

Background and aims: Current guidelines recommend antibiotic prophylaxis in all patients presenting with cirrhosis and acute variceal hemorrhage (AVH). We aimed to evaluate the characteristics and clinical impact of ''early'' infections (developing within 14 days) of AVH in a real-world setting. Methods: We analyzed retrospective data from a cohort of 371 adult patients with cirrhosis and AVH all of whom had received antibiotic prophylaxis (74% men; mean age 56 years), admitted to tertiary care hospitals in Edmonton, Alberta, Canada, and Barcelona, Spain. Sensitivity analyses were presented for culture-positive (confirmed) infections. Results: The mean MELD was 16. Fifty-two percent of patients received quinolones, 45% third-generation cephalosporins and 3% other antibiotics. Fourteen percent (51/371) developed an infection within 14 days of AVH. Seventy-five percent of infections were culture positive and occurred at a mean of six days from AVH. When all infections were considered, respiratory infections were the most common (53%) followed by urinary tract infections (17%) and bacteremia (16%). Resistance patterns differed between countries. Outpatient antibiotic prophylaxis (OR 5.4) and intubation (OR 2.6) were independent predictors of bacterial infection. Bacterial infection (OR 2.6) and the MELD (OR 1.2) were independent predictors of six-week mortality. Conclusions: Early bacterial infections develop in 14% of cirrhotic patients with AVH despite antibiotic prophylaxis, and have a negative impact on six-week mortality. Intubation and outpatient antibiotic prophylaxis are associated with increased risk of early bacterial infections. Patients at risk should be followed closely with prompt infection workup and local antibiogrambased expansion of antibiotic therapy in case of clinical decline.

Bacterial infections in patients with acute variceal bleeding in the era of antibiotic prophylaxis

“…Our study confirms that bacterial infection occurs in around one fifth (~19%) of patients with AVB despite antibiotic prophylaxis. This residual rate of bacterial infection is similar to the 15% rate reported in other recent series of patients with AVB 8,17 and to the 14% rate detected in a meta-analysis by Bernard et al addressing the efficacy of antibiotic prophylaxis in preventing bacterial infection in patients with cirrhosis. 1 These figures reflect the similar global efficacy of antibiotic prophylaxis over the last two decades.…”

“…Respiratory infection accounted for almost 50% of all the infections observed in our patients, similar to rates reported by other recently published series. 17 In contrast, spontaneous bacterial peritonitis, which was the most frequent infection encountered J o u r n a l P r e -p r o o f in the pre-prophylaxis era, only represented 8% of infections in our series, and likely reflects the high efficacy of current prophylaxis against gut microbia. Bacterial, and more specifically, respiratory infection was an early event during hospitalization occurring at a median of 3 days, which strongly indicates an association between its appearance and the maneuvers used within the first hours of admission.…”

Development and Validation of a Prognostic Model for One-year Survival of Cirrhosis Patients with First-ever Spontaneous Bacterial Peritonitis

“…31,32 Hyponatremia causes cellular edema, increased intestinal mucosal permeability, bacterial translocation, and also leads to SBP. 33 Moreover, hyponatremia causes cerebral edema, leading to decreased blood volume and induction of hepatorenal syndrome. Journal of Clinical and Translational Hepatology 2021 vol.…”

The effect of variceal bleeding on T-cell subsets in patients with cirrhosis

“…Approximately 20% of patients with cirrhosis who develop acute variceal bleeding are affected by subsequent bacterial infections within 48 h after the onset of bleeding. Bacterial infections occur more frequently in cirrhotic patients admitted with gastrointestinal bleeding than for other causes [4,5]. During acute variceal hemorrhage, prophylactic antibiotics are mainstay of treatment [6].…”