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

Abstract

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.

Review article: Evaluation and care of the critically ill patient with cirrhosis

“…MDR infections are risk factors for portal vein thrombosis as well as short and medium-term mortality among patients with liver cirrhosis. 115,117,119,[122][123][124] ACLF development is more frequent with nosocomial infections and following empirical antibiotic treatment failure. 108 Additional factors associated with increased in-hospital mortality in these patients include the requirement for pressors, acute renal failure and coma.…”

“…MDR infections are risk factors for portal vein thrombosis as well as short and medium‐term mortality among patients with liver cirrhosis 115,117,119,122–124 . ACLF development is more frequent with nosocomial infections and following empirical antibiotic treatment failure 108 .…”

Human Amniotic MSC Response in LPS-Stimulated Ascites from Patients with Cirrhosis: FOXO1 Gene and Th17 Activation in Enhanced Antibacterial Activation

“…Antibiotic resistance is a major challenge in the management of SBP, and an alternative therapeutic strategy able to immune-modulate and reduce infection susceptibility needs to be found urgently [ 14 , 15 ].…”