[Current problems in the prevention and treatment of infections in patients with cirrhosis]

Albumin for cirrhotic patients with extraperitoneal infections: A meta-analysis

BACKGROUND AND AIM

Bacterial infections are among the main causes of death in patients with cirrhosis. While there are unquestionable benefits of using albumin in patients with spontaneous bacterial peritonitis, the benefits of albumin are controversial for those with extraperitoneal infections. The aim was to compare the use of albumin associated to antibiotics and antibiotics alone in cirrhotic patients with extraperitoneal infections.

METHODS

A systematic review was performed using MEDLINE and Embase databases. Randomized controlled trials comparing albumin associated to antibiotics and antibiotics alone in cirrhotic patients with extraperitoneal infections were considered eligible, as long as at least one of the following outcomes was evaluated: mortality and renal dysfunction. Meta-analysis was performed using the random effects model, through the Mantel-Haenszel method. The study protocol was registered at PROSPERO platform (CRD42018107191).

RESULTS

The literature search yielded 812 references. Three randomized controlled trials fulfilled the selection criteria and were included in this meta-analysis. There was no evidence of significant difference between the groups regarding mortality in 30 days (risk ratio [RR] = 1.62, 95% confidence interval [CI]: 0.92-2.84, P = 0.09, I² = 0%) or in 90 days (RR = 1.27, 95% CI: 0.89-1.83, P = 0.19, I² = 0%). Regarding renal dysfunction, there was also no evidence of significant difference between the groups (RR = 0.55, 95% CI: 0.25-1.19, P = 0.13, I² = 0%).

CONCLUSION

There is no evidence of significant benefits of using albumin for cirrhotic patients with extraperitoneal infections regarding mortality or renal dysfunction.

Prevalence of current patterns and predictive trends of multidrug-resistant Salmonella Typhi in Sudan

Background

Enteric fever has persistence of great impact in Sudanese public health especially during rainy season when the causative agent Salmonella enterica serovar Typhi possesses pan endemic patterns in most regions of Sudan - Khartoum.

Objectives

The present study aims to assess the recent state of antibiotics susceptibility of Salmonella Typhi with special concern to multidrug resistance strains and predict the emergence of new resistant patterns and outbreaks.

Methods

Salmonella Typhi strains were isolated and identified according to the guidelines of the International Standardization Organization and the World Health Organization. The antibiotics susceptibilities were tested using the recommendations of the Clinical Laboratories Standards Institute. Predictions of emerging resistant bacteria patterns and outbreaks in Sudan were done using logistic regression, forecasting linear equations and in silico simulations models.

Results

A total of 124 antibiotics resistant Salmonella Typhi strains categorized in 12 average groups were isolated, different patterns of resistance statistically calculated by (y = ax − b). Minimum bactericidal concentration’s predication of resistance was given the exponential trend (y = n e^x) and the predictive coefficient R² > 0 < 1 are approximately alike. It was assumed that resistant bacteria occurred with a constant rate of antibiotic doses during the whole experimental period. Thus, the number of sensitive bacteria decreases at the same rate as resistant occur following term to the modified predictive model which solved computationally.

Conclusion

This study assesses the prediction of multi-drug resistance among S. Typhi isolates by applying low cost materials and simple statistical methods suitable for the most frequently used antibiotics as typhoid empirical therapy. Therefore, bacterial surveillance systems should be implemented to present data on the aetiology and current antimicrobial drug resistance patterns of community-acquired agents causing outbreaks.

Electronic supplementary material

The online version of this article (10.1186/s12941-017-0247-4) contains supplementary material, which is available to authorized users.

A study on the position and etiology of infection in cirrhotic patients: A potential precipitating factor contributing to hepatic encephalopathy

Hepatic encephalopathy (HE) is a severe and high-mortality complication in cirrhotic patients. In this study, we analyzed infection, one of the common precipitating factors of HE in patients with cirrhosis, in order to identify common infection sites and the etiology. In addition, we aimed to identify information useful in the early prevention and effective treatment of HE. Ninety-two patients presenting with hepatitis B virus-related cirrhosis with HE (HBC-HE) and 45 patients presenting with alcoholic cirrhosis with HE (ALD-HE) were enrolled in this study. We collected and analyzed data concerning the precipitating factors of HE using blood tests, biochemical detection and bacterial culture to identify which precipitating factor was the most common. Fifty-three patients with HE (37 with HBC-HE and 16 with HBC-HE) had infection as the precipitating factor. These infections included respiratory tract infection (56.6%), intestinal tract infection (20.7%), peritoneal infection (17.0%) and urinary tract infection (5.7%). The white blood cell (WBC) counts increased in 17 cases (32.1%) and neutrophil (NEUT) numbers increased in 39 cases (73.6%), while WBC counts were lower in the patients with respiratory tract infection compared with those in the patients with infections at other sites (P<0.05). The levels of plasma ammonia were significantly higher in patients with intestinal tract infection than in those with other sites of infection (P<0.05). The proportions of patients with hyperammonemia, increased NEUT numbers, hyponatremia and low albumin were higher in the infection group compared with those in the non-infection group (P<0.05). Pneumococci and E. coli were common bacteria that induced infection in the respiratory tract and at other infection sites, respectively. Respiratory tract infection was identified to be the most common precipitating factor for HE.

Antibiotic application in cirrhotic patients with extended-spectrum b-lactamase producing E. coli infection

AIM: To investigate the antibiotic application in cirrhotic patients with extended-spectrum b-lactamase (ESBL)-producing Escherichia coli (E. coli) infection.

METHODS: The data for cirrhotic inpatients with ESBL-producing E. coli infection from 2006 to 2011 were collected, and demographic profiles, clinical characteristics, and efficacy of anti-infection treatment were retrospectively analyzed.

RESULTS: A total of 911 infections were found among 4065 cirrhotic patients, of whom 455 were culture-positive. Fifty cirrhotic patients had ESBL-producing E. coli infection. Quinolones (mainly levofloxacin) were primarily used in 23 (46%) cases, third-generation cephalosporins in 16 (32%) cases, and β-lactam/β-lactamase inhibitors in 11 (22%) cases. These three groups of patients showed no significant difference in the clinical outcome (P > 0.05). A switch to another antibiotic was found in 28 (56%) cases. Twenty-two cases (56%) responded to antibiotic therapy, 13 cases (26%) did not respond, and nine cases (18%) died. Compared to the death group, the survival group had significantly different Child-Pugh A (P < 0.05) and initial use of quinolones (P < 0.05). Compared to the non-response group, the response group had significantly different Child-Pugh C (P < 0.05) and bacteremia (P < 0.05). Neither hepatic encephalopathy nor upper gastrointestinal hemorrhage differed significantly between the survival and death group.

CONCLUSION: The efficacy of initial use of empirical antibiotics is very low in cirrhotic patients with ESBL-producing E. coli infection. Compared to third-generation cephalosporins, quinolones are more effective as the first treatment. Liver function-protecting support therapy should be strengthened when treating such infection. Accurate bacterial identification and antimicrobial susceptibility test should be performed to provide timely targeted therapy.

Progress in prevention and treatment of rebleeding after endoscopic band ligation for esophageal variceal bleeding

Hemorrhage from esophageal varices is a serious and common complication of decompensated cirrhosis and carries a significant rate of morbidity and mortality. Endoscopic variceal ligation (EVL) is an effective treatment for esophageal varices; however, there is a very high rate of rebleeding. Prevention and treatment of rebleeding after EVL are important for improving survival in patients with liver cirrhosis. Currently, many measures, including endoscopy, surgery, medication, and a combination of them, have been developed to prevent the occurrence of rebleeding after EVL. Many clinical trials have been done to evaluate the effectiveness of various treatments, alone or in combination, for rebleeding.