Culture-Positive Spontaneous Ascitic Infection in Patients with Acute Decompensated Cirrhosis: Multidrug-Resistant Pathogens and Antibiotic Strategies

다국어 초록 (Multilingual Abstract)

Purpose: This study investigated multidrug-resistant (MDR) pathogens and antibiotic strategies of culture-positive spontaneousascitic infection (SAI) in patients with acute decompensated cirrhosis.
Materials and Methods: We retrospectively analyzed 432 acute decompensated cirrhotic patients with culture-positive SAI from11 teaching hospitals in China (January 2012 to May 2018). A Cox proportional hazards model analysis was conducted to identifyindependent predictors of 28-day mortality.
Results: A total of 455 strains were isolated from 432 ascitic culture samples. Gram-negative bacteria (GNB), gram-positive bacteria(GPB), and fungi caused 52.3, 45.5, and 2.2% of all SAI episodes, respectively. Episodes were classified as nosocomial (41.2%), healthcare-related (34.7%), and community-acquired (24.1%). Escherichia coli (13.4%) and Klebsiella pneumoniae (2.4%) were extendedspectrumβ-lactamase producing isolates. The prevalence of methicillin-resistant Staphylococcus aureus was 1.1%. Ceftazidime,cefepime, aztreonam, and amikacin were recommended as first-line antibiotics agents for non-MDR GNB infections; piperacillin/tazobactam and carbapenems for MDR GNB in community-acquired and healthcare-related or nosocomial infections, respectively;and vancomycin or linezolid for GPB infections, regardless of drug-resistance status. Multivariate analysis revealed days ofhospital stay before SAI, upper gastrointestinal bleeding, white blood cell count, alanine aminotransferase, serum creatinine concentration,total bilirubin, and international normalized ratio as key independent predictors of 28-day mortality.
Conclusion: MDR pathogens and antibiotic strategies were identified in patients with acute decompensated cirrhosis with culture-positive SAI, which may help optimize therapy and improve clinical outcomes.

참고문헌 (Reference)

1 Salerno F, "Therapeutic strategies and emergence of multiresistant bacterial strains" 5 (5): S45-S51, 2010

2 Salerno F, "The impact of infection by multidrug-resistant agents in patients with cirrhosis. A multicenter prospective study" 37 : 71-79, 2017

3 Tsung-Hsing Hung, "The Effect of the First Spontaneous Bacterial Peritonitis Event on the Mortality of Cirrhotic Patients with Ascites: A Nationwide Population-Based Study in Taiwan" 거트앤리버 소화기연관학회협의회 10 (10): 803-807, 2016

4 Dellinger RP, "Surviving Sepsis Campaign : international guidelines for management of severe sepsis and septic shock : 2008" 36 : 296-327, 2008

5 Kaymakoglu S, "Spontaneous ascitic infection in different cirrhotic groups : prevalence, risk factors and the efficacy of cefotaxime therapy" 9 : 71-76, 1997

6 Ariza X, "Risk factors for resistance to ceftriaxone and its impact on mortality in community, healthcare and nosocomial spontaneous bacterial peritonitis" 56 : 825-832, 2012

7 Schwabl P, "Risk factors for development of spontaneous bacterial peritonitis and subsequent mortality in cirrhotic patients with ascites" 35 : 2121-2128, 2015

8 CLSI, "Performance standards for antimicrobial susceptibility testing. 28th ed. CLSI supplement M100" Clinical and Laboratory Standards Institute 2018

9 Goossens H, "Outpatient antibiotic use in Europe and association with resistance : a cross-national database study" 365 : 579-587, 2005

10 Magiorakos AP, "Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria : an international expert proposal for interim standard definitions for acquired resistance" 18 : 268-281, 2012

11 Fernández J, "Multidrug-resistant bacterial infections in patients with decompensated cirrhosis and with acute-on-chronic liver failure in Europe" 70 : 398-411, 2019

12 Friedrich K, "Microbiology and resistance in first episodes of spontaneous bacterial peritonitis : implications for management and prognosis" 31 : 1191-1195, 2016

13 Leber B, "Infectious complications of acute and chronic liver disease" 33 : 80-95, 2012

14 Arvaniti V, "Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis" 139 : 1246-1256, 2010

15 Alexopoulou A, "Increasing frequency of gram-positive cocci and gram-negative multidrug-resistant bacteria in spontaneous bacterial peritonitis" 33 : 975-981, 2013

16 Tandon P, "High prevalence of antibiotic-resistant bacterial infections among patients with cirrhosis at a US liver center" 10 : 1291-1298, 2012

17 Piano S, "Epidemiology and effects of bacterial infections in patients with cirrhosis worldwide" 156 : 1368-1380, 2019

18 European Association for the Study of the Liver, "EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis" 53 : 397-417, 2010

19 European Association for the Study of the Liver, "EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis" 69 : 406-460, 2018

20 Rimola A, "Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis : a consensus document. International Ascites Club" 32 : 142-153, 2000

21 Kim JJ, "Delayed paracentesis is associated with increased inhospital mortality in patients with spontaneous bacterial peritonitis" 109 : 1436-1442, 2014

22 Cheong HS, "Clinical significance and outcome of nosocomial acquisition of spontaneous bacterial peritonitis in patients with liver cirrhosis" 48 : 1230-1236, 2009

23 Ning NZ, "Clinical and bacteriological features and prognosis of ascitic fluid infection in Chinese patients with cirrhosis" 18 : 253-, 2018

24 Garcia-Tsao G, "Bacterial infections in cirrhosis" 18 : 405-406, 2004

25 Oey RC, "Bacterascites : a study of clinical features, microbiological findings, and clinical significance" 38 : 2199-2209, 2018

26 Karvellas CJ, "Appropriate and timely antimicrobial therapy in cirrhotic patients with spontaneous bacterial peritonitis-associated septic shock : a retrospective cohort study" 41 : 747-757, 2015

27 Lutz P, "Antibiotic resistance in healthcare-related and nosocomial spontaneous bacterial peritonitis" 47 : 44-52, 2017

28 Ricart E, "Amoxicillin-clavulanic acid versus cefotaxime in the therapy of bacterial infections in cirrhotic patients" 32 : 596-602, 2000

29 Moreau R, "Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis" 144 : 1426-1437, 2013