One-Third of Bacterial Infections in Cirrhosis Patients Around the World are Multidrug-Resistant

A worldwide study initiated to investigate the epidemiology and outcomes of bacterial infections in hospitalized patients with liver cirrhosis has reported a prevalence of multi-drug-resistant (MDR) bacteria of 34% and significant regional differences in the risk of developing a multi-drug-resistant infection. Research teams from 46 centers across the world collaborated in this international study, which was promoted by the International Club of Ascites, the final results of which were presented today at The International Liver Congress™ 2018 in Paris.

Bacterial infections are common in patients with cirrhosis and are one of the most important causes of liver-related complications, progression of liver failure, and mortality in these patients. Multi-drug-resistant bacteria have emerged as a significant challenge in many countries, and infections caused by these bacteria are associated with a particularly poor prognosis in patients with cirrhosis.

The study presented today in Paris included 1,302 hospitalized patients with cirrhosis and bacterial or fungal infections in North or South America (25%), Asia (32%) and Europe (43%). The most common infections identified were spontaneous bacterial peritonitis (SBP; 27%), urinary tract infection (UTI; 22%), and pneumonia (19%). A total of 740 patients (57%) had at least one positive culture and 959 microorganisms were isolated (58% gram negative, 38% gram positive, 4% fungi).

The global prevalence of MDR bacteria was reported to be 34% (95% CI 31, 37%), with the likelihood of having such an infection being higher in Asia (OR 2.79; p=0.017), particularly India (OR 7.94; p<0.001) or in South America (OR 2.23; p=0.053). In addition, use of antibiotics in the three months prior to hospitalization (OR 1.92; p=0.001), the category of infection (nosocomial: OR 2.65; p<0.001; healthcare-associated: OR 1.62; p=0.032) and the site of infection (pneumonia: OR 3.20; p<0.001; UTI: OR 2.48; p<0.001; skin and soft tissue: OR 2.92; p=0.004) were associated with an increased risk.

"Not surprisingly, we found a significantly lower rate of response to empirical antibiotic treatment in patients with infections caused by MDR bacteria compared with those due to non-MDR bacteria," said the authors of the presentation. "We also saw a significantly higher incidence of shock and new organ failures, and a higher rate of in-hospital mortality among those with MDR bacterial infections."

In light of these findings, they also stressed the urgent need to develop different empirical antibiotic strategies across different parts of the world: "In the meantime, while we wait for new antibiotics to be developed, we must focus our efforts on reducing the spread of MDR bacteria among our patients with cirrhosis."

"The finding that over one in three of bacterial infections occurring in hospitalized patients with cirrhosis are induced by multidrug resistance microorganisms is very worrisome," said professor Annalisa Berzigotti from the University of Bern, Switzerland. "Awareness of this increasing problem is key in implementing the correct management procedures, such as the enhancement of hygiene measures (e.g. contact isolation), and to guide the choice of empiric antibiotic therapy in patients with a high risk of infection by MDR bacteria."

European Association for the Study of the Liver (EASL)