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

Abstract

Background and purpose 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. Methods 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). Results 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). Conclusions 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.

Pulmonary Bacterial Infection and Liver Cirrhosis: Current Status and Treatment

“…Another study showed that cirrhotic patients with MDR bacterial infections had increased model of end-stage liver disease (MELD) scores (12.6 ± 6.1vs 8.7 ± 2.4, P = 0.05) and Child-Pugh scores (41 vs 12, P < 0.001) compared with patients with non-MDR bacterial infections. 19 MELD-Na scores (24.6 ± 4.8 vs 19.2 ± 5.3, P < 0.001) and chronic liver failure consortium ACLF scores (49.6 ± 4 vs 41.7 ± 3.4, P < 0.001) were also significantly higher in patients with MDR bacterial infections, and MDR bacteremia was more common in patients with more severe liver disease ( P = 0.008). 31 Compared to pneumonia patients without cirrhosis, pneumonia patients with cirrhosis are usually more susceptible to bacteremia and often have higher pneumonia severity index scores.…”

“…Zhao et al 28 found that among cirrhotic patients infected with MDR bacteria, increased 28-day mortality was mainly attributed to MRSA (HR, 2.964; 95% CI, 1.175–7.478; P = 0.021). Another study showed that cirrhotic patients with MDR bacterial infections had increased model of end-stage liver disease (MELD) scores (12.6 ± 6.1vs 8.7 ± 2.4, P = 0.05) and Child-Pugh scores (41 vs 12, P < 0.001) compared with patients with non-MDR bacterial infections 19 . MELD-Na scores (24.6 ± 4.8 vs 19.2 ± 5.3, P < 0.001) and chronic liver failure consortium ACLF scores (49.6 ± 4 vs 41.7 ± 3.4, P < 0.001) were also significantly higher in patients with MDR bacterial infections, and MDR bacteremia was more common in patients with more severe liver disease ( P = 0.008) 31 …”

“…According to a global study of bacterial infections in patients with liver cirrhosis, 11 bacterial pneumonia is one of the most common infections, affecting 8.8%-28.2% of cirrhotic patients. [11][12][13][14][15][16][17][18][19] Bacterial pneumonia acquired outside of the hospital setting is termed community-acquired pneumonia (CAP), while bacterial pneumonia acquired after at least 48 hours of hospitalization is defined as hospital-acquired pneumonia (HAP) or nosocomial pneumonia. 20 Most cases of bacterial pneumonia are CAP (48%), while the proportion of HAP is 26%.…”

“…Pneumonia caused by MDR bacteria has been associated with prolonged hospital stay and elevated mortality in cirrhotic patients. 19,28,29 Cox regression analysis showed that mortality was higher in patients infected by MDR bacteria (OR, 4.45; 95% CI, 1.131-10.528). 19 Similarly, Gupta et al 18 found that MDR infection was an independent predictor for 28-day mortality in acute decompensation of cirrhosis (HR, 1.263; 95% CI, 1.07 -2.19; P < 0.007).…”

“…19,28,29 Cox regression analysis showed that mortality was higher in patients infected by MDR bacteria (OR, 4.45; 95% CI, 1.131-10.528). 19 Similarly, Gupta et al 18 found that MDR infection was an independent predictor for 28-day mortality in acute decompensation of cirrhosis (HR, 1.263; 95% CI, 1.07 -2.19; P < 0.007). Furthermore, sepsis (54.9% vs 13%) and lethal sepsis are significantly more frequent in patients with carbapenem-resistant GNB infections.…”