The Korean journal of internal medicine

The Korean Association of Internal Medicine (대한내과학회)
권호 표지
DOI QR코드

DOI QR Code

Prevalence and predictors of multidrug-resistant bacteremia in liver cirrhosis

  • Aryoung Kim (Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Byeong Geun Song (Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Wonseok Kang (Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Dong Hyun Sinn (Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Geum-Youn Gwak (Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Yong-Han Paik (Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Moon Seok Choi (Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Joon Hyeok Lee (Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine) ;
  • Myung Ji Goh (Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine)
  • Received : 2023.08.23
  • Accepted : 2024.01.02
  • Published : 2024.05.01
Download PDF
⟨ Previous Next ⟩

Abstract

Background/Aims: Improved knowledge of local epidemiology and predicting risk factors of multidrug-resistant (MDR) bacteria are required to optimize the management of infections. This study examined local epidemiology and antibiotic resistance patterns of liver cirrhosis (LC) patients and evaluated the predictors of MDR bacteremia in Korea. Methods: This was a retrospective study including 140 LC patients diagnosed with bacteremia between January 2017 and December 2022. Local epidemiology and antibiotic resistance patterns and the determinants of MDR bacteremia were analyzed using logistic regression analysis. Results: The most frequently isolated bacteria, from the bloodstream, were Escherichia coli (n = 45, 31.7%) and Klebsiella spp. (n = 35, 24.6%). Thirty-four isolates (23.9%) were MDR, and extended-spectrum beta-lactamase E. coli (52.9%) and methicillin-resistant Staphylococcus aureus (17.6%) were the most commonly isolated MDR bacteria. When Enterococcus spp. were cultured, the majority were MDR (MDR 83.3% vs. 16.7%, p = 0.003), particularly vancomycin-susceptible Enterococcus faecium. Antibiotics administration within 30 days and/or nosocomial infection was a significant predictor of MDR bacteremia (OR: 3.40, 95% CI: 1.24-9.27, p = 0.02). MDR bacteremia was not predicted by sepsis predictors, such as positive systemic inflammatory response syndrome (SIRS) or quick Sequential Organ Failure Assessment (qSOFA). Conclusions: More than 70% of strains that can be treated with a third-generation cephalosporin have been cultured. In cirrhotic patients, antibiotic administration within 30 days and/or nosocomial infection are predictors of MDR bacteremia; therefore, empirical administration of broad-spectrum antibiotics should be considered when these risk factors are present.

Keywords

References

  1. Shankar N, Ramani A, Griffin C, et al. Extrahepatic causes of death in cirrhosis compared to other chronic conditions in the United States, 1999-2017. Ann Hepatol 2021;26:100565.
  2. Thulstrup AM, Sorensen HT, Schonheyder HC, Moller JK, Tage-Jensen U. Population-based study of the risk and short-term prognosis for bacteremia in patients with liver cirrhosis. Clin Infect Dis 2000;31:1357-1361. https://doi.org/10.1086/317494
  3. Bartoletti M, Giannella M, Lewis RE, Viale P. Bloodstream infections in patients with liver cirrhosis. Virulence 2016;7:309-319. https://doi.org/10.1080/21505594.2016.1141162
  4. Piano S, Tonon M, Angeli P. Changes in the epidemiology and management of bacterial infections in cirrhosis. Clin Mol Hepatol 2021;27:437-445. https://doi.org/10.3350/cmh.2020.0329
  5. Arvaniti V, D'Amico G, Fede G, et al. Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis. Gastroenterology 2010;139:1246-1256, 1256.e1-e5. https://doi.org/10.1053/j.gastro.2010.06.019
  6. Fernandez J, Acevedo J, Castro M, et al. Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study. Hepatology 2012;55:1551-1561. https://doi.org/10.1002/hep.25532
  7. Bartoletti M, Giannella M, Caraceni P, et al. Epidemiology and outcomes of bloodstream infection in patients with cirrhosis. J Hepatol 2014;61:51-58. https://doi.org/10.1016/j.jhep.2014.03.021
  8. Piano S, Singh V, Caraceni P, et al. Epidemiology and effects of bacterial infections in patients with cirrhosis worldwide. Gastroenterology 2019;156:1368-1380.e10. https://doi.org/10.1053/j.gastro.2018.12.005
  9. Addo Smith JN, Yau R, Russo HP, et al. Bacteremia in patients with liver cirrhosis: prevalence and predictors of multidrug resistant organisms. J Clin Gastroenterol 2018;52:648-654. https://doi.org/10.1097/MCG.0000000000000964
  10. Milovanovic T, Pantic I, Velickovic J, et al. Bacteremia in patients with liver cirrhosis in the era of increasing antimicrobial resistance: single-center epidemiology. J Infect Dev Ctries 2021;15:1883-1890. https://doi.org/10.3855/jidc.14508
  11. Johnson AL, Ratnasekera IU, Irvine KM, Henderson A, Powell EE, Valery PC. Bacteraemia, sepsis and antibiotic resistance in Australian patients with cirrhosis: a population-based study. BMJ Open Gastroenterol 2021;8:e000695.
  12. Tandon P, Delisle A, Topal JE, Garcia-Tsao G. High prevalence of antibiotic-resistant bacterial infections among patients with cirrhosis at a US liver center. Clin Gastroenterol Hepatol 2012;10:1291-1298. https://doi.org/10.1016/j.cgh.2012.08.017
  13. Milovanovic T, Dumic I, Velickovic J, Lalosevic MS, Nikolic V, Palibrk I. Epidemiology and risk factors for multi-drug resistant hospital-acquired urinary tract infection in patients with liver cirrhosis: single center experience in Serbia. BMC Infect Dis 2019;19:141.
  14. Kuo CH, Changchien CS, Yang CY, Sheen IS, Liaw YF. Bacteremia in patients with cirrhosis of the liver. Liver 1991;11:334-339. https://doi.org/10.1111/j.1600-0676.1991.tb00539.x
  15. Kamath PS, Wiesner RH, Malinchoc M, et al. A model to predict survival in patients with end-stage liver disease. Hepatology 2001;33:464-470. https://doi.org/10.1053/jhep.2001.22172
  16. Magiorakos AP, Srinivasan A, Carey RB, et al. Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect 2012;18:268-281. https://doi.org/10.1111/j.1469-0691.2011.03570.x
  17. Fernandez J, Prado V, Trebicka J, et al. Multidrug-resistant bacterial infections in patients with decompensated cirrhosis and with acute-on-chronic liver failure in Europe. J Hepatol 2019;70:398-411. https://doi.org/10.1016/j.jhep.2018.10.027
  18. Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 1992;101:1644-1655. https://doi.org/10.1378/chest.101.6.1644
  19. Singer M, Deutschman CS, Seymour CW, et al. The third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016;315:801-810. https://doi.org/10.1001/jama.2016.0287
  20. Friedman ND, Kaye KS, Stout JE, et al. Health care--associated bloodstream infections in adults: a reason to change the accepted definition of community-acquired infections. Ann Intern Med 2002;137:791-797. https://doi.org/10.7326/0003-4819-137-10-200211190-00007
  21. Chen SY, Tsai CL, Lin CH, et al. Impact of liver cirrhosis on mortality in patients with community-acquired bacteremia. Diagn Microbiol Infect Dis 2009;64:124-130. https://doi.org/10.1016/j.diagmicrobio.2009.01.008
  22. Kang CI, Song JH, Chung DR, et al. Liver cirrhosis as a risk factor for mortality in a national cohort of patients with bacteremia. J Infect 2011;63:336-343. https://doi.org/10.1016/j.jinf.2011.07.012
  23. Fernandez J, Navasa M, Gomez J, et al. Bacterial infections in cirrhosis: epidemiological changes with invasive procedures and norfloxacin prophylaxis. Hepatology 2002;35:140-148. https://doi.org/10.1053/jhep.2002.30082
  24. Xie Y, Tu B, Xu Z, et al. Bacterial distributions and prognosis of bloodstream infections in patients with liver cirrhosis. Sci Rep 2017;7:11482.
  25. Kim JH, Jun BG, Lee M, et al. Reappraisal of sepsis-3 and CLIF-SOFA as predictors of mortality in patients with cirrhosis and infection presenting to the emergency department: A multicenter study. Clin Mol Hepatol 2022;28:540-552. https://doi.org/10.3350/cmh.2021.0169
  26. Siegel JD, Rhinehart E, Jackson M, Chiarello L. Management of multidrug-resistant organisms in health care settings, 2006. Am J Infect Control 2007;35(10 Suppl 2):S165-S193. https://doi.org/10.1016/j.ajic.2007.10.006
  27. European Association for the Study of the Liver. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018;69:406-460. https://doi.org/10.1016/j.jhep.2018.03.024
  28. Arabi YM, Dara SI, Memish Z, et al. Antimicrobial therapeutic determinants of outcomes from septic shock among patients with cirrhosis. Hepatology 2012;56:2305-2315. https://doi.org/10.1002/hep.25931
  29. Moreau R, Hadengue A, Soupison T, et al. Septic shock in patients with cirrhosis: hemodynamic and metabolic characteristics and intensive care unit outcome. Crit Care Med 1992;20:746-750. https://doi.org/10.1097/00003246-199206000-00008
  30. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 1992;20:864-874. https://doi.org/10.1097/00003246-199206000-00025
  31. Son J, Choi S, Huh JW, et al. The quick sepsis-related organ failure score has limited value for predicting adverse outcomes in sepsis patients with liver cirrhosis. Korean J Intern Med 2020;35:861-872. https://doi.org/10.3904/kjim.2018.229