Salvatore Piano1, Virendra Singh2, Paolo Caraceni3, Rakhi Maiwall4, Carlo Alessandria5, Javier Fernandez6, Elza Cotrim Soares7, Dong Joon Kim8, Sung Eun Kim9, Monica Marino10, Julio Vorobioff11, Rita de Cassia Ribeiro Barea12, Manuela Merli13, Laure Elkrief14, Victor Vargas15, Aleksander Krag16, Shivaram Prasad Singh17, Laurentius Adrianto Lesmana18, Claudio Toledo19, Sebastian Marciano20, Xavier Verhelst21, Florence Wong22, Nicolas Intagliata23, Liane Rabinowich24, Luis Colombato25, Sang Gyune Kim26, Alexander Gerbes27, Francois Durand28, Juan Pablo Roblero29, Kalyan Ram Bhamidimarri30, Thomas D Boyer31, Marina Maevskaya32, Eduardo Fassio33, Hyoung Su Kim34, Jae Seok Hwang35, Pere Gines36, Adrian Gadano20, Shiv Kumar Sarin4, Paolo Angeli37. 1. Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy. 2. Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. 3. Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy. 4. Institute of Liver and Biliary Sciences, New Delhi, India. 5. Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy. 6. Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Catalonia, Spain; European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Catalonia, Spain. 7. Gastroenterology Division, Medicine Department, Faculty of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil. 8. Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Republic of Korea. 9. Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym Sacred Heart Hospital, College of Medicine, Hallym University, Anyang City, Republic of Korea. 10. Liver Unit, Hospital Dr. Carlos B. Udaondo, Buenos Aires, Argentina. 11. Rosario University Medical School, Rosario, Argentina. 12. Serviço de Hepatologia do Hospital Regional de Mato Grosso Do Sul, Campo Grande, Brazil. 13. Gastroenterology and Hepatology Unit, Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy. 14. Service de Transplantation, Service d'Hépato-gastroentérologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland. 15. Liver Unit, Department of Internal Medicine, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain. 16. Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark. 17. Department of Gastroenterology, S.C.B. Medical College, Cuttack, India. 18. Digestive Disease and Oncology Centre, Medistra Hospital, Jakarta, Indonesia. 19. Gastroenterology Unit, Hospital Valdivia, Universidad Austral de Chile, Valdivia, Chile. 20. Liver Unit and Department of Research, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina. 21. Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium. 22. Division of Gastroenterology, Department of Medicine, University of Toronto, Ontario, Canada. 23. Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia. 24. Liver Unit, Department of Gastroenterology, Tel-Aviv Medical Center and Tel-Aviv University, Tel-Aviv, Israel. 25. Gastroenterology Department, Buenos Aires British Hospital, Argentine Catholic University, Buenos Aires, Argentina. 26. Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea. 27. Department of Medicine II, Liver Centre Munich, University Hospital, LMU Munich, Germany. 28. Hepatology & Liver Intensive Care, Hospital Beaujon, Clichy, University Paris Diderot, Paris, France. 29. Departamento de Medicina, Universidad de Chile Campus Centro, Hospital Clínico San Borja Arriarán, Santiago, Chile. 30. Division of Gastroenterology/Hepatology, University of Miami, Miami, Florida. 31. Department of Medicine, University of Arizona, Tucson, Arizona. 32. University of Moscow, Moscow, Russia. 33. Liver Unit, Hospital Nacional Prof. Alejandro Posadas, El Palomar, Buenos Aires, Argentina. 34. Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Republic of Korea. 35. Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Republic of Korea. 36. Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Catalonia, Spain. 37. Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy. Electronic address: pangeli@unipd.it.
Abstract
BACKGROUND & AIMS: Bacterial infections are common and life-threatening in patients with cirrhosis. Little is known about the epidemiology of bacterial infections in different regions. We performed a multicenter prospective intercontinental study to assess the prevalence and outcomes of bacterial and fungal infections in patients with cirrhosis. METHODS: We collected data from 1302 hospitalized patients with cirrhosis and bacterial or fungal infections at 46 centers (15 in Asia, 15 in Europe, 11 in South America, and 5 in North America) from October 2015 through September 2016. We obtained demographic, clinical, microbiology, and treatment data at time of diagnosis of infection and during hospitalization. Patients were followed until death, liver transplantation, or discharge. RESULTS: The global prevalence of multidrug-resistant (MDR) bacteria was 34% (95% confidence interval 31%-37%). The prevalence of MDR bacteria differed significantly among geographic areas, with the greatest prevalence in Asia. Independent risk factors for infection with MDR bacteria were infection in Asia (particularly in India), use of antibiotics in the 3 months before hospitalization, prior health care exposure, and site of infection. Infections caused by MDR bacteria were associated with a lower rate of resolution of infection, a higher incidence of shock and new organ failures, and higher in-hospital mortality than those caused by non-MDR bacteria. Administration of adequate empirical antibiotic treatment was independently associated with improved in-hospital and 28-day survival. CONCLUSIONS: In a worldwide study of hospitalized patients, we found a high prevalence of infection with MDR bacteria in patients with cirrhosis. Differences in the prevalence of MDR bacterial infections in different global regions indicate the need for different empirical antibiotic strategies in different continents and countries. While we await new antibiotics, effort should be made to decrease the spread of MDR bacteria in patients with cirrhosis.
BACKGROUND & AIMS:Bacterial infections are common and life-threatening in patients with cirrhosis. Little is known about the epidemiology of bacterial infections in different regions. We performed a multicenter prospective intercontinental study to assess the prevalence and outcomes of bacterial and fungal infections in patients with cirrhosis. METHODS: We collected data from 1302 hospitalized patients with cirrhosis and bacterial or fungal infections at 46 centers (15 in Asia, 15 in Europe, 11 in South America, and 5 in North America) from October 2015 through September 2016. We obtained demographic, clinical, microbiology, and treatment data at time of diagnosis of infection and during hospitalization. Patients were followed until death, liver transplantation, or discharge. RESULTS: The global prevalence of multidrug-resistant (MDR) bacteria was 34% (95% confidence interval 31%-37%). The prevalence of MDR bacteria differed significantly among geographic areas, with the greatest prevalence in Asia. Independent risk factors for infection with MDR bacteria were infection in Asia (particularly in India), use of antibiotics in the 3 months before hospitalization, prior health care exposure, and site of infection. Infections caused by MDR bacteria were associated with a lower rate of resolution of infection, a higher incidence of shock and new organ failures, and higher in-hospital mortality than those caused by non-MDR bacteria. Administration of adequate empirical antibiotic treatment was independently associated with improved in-hospital and 28-day survival. CONCLUSIONS: In a worldwide study of hospitalized patients, we found a high prevalence of infection with MDR bacteria in patients with cirrhosis. Differences in the prevalence of MDR bacterial infections in different global regions indicate the need for different empirical antibiotic strategies in different continents and countries. While we await new antibiotics, effort should be made to decrease the spread of MDR bacteria in patients with cirrhosis.