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De Gasperi A, Petrò L, Amici O, Scaffidi I, Molinari P, Barbaglio C, Cibelli E, Penzo B, Roselli E, Brunetti A, Neganov M, Giacomoni A, Aseni P, Guffanti E. Major liver resections, perioperative issues and posthepatectomy liver failure: A comprehensive update for the anesthesiologist. World J Crit Care Med 2024; 13:92751. [PMID: 38855273 PMCID: PMC11155507 DOI: 10.5492/wjccm.v13.i2.92751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 03/15/2024] [Accepted: 05/07/2024] [Indexed: 06/03/2024] Open
Abstract
Significant advances in surgical techniques and relevant medium- and long-term outcomes over the past two decades have led to a substantial expansion in the indications for major liver resections. To support these outstanding results and to reduce perioperative complications, anesthesiologists must address and master key perioperative issues (preoperative assessment, proactive intraoperative anesthesia strategies, and implementation of the Enhanced Recovery After Surgery approach). Intensive care unit monitoring immediately following liver surgery remains a subject of active and often unresolved debate. Among postoperative complications, posthepatectomy liver failure (PHLF) occurs in different grades of severity (A-C) and frequency (9%-30%), and it is the main cause of 90-d postoperative mortality. PHLF, recently redefined with pragmatic clinical criteria and perioperative scores, can be predicted, prevented, or anticipated. This review highlights: (1) The systemic consequences of surgical manipulations anesthesiologists must respond to or prevent, to positively impact PHLF (a proactive approach); and (2) the maximal intensive treatment of PHLF, including artificial options, mainly based, so far, on Acute Liver Failure treatment(s), to buy time waiting for the recovery of the native liver or, when appropriate and in very selected cases, toward liver transplant. Such a clinical context requires a strong commitment to surgeons, anesthesiologists, and intensivists to work together, for a fruitful collaboration in a mandatory clinical continuum.
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Affiliation(s)
- Andrea De Gasperi
- Former Head, Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda ASST GOM Niguarda, Milan 20163, Italy
| | - Laura Petrò
- AR1, Ospedale Papa Giovanni 23, Bergamo 24100, Italy
| | - Ombretta Amici
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Ilenia Scaffidi
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Pietro Molinari
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Caterina Barbaglio
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Eva Cibelli
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Beatrice Penzo
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Elena Roselli
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Andrea Brunetti
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
| | - Maxim Neganov
- Anestesia e Terapia Intensiva Generale, Istituto Clinico Humanitas, Rozzano 20089, Italy
| | - Alessandro Giacomoni
- Chirurgia Oncologica Miniinvasiva, Grande Ospedale Metropolitano Niguarda ASST GOM Niguarda, Milan 20163, Italy
| | - Paolo Aseni
- Dipartimento di Medicina d’Urgenza ed Emergenza, Grande Ospedale Metropolitano Niguarda ASST GOM Niguarda, Milano 20163, MI, Italy
| | - Elena Guffanti
- Anesthesia and Critical Care Service 2, Grande Ospedale Metropolitano Niguarda AR2, ASST GOM Niguarda, Milan 20163, Italy
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2
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Trad N, Mohamed G, Bizid S, Abdallah HB, Bouali R, Abdelli MN. Clinical impact of multidrug-resistant bacterial infections in patients with cirrhosis. Future Sci OA 2024; 10:FSO945. [PMID: 38813115 PMCID: PMC11131343 DOI: 10.2144/fsoa-2023-0160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/17/2023] [Indexed: 05/31/2024] Open
Abstract
Aim: Recently, the emergency of multidrug-resistant organisms (MDRO) has complicated the management of bacterial infections (BI) in cirrhosis. We aimed to assess their clinical impact on patients with decompensated cirrhosis. Methods: A retrospective study included consecutive cirrhotic patients hospitalized for acute decompensation (AD) between January 2010 and December 2019. Results: A total of 518 AD admissions in 219 patients were included, with 260 BI episodes (50.2%). MDRO prevalence was 38.2% of the total isolates. Recent antibiotic use (OR = 4.91), nosocomial infection (OR = 2.95), and healthcare-associated infection (OR = 3.45) were their main risk factors. MDROs were associated with empiric treatment failure (OR = 23.42), a higher prevalence of sepsis (OR = 4.93), ACLF (OR = 3.42) and mortality. Conclusion: The clinical impact of MDROs was pejorative, with an increased risk of empiric treatment failure, organ failure and death.
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Affiliation(s)
- Nouha Trad
- Gastroenterology department, Principal Military Hospital of Instruction of Tunis, Faculty of medicine of Tunis, University Tunis El Manar Tunis, Tunisia
| | - Ghanem Mohamed
- Gastroenterology department, Principal Military Hospital of Instruction of Tunis, Faculty of medicine of Tunis, University Tunis El Manar Tunis, Tunisia
| | - Sondes Bizid
- Gastroenterology department, Principal Military Hospital of Instruction of Tunis, Faculty of medicine of Tunis, University Tunis El Manar Tunis, Tunisia
| | - Hatem Ben Abdallah
- Gastroenterology department, Principal Military Hospital of Instruction of Tunis, Faculty of medicine of Tunis, University Tunis El Manar Tunis, Tunisia
| | - Riadh Bouali
- Gastroenterology department, Principal Military Hospital of Instruction of Tunis, Faculty of medicine of Tunis, University Tunis El Manar Tunis, Tunisia
| | - Mohamed Nabil Abdelli
- Gastroenterology department, Principal Military Hospital of Instruction of Tunis, Faculty of medicine of Tunis, University Tunis El Manar Tunis, Tunisia
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3
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Carrara E, Grossi PA, Gori A, Lambertenghi L, Antonelli M, Lombardi A, Bongiovanni F, Magrini N, Manfredi C, Stefani S, Tumbarello M, Tacconelli E. How to tailor recommendations on the treatment of multi-drug resistant Gram-negative infections at country level integrating antibiotic stewardship principles within the GRADE-ADOLOPMENT framework. THE LANCET. INFECTIOUS DISEASES 2024; 24:e113-e126. [PMID: 37678308 DOI: 10.1016/s1473-3099(23)00435-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 06/26/2023] [Accepted: 07/06/2023] [Indexed: 09/09/2023]
Abstract
Promoting the optimal use of antibiotics through evidence-based recommendations should be regarded as a crucial step in the global fight against antimicrobial resistance. Within this scope, several guidelines and guidance documents for antibiotic therapy have been published in recent years. All documents underline the limitations of existing evidence and remark on the need for tailoring recommendations at the national level, based on local epidemiology, availability of diagnostics and drugs, and antimicrobial stewardship principles. The GRADE-ADOLOPMENT methodology is an evidence-based methodology that allows the adoption, adaptation, and update of existing recommendations to specific settings without performing de novo systematic reviews and grading of the evidence. However, procedures to integrate this evidence with stewardship principles, countries' surveillance data, and capacity in terms of diagnostics and antibiotics' availability have never been defined. This Personal View provides the first example of a country's calibration of international evidence-based guidance documents on treating infections caused by multidrug-resistant bacteria. A panel of experts convened by the Italian Medicine Agency (AIFA) used the GRADE methodology for systematically extracting and evaluating 100 recommendations on the treatment of infections due to multidrug-resistant Gram-negative bacteria from 11 guidance documents and 24 systematic reviews. The ADOLOPMENT procedure was used to calibrate the existing recommendations to the national context, leading to the adoption of 64, the adaptation of 27, and the rejection of nine recommendations. We discuss the technical details of the GRADE-ADOLOPMENT application, the calibration process, and the human resources required to support such an effort. This Personal View also covers the challenges of integrating antibiotic stewardship principles in evidence-based recommendations for treating infections with very limited therapeutic and diagnostic options. The details presented here could support the easy transferability of the methodology to other countries and settings, particularly where the incidence of antibiotic-resistant infections is high.
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Affiliation(s)
- Elena Carrara
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Paolo Antonio Grossi
- Infectious and Tropical Diseases Unit, Department of Medicine and Surgery University of Insubria and ASST-Sette Laghi, Varese, Italy
| | - Andrea Gori
- Centre for Multidisciplinary Research in Health Science, Department of Infectious Diseases Ospedale Luigi Sacco, University of Milan, Milan, Italy
| | - Lorenza Lambertenghi
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Andrea Lombardi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Infectious Diseases Unit, Milan, Italy
| | - Filippo Bongiovanni
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome, Italy
| | - Nicola Magrini
- Italian Medicines Agency, Rome, Italy; NHS Clinical Governance Unit, Romagna Health Authority, Forli, Italy; WHO Collaborating Centre in Evidence Synthesis and Guideline Development, Health Directorate Regione Emilia Romagna, Bologna, Italy
| | - Carlo Manfredi
- Order of Physicians, Surgeons and Dentists of Massa Carrara- Health Authority Toscana North-West, Italy
| | - Stefania Stefani
- Department of Biomedical and Biotechnological Sciences, Biological Tower, University of Catania, Catania, Italy
| | - Mario Tumbarello
- Department of Medical Biotechnologies, University of Siena, Siena, Italy
| | - Evelina Tacconelli
- Infectious Diseases Division, Department of Diagnostics and Public Health, University of Verona, Verona, Italy.
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Terra C, de Mattos ÂZ, Chagas MS, Torres A, Wiltgen D, Souza BM, Perez RM. Impact of multidrug resistance on the management of bacterial infections in cirrhosis. World J Clin Cases 2023; 11:534-544. [PMID: 36793638 PMCID: PMC9923851 DOI: 10.12998/wjcc.v11.i3.534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/22/2022] [Accepted: 01/05/2023] [Indexed: 01/23/2023] Open
Abstract
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.
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Affiliation(s)
- Carlos Terra
- Gastroenterology-Liver Unit, State University of Rio de Janeiro, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
- Liver Unit, Casa de Saúde São José-Rede Santa Catarina, Rio de Janeiro 22271-080, Rio de Janeiro, Brazil
- Alliance of Brazilian Centers for Cirrhosis Car, The ABC Group, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
- Liver Unit, Federal Hospital of Lagoa, Rio de Janeiro 22470-050, Rio de Janeiro, Brazil
| | - Ângelo Zambam de Mattos
- Alliance of Brazilian Centers for Cirrhosis Car, The ABC Group, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
- Graduate Program in Medicine: Hepatology, Federal University of Health Sciences of Porto Alegre, Porto Alegre 90020-090, Rio Grande do Sul, Brazil
- Gastroenterology and Hepatology Unit, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90020-090, Rio Grande do Sul, Brazil
| | - Marcelo Souza Chagas
- Gastroenterology-Liver Unit, State University of Rio de Janeiro, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
- Alliance of Brazilian Centers for Cirrhosis Car, The ABC Group, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
- Internal Medicine, Federal Hospital of Lagoa, Rio de Janeiro 22470-050, Rio de Janeiro, Brazil
| | - Andre Torres
- Gastroenterology-Liver Unit, State University of Rio de Janeiro, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
- Alliance of Brazilian Centers for Cirrhosis Car, The ABC Group, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
| | - Denusa Wiltgen
- Alliance of Brazilian Centers for Cirrhosis Car, The ABC Group, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
- Department of Internal Medicine, Federal University of Health Sciences of Porto Alegre, Porto Alegre 90020-090, Brazil
| | - Barbara Muniz Souza
- Gastroenterology-Liver Unit, State University of Rio de Janeiro, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
- Alliance of Brazilian Centers for Cirrhosis Car, The ABC Group, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
| | - Renata Mello Perez
- Alliance of Brazilian Centers for Cirrhosis Car, The ABC Group, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
- Hepatology Division, Federal University of Rio de Janeiro, Rio de Janeiro 21941-617, Rio de Janeiro, Brazil
- IDOR, D’Or Institute for Research and Education, Rio de Janeiro 22281-100, Rio de Janeiro, Brazil
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5
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Freire MP, Rinaldi M, Terrabuio DRB, Furtado M, Pasquini Z, Bartoletti M, de Oliveira TA, Nunes NN, Lemos GT, Maccaro A, Siniscalchi A, Laici C, Cescon M, D Albuquerque LAC, Morelli MC, Song ATW, Abdala E, Viale P, Filho ADPC, Giannella M. Prediction models for carbapenem-resistant Enterobacterales carriage at liver transplantation: A multicenter retrospective study. Transpl Infect Dis 2022; 24:e13920. [PMID: 35942941 DOI: 10.1111/tid.13920] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/20/2022] [Accepted: 07/04/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Carbapenem-resistant Enterobacterales (CRE) colonisation at liver transplantation (LT) increases the risk of CRE infection after LT, which impacts on recipients' survival. Colonization status usually becomes evident only near LT. Thus, predictive models can be useful to guide antibiotic prophylaxis in endemic centres. AIMS This study aimed to identify risk factors for CRE colonisation at LT in order to build a predictive model. METHODS Retrospective multicentre study including consecutive adult patients who underwent LT, from 2010 to 2019, at two large teaching hospitals. We excluded patients who had CRE infections within 90 days before LT. CRE screening was performed in all patients on the day of LT. Exposure variables were considered within 90 days before LT and included cirrhosis complications, underlying disease, time on the waiting list, MELD and CLIF-SOFA scores, antibiotic use, intensive care unit and hospital stay, and infections. A machine learning model was trained to detect the probability of a patient being colonized with CRE at LT. RESULTS A total of 1544 patients were analyzed, 116 (7.5%) patients were colonized by CRE at LT. The median time from CRE isolation to LT was 5 days. Use of antibiotics, hepato-renal syndrome, worst CLIF sofa score, and use of beta-lactam/beta-lactamase inhibitor increased the probability of a patient having pre-LT CRE. The proposed algorithm had a sensitivity of 66% and a specificity of 83% with a negative predictive value of 97%. CONCLUSIONS We created a model able to predict CRE colonization at LT based on easy-to-obtain features that could guide antibiotic prophylaxis.
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Affiliation(s)
- Maristela Pinheiro Freire
- Hospital Epidemiology and Infection Control, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, São Paulo, Brazil
| | - Matteo Rinaldi
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Bologna, Italy
| | - Debora Raquel Benedita Terrabuio
- Division of Clinical Gastroenterology and Hepatology, Hospital das Clínicas, Department of Gastroenterology of University of São Paulo School of Medicine, São Paulo, São Paulo, Brazil.,Division of Liver and Gastrointestinal Transplant, Hospital das Clínicas, Department of Surgery, University of São Paulo School of Medicine, São Paulo, São Paulo, Brazil
| | - Mariane Furtado
- School of Public Health, University of São Paulo, São Paulo, Brazil
| | - Zeno Pasquini
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Bologna, Italy
| | - Michele Bartoletti
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Bologna, Italy
| | - Tiago Almeida de Oliveira
- School of Public Health, University of São Paulo, São Paulo, Brazil.,Statistics Department, Paraíba State University Paraíba, Campina Grande, Paraiba, Brazil
| | - Nathalia Neves Nunes
- Department of Infectious Diseases, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | - Gabriela Takeshigue Lemos
- Department of Infectious Diseases, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | - Angelo Maccaro
- Infectious Diseases Unit, Department of Medical and Surgical Sciences, Policlinico Sant'Orsola Malpighi, University of Bologna, Bologna, Italy
| | - Antonio Siniscalchi
- Department of General Surgery and Transplantation, University of Bologna Sant'Orsola - Malpighi Hospital, Bologna, Italy
| | - Cristiana Laici
- Department of General Surgery and Transplantation, University of Bologna Sant'Orsola - Malpighi Hospital, Bologna, Italy
| | - Matteo Cescon
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Emilia-Romagna, Italy
| | - Luiz Augusto Carneiro D Albuquerque
- Division of Liver and Gastrointestinal Transplant, Hospital das Clínicas, Department of Surgery, University of São Paulo School of Medicine, São Paulo, São Paulo, Brazil
| | - Maria Cristina Morelli
- Department of General Surgery and Transplantation, University of Bologna Sant'Orsola - Malpighi Hospital, Bologna, Italy
| | - Alice T W Song
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Emilia-Romagna, Italy
| | - Edson Abdala
- Department of Infectious Diseases, University of São Paulo School of Medicine Hospital das Clínicas, São Paulo, Brazil
| | - Pierluigi Viale
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di Sant'Orsola, Bologna, Italy
| | | | - Maddalena Giannella
- Infectious Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico di Sant'Orsola, Bologna, Italy
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Zeng G, Pang Y, Zheng J, Zhuo C, Guo Y, Liang J, Li X, Lei Z, Zhu J, Xu L, Gao Z, Zhuo C, Liu J. Colonization with Carbapenem-Resistant Enterobacteriaceae Contributes to Unfavorable Outcomes in End-Stage Liver Disease Patients. Antibiotics (Basel) 2022; 11:1667. [PMID: 36421311 PMCID: PMC9686982 DOI: 10.3390/antibiotics11111667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/10/2022] [Accepted: 11/17/2022] [Indexed: 12/25/2023] Open
Abstract
Carbapenem-resistant Enterobacteriaceae (CRE) are the highest priority pathogens of the World Health Organization, and their prevalence in end-stage liver disease (ESLD) patients is increasing. CRE colonization is an independent risk factor for CRE infections. We aimed to assess risk factors and explore the relationship between CRE colonization, infection, and prognosis in patients with ESLD. A total of 311 patients with ESLD were screened for CRE colonization by fecal swabs from October 2020 to January 2022. Antimicrobial susceptibility was tested using the broth microdilution method. Carbapenem resistance genes, multilocus sequence type, and capsular serotype were analyzed by polymerase chain reaction (PCR). Seventeen CRE strains were detected, among which the most common was Klebsiella pneumoniae. The CRE colonization rate was 5.5%. Artificial liver support was an independent risk factor for CRE colonization. Compared to the non-CRE colonization group, the colonization group had a higher incidence of CRE infection and a worse prognosis. Furthermore, these strains were not closely related, and all were sensitive to polymyxin and tigecycline. There was a high colonization rate in ESLD patients, and colonization strains were highly diverse. CRE colonization deserves attention in these patients, especially when treated with artificial liver support.
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Affiliation(s)
- Guofen Zeng
- Department of Infectious Diseases, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
- Department of Infectious Diseases, The Affiliated Kashi Hospital, Sun Yat-sen University, Kashi 844000, China
| | - Yihua Pang
- Department of Infectious Diseases, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Jiaxin Zheng
- Department of Infectious Diseases, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Chuyue Zhuo
- Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510030, China
| | - Yingyi Guo
- Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510030, China
| | - Jiayin Liang
- Department of Laboratory Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Xiaojie Li
- Department of Laboratory Medicine, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Ziying Lei
- Department of Infectious Diseases, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Jianyun Zhu
- Department of Infectious Diseases, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Lejia Xu
- Department of Pharmacy, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Zhiliang Gao
- Department of Infectious Diseases, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
| | - Chao Zhuo
- Department of Infectious Diseases, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
- Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou 510030, China
| | - Jing Liu
- Department of Infectious Diseases, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou 510630, China
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7
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Feldman S, Russo A, Ceccarelli G, Borrazzo C, Madge C, Venditti M, Merli M. Ceftazidime-Avibactam for the Treatment of Carbapenem-Resistant Klebsiella pneumoniae Infections in Patients With Liver Cirrhosis. J Clin Exp Hepatol 2022; 12:1293-1300. [PMID: 36157152 PMCID: PMC9499843 DOI: 10.1016/j.jceh.2022.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 04/17/2022] [Indexed: 12/12/2022] Open
Abstract
Background Carbapenem-resistant Klebsiella pneumoniae (CRKP) infections in patients with cirrhosis represent a significant therapeutic challenge as they are associated with poor outcomes due to high rates of treatment failure, and frequently induce liver decompensation. Aims To evaluate treatment failure and in-hospital mortality in two cohorts of patients with cirrhosis and with CRKP infections treated with antibiotic regimens including or excluding Ceftazidime-avibactam. Methods Data from hospitalized patients with liver cirrhosis and CRKP infections were extracted and retrospectively analyzed. Results During the study period, 39 cirrhotic patients with confirmed invasive CRKP infections were enrolled. Overall, the median age was 60 years with a median MELD score of 16 points. Urinary tract infections were diagnosed in 46%, followed by pneumonia in 23%, and primary bacteremia in 18% of patients. Treatment failure was reported in 10 patients (26%), while in-hospital mortality in 15 patients (38%). A monotherapy was used in 8 patients (20.5%), while a combination therapy was required in 31 patients (79.5%). Ceftazidime-avibactam therapy was associated with lower rates of treatment failure (7% vs. 38%, P = 0.032) independent of severity of liver disease (Child Class) and mono or combination antibiotic therapy. Acute kidney injury, hepatorenal syndrome, and acute-on-chronic liver failure were the consequences more frequently observed in patients with treatment failure. In-hospital mortality was associated with treatment failure, and Ceftazidime-avibactam therapy improved in-hospital survival (log rank test: P = 0.035) adjusted for Child class and mono or combination therapy. Conclusion Treatment including ceftazidime-avibactam was associated with a lower rate of treatment failure in cirrhotic patients with CRKP infections. Considering the favorable efficacy and outcomes of ceftazidime-avibactam, this drug should be considered for the treatment of these severe infections in patients with liver cirrhosis, though further investigation is required.
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Key Words
- ACLF, Acute-on-Chronic Liver Failure
- AKI, Acute Kidney Injury
- CAZ-AVI, Ceftazidime-Avibactam
- COPD, Chronic Obstructive Pulmonary Disease
- CRKP, Carbapenem-Resistant Klebsiella Pneumoniae
- DCT, Double-Carbapenem Therapy
- EASL-CLIF, European Association for the Study of the Liver- Chronic Liver Failure
- EUCAST, EUropean Committee for Antimicrobial Susceptibility Testing
- Ecdc, European Centre for Disease Prevention and Control
- HCC, Hepatocellular Carcinoma
- HRS, Hepatorenal Syndrome
- MDR, Multi-Drug Resistant
- MELD, Model for End-stage Liver Disease
- MIC, Minimum Inhibitory Concentration
- NASH, Non-Alcoholic Steatohepatitis
- TIPS, Transjugular Intrahepatic Portosystemic Shunt
- antibiotic therapy
- bacterial infections
- carbapenem-resistant strains
- liver cirrhosis
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Affiliation(s)
- Shani Feldman
- Division of Gastroenterology, Department of Translational and Precision Medicine, “Sapienza” University of Rome, Viale Dell’Università 37, 00185 Rome, Italy
| | - Alessandro Russo
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, Viale Dell’Università 37, 00185, Rome, Italy
| | - Giancarlo Ceccarelli
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, Viale Dell’Università 37, 00185, Rome, Italy
| | - Cristian Borrazzo
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, Viale Dell’Università 37, 00185, Rome, Italy
| | - Chiara Madge
- Division of Gastroenterology, Department of Translational and Precision Medicine, “Sapienza” University of Rome, Viale Dell’Università 37, 00185 Rome, Italy
| | - Mario Venditti
- Department of Public Health and Infectious Diseases, “Sapienza” University of Rome, Viale Dell’Università 37, 00185, Rome, Italy
| | - Manuela Merli
- Division of Gastroenterology, Department of Translational and Precision Medicine, “Sapienza” University of Rome, Viale Dell’Università 37, 00185 Rome, Italy
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Onorato L, Monari C, Capuano S, Grimaldi P, Coppola N. Prevalence and Therapeutic Management of Infections by Multi-Drug-Resistant Organisms (MDROs) in Patients with Liver Cirrhosis: A Narrative Review. Antibiotics (Basel) 2022; 11:232. [PMID: 35203834 PMCID: PMC8868525 DOI: 10.3390/antibiotics11020232] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/06/2022] [Accepted: 02/08/2022] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | - Nicola Coppola
- Department of Mental Health and Public Medicine, Section of Infectious Diseases, University of Campania Luigi Vanvitelli, 80138 Naples, Italy; (L.O.); (C.M.); (S.C.); (P.G.)
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