Bacterial infections in cirrhosis: Current treatment

The Yin and the Yang of Hemostasis in End-Stage Liver Disease

Patients with end-stage liver disease (ESLD) undergoing liver transplantation (LT) are prone to thromboses both while on the waiting list and in the perioperative period. This hypercoagulability is associated with significant endothelial dysfunction (ED) due to nitric oxide dysregulation. ED and increased thrombin generation are the main factors responsible for this hypercoagulability. Sepsis alone can significantly alter a patient's coagulation profile. In combination with ESLD, however, sepsis or septic shock are responsible for very complex changes. This makes both the assessment and management of coagulation in septic patients with ESLD very challenging. Viscoelastic testing (VET) is the preferred method of coagulation management in patients with cirrhosis because, as with standard laboratory testing, VET can assess the entire coagulation system including the interaction between both pro- and anticoagulants and platelets.

Implementation and impact of an antibiotic control program and multidrug-resistant bacterial colonization in a liver transplant unit

INTRODUCTION

infections by multidrug-resistant bacteria are a major cause of morbidity and mortality in transplant patients.

OBJECTIVE

a retrospective single-center study was performed to evaluate the implementation of an Antimicrobial Treatment Optimization Program (PROA) on multidrug-resistant bacteria colonization and infection after liver transplant (LT).

METHODS

colonization by multidrug-resistant bacteria and infections during the first year after a liver transplant were analyzed in a group of 76 transplanted patients in two stages, before and after PROA (2016-2019). Clinical variables related to infection, readmissions and survival one year after the liver transplant were analyzed.

RESULTS

there was good adherence to the PROA. Infection was the most frequent cause for readmission during the first year after the liver transplant. Incidence of infections was similar during both periods (mean of 1.25 and 1.5 episodes of bacterial infection per patient/year, respectively) with 19 bacterial infectious episodes, six by hospital-acquired multidrug-resistant and extensively drug-resistant (MDR-XDR) bacteria in the pre-PROA stage, and 18 bacterial infectious episodes, five by MDR-XDR in the post-PROA stage. A 37 % decrease of post-TH of rectal colonization by MDR-XDR after liver transplant was observed during 2019.

CONCLUSIONS

epidemiological surveillance policies and antibiotic optimization are key to control the increase of colonization and infection by multidrug-resistant bacteria in liver transplant units. Long-term studies are needed to better evaluate the impact of these programs.

Impact of multidrug resistance on the management of bacterial infections in cirrhosis

Patients with cirrhosis have an increased risk of infection and differently from other complications, that over the years are improving in their outcomes, infections in cirrhotic patients are still a major cause of hospitalization and death (up to 50% in-hospital mortality). Infections by multidrug-resistant organisms (MDRO) have become a major challenge in the management of cirrhotic patients with significant prognostic and cost-related impact. About one third of cirrhotic patients with bacterial infections is infected with MDR bacteria and their prevalence has increased in recent years. MDR infections have a worse prognosis compared to infections by non-resistant bacteria because they are associated with lower rate of infection resolution. An adequate management of cirrhotic patients with infections caused by MDR bacteria depends on the knowledge of some epidemiological aspects, such as the type of infection (spontaneous bacterial peritonitis, pneumonia, urinary tract infection and spontaneous bacteremia), bacteriological profile of antibiotic resistance at each health care unit and site of infection acquisition (community acquired, healthcare associated or nosocomial). Furthermore, regional variations in the prevalence of MDR infections determine that the choice of empirical antibiotic therapy must be adapted to the local microbiological epidemiology. Antibiotic treatment is the most effective measure to treat infections caused by MDRO. Therefore, optimizing antibiotic prescribing is critical to effectively treat these infections. Identification of risk factors for multidrug resistance is essential to define the best antibiotic treatment strategy in each case and the choice of an effective empirical antibiotic therapy and its early administration is cardinal to reduce mortality. On the other hand, the supply of new agents to treat these infections is very limited. Thus, specific protocols that include preventive measures must be implemented in order to limit the negative impact of this severe complication in cirrhotic patients.

Evaluating the Role of Antibiotics in Patients Admitted to Hospital With Decompensated Cirrhosis: Lessons From the ATTIRE Trial

INTRODUCTION

Hospital-acquired infections (HAI) are common in cirrhosis with antibiotics frequently used to prevent infections, but their efficacy for this role is unknown. To investigate this, we used Albumin to Prevent Infection in Chronic Liver Failure (ATTIRE) data to evaluate whether antibiotic use in patients without infection prevented HAI.

METHODS

In ATTIRE patients without infection at baseline grouped by antibiotic prescription or not, we studied HAI during trial treatment period and mortality, with propensity score matching to account for differences in disease severity.

RESULTS

Two hundred three of 408 patients prescribed antibiotics at enrollment did not have infection and they were more unwell than noninfected patients not given antibiotics. There were no differences in subsequent HAI comparing antibiotic treated (39/203, 19.2%) to nonantibiotic treated (73/360, 20.3%; P = 0.83). Twenty-eight-day mortality was higher in antibiotic-treated patients ( P = 0.004) likely reflecting increased disease severity. Matching groups using propensity scoring revealed no differences in HAI or mortality. In noninfected patients at enrollment treated with/without rifaximin, there were no differences in HAI ( P = 0.16) or mortality, confirmed with propensity matching. Patients given long-term antibiotic prophylaxis at discharge had no differences in 6-month mortality compared with nonantibiotic patients, although antibiotic-treated patients had more infections at trial entry, with numbers too small for matching.

DISCUSSION

Half of antibiotics at study entry were given to patients without an infection diagnosis which did not reduce the overall risk of HAI or improve mortality. This supports prompt de-escalation or discontinuation of antibiotics guided by culture sensitivities at 24-48 hours after commencement if no infection and the patient is improving.

Treatment of Hospital-Acquired Infections in Patients with Cirrhosis - New Challenges

Background

Hospital acquired infections (HAI) in the cirrhotic patients contribute to hepatic decompensation. With emergence of bacterial drug resistance, designing the treatment protocol of HA infection has become the foremost challenge.

Purpose

To analyze the resistance pattern of organisms isolated from hospital-acquired (HA) infections and determine appropriate antibiotics treatment protocols for these infections.

Study Design

A prospective hospital based observational study was undertaken.

Patients and Methods

The present study was conducted over 18 months at Kasturba Medical College, Mangalore, Karnataka, India. Patients with suspected HA infections were subjected to clinical, hematological and microbiological evaluation. Antibiotic sensitivity evaluation was undertaken for the bacteria isolated from these patients.

Results

During the study period, 398 patients with cirrhosis were 472 times admitted to the hospital for treatment. Out of these patients, 40 patients were diagnosed with 50 HA infections. Fifty five different organisms were isolated from these infections. It was found that these 55 bacteria isolates comprised 30 (54.54%) gram-negative (GN) and 25 (45.45%) gram-positive (GP) bacteria. Quite seriously, extended-spectrum beta-lactamase (ESBL) producers and methicillin-resistant Staphylococcus aureus (MRSA) were detected in 40% and 58% of GN and GP infections respectively. A total of 36 (65.4%) and (14.5%) 8 out of 55 isolated organisms exhibited multi–drug resistance (MDR) and extensive drug resistance (XDR) behavior, respectively.

Conclusion

Cirrhosis patients with HA infection possess higher prevalence of MDR and XDR infections. In such sick patients, cephalosporin and quinolones are not the appropriate empirical antibiotics. Herein, we propose a tigecycline with carbapenem like meropenem and vancomycin based empirical antibiotics protocol to be prescribed for such patients. De-escalation is advised after the culture sensitivity report is obtained.

Prevalence and Therapeutic Management of Infections by Multi-Drug-Resistant Organisms (MDROs) in Patients with Liver Cirrhosis: A Narrative Review

Bacterial infections are common events that significantly impact the clinical course of patients with cirrhosis. As in the general population, infections caused by multi-drug-resistant organisms (MDROs) are progressively increasing in cirrhotic patients, accounting for up to 30-35% of all infections. Nosocomial acquisition and prior exposure to antimicrobial treatment or invasive procedures are well-known risk factors for MDRO infections. Several studies have demonstrated that infections due to MDROs have a poorer prognosis and higher rates of treatment failure, septic shock, and hospital mortality. Due to the increasing rate of antimicrobial resistance, the approach to empirical treatment in cirrhotic patients with life-threatening infections has become significantly more challenging. In order to ensure a prompt administration of effective antibiotic therapy while avoiding unnecessary antibiotic exposure at the same time, it is of utmost importance to choose the correct antimicrobial therapy and administration schedule based on individual clinical characteristics and risk factors and rapidly adopt de-escalation strategies as soon as microbiological data are available. In the present paper, we aimed to provide an overview of the most frequent infections diagnosed in cirrhotic patients, the prevalence and impact of antimicrobial resistance, and potential therapeutic options in this population.

Naked-eye sensing and target-guiding treatment of bacterial infection using pH-tunable multicolor luminescent lanthanide-based hydrogel

In this work, a pH-tunable multicolor luminescent lanthanide-based hydrogel (CS/DEX/CP) was prepared based on lanthanide coordination polymer (CP), dextran aldehyde (DEX) and chitosan (CS). The CP was obtained by the self-assembly of guanosine acid (GMP), ciprofloxacin (CIP), Eu³⁺, and Tb³⁺. As-prepared CS/DEX/CP hydrogel could emit blue, green, and red luminescence of CIP, Tb³⁺, and Eu³⁺, respectively. It was also found that the luminescence of CS/DEX/CP hydrogel exhibited visual color change in the pH range of 5.5 to 8. Such pH-sensitive hydrogel was multicolor-responsive to protons produced by bacterial growth, therefore, it could provide early warning of bacterial infection by naked-eye. In addition, the increased acidity resulted in not only the degradation of acid-labile Schiff base linkages between DEX and CS, but also the fracture of coordination between CIP and lanthanide ions. As a result, the released CIP and CS showed significantly antibacterial activity against both S. aureus and E. coli.

Tumor Immune Microenvironment and Immunosuppressive Therapy in Hepatocellular Carcinoma: A Review

Liver cancer has the fourth highest mortality rate of all cancers worldwide, with hepatocellular carcinoma (HCC) being the most prevalent subtype. Despite great advances in systemic therapy, such as molecular-targeted agents, HCC has one of the worst prognoses due to drug resistance and frequent recurrence and metastasis. Recently, new therapeutic strategies such as cancer immunosuppressive therapy have prolonged patients' lives, and the combination of an immune checkpoint inhibitor (ICI) and VEGF inhibitor is now positioned as the first-line therapy for advanced HCC. Since the efficacy of ICIs depends on the tumor immune microenvironment, it is necessary to elucidate the immune environment of HCC to select appropriate ICIs. In this review, we summarize the findings on the immune microenvironment and immunosuppressive approaches focused on monoclonal antibodies against cytotoxic T lymphocyte-associated protein 4 and programmed cell death protein 1 for HCC. We also describe ongoing treatment modalities, including adoptive cell transfer-based therapies and future areas of exploration based on recent literature. The results of pre-clinical studies using immunological classification and animal models will contribute to the development of biomarkers that predict the efficacy of immunosuppressive therapy and aid in the selection of appropriate strategies for HCC treatment.