Bloodstream infections in patients with liver cirrhosis

Outcomes of transcatheter vs surgical aortic valve replacement in pre-existing chronic liver disease patients: A meta-analysis of observational studies

Aortic valve stenosis in patients with chronic liver diseases, particularly liver cirrhosis and End-Stage Liver Disease, poses significant management challenges due to the interplay between cardiovascular and hepatic dysfunction. This systematic review and meta-analysis compared the safety and efficacy of Transcatheter Aortic Valve Replacement (TAVR) and Surgical Aortic Valve Replacement in this high-risk population. An extensive search of PubMed, Embase, and Web of Science (inception to January 5, 2025) identified 11 retrospective studies comprising 19,097 patients. Risk ratios for dichotomous outcomes and mean differences (MD) for continuous outcomes, each with 95% confidence intervals, were calculated using random-effects models. The analysis revealed that TAVR significantly reduced hospital mortality (RR 0.36, 95 % CI: 0.30-0.42; I2 = 7.6 %), acute kidney injury (RR 0.51, 95 % CI: 0.33-0.78; I2 = 57.2 %), bleeding (RR 0.33, 95 % CI: 0.28-0.39; I2 = 0.0 %), stroke (RR 0.35, 95 % CI: 0.23-0.51; I2 = 6.1 %), and blood transfusion (RR 0.48, 95 % CI: 0.40-0.57; I2 = 7.6 %). TAVR was also associated with shorter hospital stays (MD -6.77 days, 95 % CI: -9.17 to -4.38; I2 = 97.5 %). No significant differences were observed in vascular complications requiring surgery or hospital charges and post-operative infections. These findings suggest TAVR offers significant advantages over SAVR in reducing complications such as mortality, acute kidney injury, and bleeding in patients with liver disease. However, further randomized trials are necessary to confirm long-term outcomes and establish optimal treatment strategies for this high-risk population.

Carbohydrate consumption drives adaptive mutations in Escherichia coli associated with increased risk for systemic infection

Dissemination of organisms from the gut microbiota is a major contributor to sepsis and critical illness. Patients with cirrhosis are prone to systemic infections and are commonly prescribed the carbohydrate lactulose to manage hepatic encephalopathy (HE) 1 . Commensal metabolism of lactulose is believed to reduce pathobiont colonization through short-chain fatty acid production, but its direct effects on gut pathobionts remain unexplored 2 . Here, we show that lactulose consumption unexpectedly selects for mutations in Escherichia coli lactose (lac) operon regulation, enhancing its metabolic fitness and colonization capacity. This is mediated by selection for constitutive expression of the lac operon through mutations in its regulatory components. Using in vitro systems, murine models, and clinical samples, we demonstrate that these mutations enable E. coli to exploit lactulose as a carbon source, bypassing host carbohydrate metabolism and increasing its intestinal colonization. Despite its long-standing use in HE treatment, we find that lactulose has a paradoxical association with risk of infection hospitalization in patients with cirrhosis in a large epidemiologic study. The emergence of lactulose-adapted E. coli strains could be suppressed by a dietary oligosaccharide that competitively inhibits lactulose uptake. These findings reveal a mechanism by which dietary substrates exert selective pressure on the microbiome, with implications for diet-based strategies to modulate microbial evolution and infection risk.

A Case of Complicated Bacteremia: When the Source Is in the Blood

Infective endocarditis is an infectious disease of the heart tissue, mainly affecting heart valves and intracardiac devices. We present the case of a 71-year-old male pacemaker carrier with a history of hepatic cirrhosis, esophageal varices, hepatocellular carcinoma, and severe aortic stenosis, who was admitted to the emergency room and hospitalized due to upper gastrointestinal bleeding. Although upper endoscopy showed no signs of active acute hemorrhage, the patient required a red blood cell transfusion. Upon admission, elevated inflammatory parameters prompted the initiation of empirical therapy with ceftriaxone. Although urinalysis, chest X-ray, thoracoabdominopelvic computed tomography, and transthoracic echocardiogram weren't suggestive of infection, an Enterococcus faecium was isolated in blood cultures. Following an antibiotic switch to daptomycin, based on susceptibility testing, and the patient's hemodynamic stability, he was transferred to a home hospitalization unit for continued care. Despite good clinical and analytical progress, the patient's history of aortic valve stenosis and pacemaker, along with persistently positive blood cultures despite antibiotic therapy and sustained fever, raised a high level of clinical suspicion. This led to the decision to perform a new echocardiogram, which revealed several aortic valve vegetations, allowing the diagnosis of infective endocarditis. Following a multidisciplinary discussion, and in accordance with antibiotic susceptibility tests, linezolid was initiated. After 40 days, although the echocardiogram was still suggestive of aortic valve infiltration due to an infectious process, hemodynamic stability, sustained apyrexia, and sterile blood cultures allowed for a possible discharge on oral therapy with moxifloxacin and rifampicin. Although this is a case of infective endocarditis in a high-risk patient, the chronology is unusual, as endocarditis was not detected in the initial echocardiogram. The diagnosis was only possible after weeks of persistent positive blood cultures, thanks to the medical team's high level of suspicion, which led them to insist on repeating the echocardiogram. In fact, the diagnosis of infective endocarditis remains a challenge to this day. This case highlights the importance of recognizing risk factors and pursuing the diagnosis when clinical suspicion persists, including repeating imaging when necessary to ensure timely diagnosis and appropriate management.

Hospital-acquired bloodstream infections in critically ill cirrhotic patients: a post-hoc analysis of the EUROBACT-2 international cohort study

BACKGROUND

Hospital-acquired bloodstream infections are common in the intensive care unit (ICU) and have a high mortality rate. Patients with cirrhosis are especially susceptible to infections, yet there is a knowledge gap in the epidemiological distinctions in hospital-acquired bloodstream infections between cirrhotic and non-cirrhotic patients in the ICU. It has been suggested that cirrhotic patients, present a trend towards more gram-positive infections, and especially enterococcal infections. This study aims to describe epidemiological differences in hospital-acquired bloodstream infections between cirrhotic and non-cirrhotic patients hospitalized in the ICU regarding infection sources, microorganisms and mortality.

METHODS

Using prospective Eurobact-2 international cohort study data, we compared hospital-acquired bloodstream infections sources and microorganisms in cirrhotic and non-cirrhotic patients. The association between Enterococcus faecium and cirrhosis was studied using a multivariable mixed logistic regression. The association between cirrhosis and mortality was assessed by a multivariable frailty Cox model.

RESULTS

Among the 1059 hospital-acquired bloodstream infections patients included from 101 centers, 160 had cirrhosis. Hospital-acquired bloodstream infection source in cirrhotic patients was primarily abdominal (35.6%), while it was pulmonary (18.9%) for non-cirrhotic (p < 0.01). Gram-positive hospital-acquired bloodstream infections accounted for 42.3% in cirrhotic patients compared to 33.2% in non-cirrhotic patients (p = 0.02). Hospital-acquired bloodstream infections in cirrhotic patients were most frequently caused by Klebsiella spp (16.5%), coagulase-negative Staphylococci (13.7%) and E. faecium (11.5%). E. faecium bacteremia was more frequent in cirrhotic patients (11.5% versus 4.5%, p < 0.01). After adjusting for possible confounding factors, cirrhosis was associated with higher E. faecium hospital-acquired bloodstream infections risk (Odds ratio 2.5, 95% CI 1.3-4.5, p < 0.01). Cirrhotic patients had increased mortality compared to non-cirrhotic patients (Hazard Ratio 1.3, 95% CI 1.01-1.7, p = 0.045).

CONCLUSIONS

Critically ill cirrhotic patients with hospital-acquired bloodstream infections exhibit distinct epidemiology, with more Gram-positive infections and particularly Enterococcus faecium.

Evaluation of mucosal-associated invariant T-cells as a potential biomarker to predict infection risk in liver cirrhosis

BACKGROUND AND AIMS

Infection is a serious complication in patients with cirrhosis. Mucosal-associated invariant T (MAIT) cells are involved in the immune defense against infections and known to be impaired in several chronic conditions, including cirrhosis. Here, we evaluated if MAIT cell levels in peripheral blood are associated with risk of bacterial infections in patients with cirrhosis.

METHODS

Patients with cirrhosis seen at the Karolinska University Hospital, Stockholm, Sweden, between 2016 and 2019 were included. Levels of MAIT cells in peripheral blood were determined using flow cytometry. Baseline and follow-up data after at least two years of follow-up were collected by chart review for the primary outcome (bacterial infection) and secondary outcomes (decompensation and death). Competing risk and Cox regression were performed.

RESULTS

We included 106 patients with cirrhosis. The median MAIT cells fraction in the circulation was 0.8% in cirrhosis compared to 6.1% in healthy controls. In contrast to our hypothesis, we found an association in the adjusted analysis between relatively preserved MAIT cell levels, and a slightly higher risk to develop bacterial infections (adjusted subdistribution hazard ratio (aSHR) 1.15 (95%CI = 1.01-1.31). However, MAIT cell levels were not associated with the risk of hepatic decompensation (aSHR 1.19 (95%CI = 0.91-1.56)) nor with death (adjusted hazard ratio 1.10 (95%CI = 0.97-1.22)).

CONCLUSIONS

Relatively preserved MAIT cell levels in blood of patients with cirrhosis were associated with a somewhat higher risk of bacterial infections. The clinical relevance of this might not be strong. MAIT cells might however be an interesting biomarker to explore in future studies.

Prevalence and predictors of multidrug-resistant bacteremia in liver cirrhosis

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).

CONCLUSION

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.

Nosocomial vs healthcare associated vs community acquired spontaneous bacterial peritonitis: Network meta-analysis

INTRODUCTION

Spontaneous bacterial peritonitis (SBP) is a common complication in decompensated liver cirrhosis with ascitic fluid polymorphonuclear cell count > 250/mm3. Community acquired SBP (CA-SBP) occurs within the first 48 hours after hospital admission. Nosocomial SBP (N-SBP) occurs 48-72 hours after hospitalization. Healthcare associated SBP (HA-SBP) occurs in patients hospitalized in the preceding 90 days to months. We aim to evaluate mortality and resistance patterns to third generation cephalosporin among the three types.

METHODS

Multiple databases were systematically searched from inception through August 1st, 2022. Both pairwise (direct) and network (direct + indirect) meta-analysis was performed using a random effects model and DerSimonian Laird approach. Relative Risk (RR) with 95% confidence intervals (CI) were calculated. Network meta-analysis was conducted using frequentist approach.

RESULTS

A total of 14 studies with a total of 2302 SBP episodes were evaluated. On direct meta-analysis, mortality rate was higher in N-SBP compared to HA-SBP (RR 1.84, CI 1.43- 2.37) and CA-SBP (RR 1.69, CI 1.4-1.98), but not significantly different between HA-SBP and CA-SBP (RR=1.40, CI=0.71-2.76). Resistance to third generation cephalosporins was significantly higher in N-SBP compared to HA-SBP (RR=2.02, CI 1.26-3.22) and CA-SBP (RR=3.96, CI=2.50-3.60) as well as in HA-SBP compared to CA-SBP (RR=2.25, CI=1.33-3.81).

CONCLUSIONS

Our network meta-analysis shows increased mortality and antibiotic resistance with nosocomial SBP. We recommend clearly identifying such patients to manage accordingly as well as developing guidelines geared towards nosocomial infections to be able to optimally steer resistance patterns and reduce mortality.

Prevalence of Multidrug-Resistant Bacteria in Healthcare-Associated Bloodstream Infections at Hospitals in Riyadh, Saudi Arabia

Bloodstream infection (BSI) prevalence in hospitalized patients has increased owing to the spread of antibiotic-resistant pathogens; moreover, antimicrobial resistance in bacteria is a global problem. Here, BSIs are investigated in several patients at a hospital in Saudi Arabia, and the resistance of bacterial isolates to widely used drugs is determined. Throughout 2020, bacteria isolated from patients were identified and subjected to antibiotic susceptibility testing. In total, 1125 bacterial isolates were obtained from 1039 patients; among them, gram-positive bacteria were significantly more abundant than gram-negative bacteria. The most prevalent bacteria were Staphylococcus epidermidis and Klebsiella pneumoniae. Notably, gram-negative bacteria were mainly isolated from adult patients, and 20.63% of the gram-positive isolates were from pediatric patients, which was significantly higher than the corresponding percentages in elders and adults. The gram-positive isolates were mainly resistant to cephalothin, oxacillin, amoxicillin-clavulanate, and erythromycin and susceptible to penicillin, gentamicin, ciprofloxacin, and vancomycin. Additionally, the gram-negative isolates were mainly resistant to ampicillin, cephalothin, and amoxicillin-clavulanate and susceptible to amikacin, ertapenem, aztreonam, colistin, and trimethoprim-sulfamethoxazole. Consequently, the high prevalence of infective multidrug-resistant bacteria may account as a significant health issue; it is considered a hazard in Riyadh hospitals and must be prevented at all costs.

Effectiveness of Disinfecting Caps for Intravenous Access Points in Reducing Central Line-Associated Bloodstream Infections, Clinical Utilization, and Cost of Care During COVID-19

Purpose

Intravenous (IV) access point protectors, serving as passive disinfection devices and a cover between line accesses, are available to help reduce the risk of central line-associated bloodstream infections (CLABSIs). This low-maintenance disinfection solution is particularly valuable in situations with excessive workloads. This study examined the effect of a disinfecting cap for an IV access point on CLABSI rates, hospital length of stay, and cost of care in an inpatient setting during the coronavirus disease 2019 (COVID-19) pandemic.

Methods

The study utilized data from the Premier Healthcare Database, focusing on 200,411 hospitalizations involving central venous catheters between January 2020 and September 2020. Among these cases, 7423 patients received a disinfecting cap, while 192,988 patients did not use any disinfecting caps and followed the standard practice of hub scrubbing. The two cohorts, Disinfecting Cap and No-Disinfecting Cap groups, were compared in terms of CLABSI rates, hospital length of stay (LOS), and hospitalization costs. The analysis accounted for baseline group differences and random clustering effects by employing a 34-variable propensity score and mixed-effect multiple regression, respectively.

Results

The findings demonstrated a significant 73% decrease in CLABSI rates (p= 0.0013) in the Disinfecting Cap group, with an adjusted CLABSI rate of 0.3% compared to 1.1% in the No-Disinfecting Cap group. Additionally, the Disinfecting Cap group exhibited a 0.5-day reduction in hospital stay (9.2 days versus 9.7 days; p = 0.0169) and cost savings of $6703 ($35,604 versus $42,307; p = 0.0063) per hospital stay compared to the No-Disinfecting Cap group.

Conclusion

This study provides real-world evidence that implementing a disinfecting cap to protect IV access points effectively reduces the risk of CLABSIs in hospitalized patients compared to standard care, ultimately optimizing the utilization of healthcare resources, particularly in situations where the healthcare system is under significant strain or overloaded.

Comparative Effectiveness of 2 Chlorhexidine Gluconate-Containing Dressings in Reducing Central Line-Associated Bloodstream Infections, Hospital Stay, and Costs

Chlorhexidine gluconate (CHG)-containing dressings are recommended to prevent central line associated bloodstream infections (CLABSIs) and other catheter-related infections. This study compared the effect of 2 CHG dressings on CLABSI, cost of care, and contact dermatitis. A retrospective analysis was conducted using the Premier Healthcare Database of hospitalized patients (n = 53 149) with central venous catheters (CVCs) and receiving either a transparent CHG gel dressing (n = 14 488) or an opaque CHG sponge dressing (n = 38 661) between January 2019 and September 2020. Two cohorts (n = 14 488 each), CHG-Gel and CHG-Sponge, were matched 1:1 using a propensity score method on 33 patient and facility characteristics. CLABSI and contact dermatitis rates, hospital length of stay (LOS), and hospitalization costs were compared using mixed-effect multiple regression. This approach effectively controlled for random clustering effects across hospitals and patients' Diagnosis-Related Group (DRG) classifications. CHG gel dressings were associated with a 41% decrease in CLABSI rates (P = .0008) compared to CHG sponge dressings (0.35%vs 0.60%). A 0.4-day shorter LOS (9.53vs 9.90 days, P = .0001) and a cost saving of $3576 per hospital stay ($40 197 vs $43 774, P = .0179) was observed with CHG gel dressing use. There was no statistically significant difference in contact dermatitis rates (P = .7854) between the CHG-Gel and CHG-Sponge cohorts. The findings of this study suggest that the use of CHG gel dressings may be more effective in reducing the risk of CLABSIs and associated clinical costs compared to CHG sponge dressings in hospitalized patients. Moreover, there appears to be no significant discrepancy in contact dermatitis rates between CHG gel and CHG sponge dressings. Healthcare providers may consider using CHG gel dressings as a standard practice for patients with CVCs to reduce the risk of infections and improve patient outcomes.

Successful treatment of giant perinephric abscess associated with decompensated cirrhosis caused by hepatitis B and alcohol consumption: A case report

We describe the case of a 67-year-old male with decompensated liver cirrhosis caused by hepatitis B virus and alcohol consumption who presented with diarrhea and fever. Contrast CT of the abdomen revealed giant perirenal abscess. Klebsiella pneumoniae ssp pneumoniae was cultured from pus in perirenal abscess but not the blood. Haematogenous spread may have resulted in perirenal abscess in this case. The patient was successfully treated by percutaneous drainage, antimicrobial therapy and albumin infusion. With high mortality rates, early diagnosis and effectively treatment of perirenal abscess is required to improve the prognosis of patients.

Klebsiella pneumoniae Infection as a Mimicker of Multiple Metastatic Lesions

We describe the case of a 42-year-old man with cirrhosis who presented with fever and imaging concerning for metastatic disease from suspected renal cell carcinoma. He had a right renal mass with multiple pulmonary masses and underwent a lung biopsy and oncology consultation. Blood cultures revealed Klebsiella pneumoniae, and all the lesions disappeared after intravenous (IV) antibiotics. Our case attempts to increase awareness of this unique presentation of invasive Klebsiella infections and discusses host factors that can predispose to this condition.

Interspecies differences in clinical characteristics and risk factors for third-generation cephalosporin resistance between Escherichia coli and Klebsiella pneumoniae bloodstream infection in patients with liver cirrhosis

This retrospective study aimed to clarify the interspecies differences in the clinical characteristics and risk factors of bloodstream infection (BSI) due to third-generation cephalosporin-resistant (3GC-R) Escherichia coli (EC) and Klebsiella pneumoniae (KP) in patients with liver cirrhosis (LC). KP BSI had more comorbidities and higher treatment failure rate than EC BSI. Non-alcoholic LC was a risk factor for treatment failure in EC, whereas it was not associated with KP. Risk factors for BSI due to 3GC-R strain were nosocomial infection in EC, and β-lactam/fluoroquinolone treatment ≤ 30 days in KP. These results could help predict outcomes of BSI and improve clinical practice.

Analysis of SGLT2 Inhibitor Therapy and Other Potential Risk Factors for the Development of Bacteremia in Patients With Urosepsis

Background: Risk factors for the development of bacteremia in patients with urosepsis are not well-defined in the current literature. Objective: To assess potential risk factors, including receipt of SGLT2 inhibitor therapy (SGLT2-I), for the development of bacteremia in patients with urosepsis. Methods: A retrospective case control study was performed on patients admitted to a community hospital. Patients were included if they had a positive urine culture and met criteria for urosepsis. Exclusion criteria included proven source of infection outside of the urogenital tract, age less than or equal to 18 years old, and pregnancy. Included patients were placed into 1 of 2 groups: bacteremia or non-bacteremia. The primary endpoint was the percentage of patients taking an SGLT2-I in the bacteremia versus the non-bacteremia group. Secondary endpoints included an assessment of potential risk factors for the development of bacteremia in patients with urosepsis via univariate and multivariate regression analysis and comparison of clinical outcomes in patients receiving SGLT2-I prior to admission versus those not receiving SGLT2-I. Results: There was no difference in the proportion of patients within the bacteremia and non-bacteremia groups who were receiving an SGLT2-I (12% vs. 19%, P = 0.277). Binary multivariate regression analysis identified 2 variables associated with increased risk of bacteremia: male gender and cirrhosis. Conclusion: Within this study, there was no difference in the proportion of patients receiving an SGLT2-I in bacteremia and non-bacteremia groups. Potential risk factors for the development of bacteremia identified included male gender and cirrhosis. However, results from our study should be confirmed in larger scale studies.

Candidemia in hospitalized cirrhotic patients with bloodstream infection: A retrospective analysis and brief summary of published studies

BACKGROUND

Candidemia is a life-threatening condition; however, the predictive markers for candidemia and mortality are inadequate in cirrhotic patients. This study was conducted to propose candidate predictors for the occurrence of candidemia and 30-day mortality in hospitalized cirrhotic patients with bloodstream infection (BSI) and review the related literature.

METHODS

Cirrhotic patients with BSI between January 2011 and March 2020 were screened from the databank of a medical center and eligible patients were enrolled. Patients were separated into candidemia and bacteremia groups according to the results of blood cultures. Baseline characteristics, clinical presentation, and biochemistry data were collected at this time, as were microbiological data, medical management, use of antimicrobial agents, and outcome of the patients. The parameters and 30-day mortality were compared between candidemia and bacteremia groups. A combination of the MeSH terms and text terms related to candidemia and cirrhosis was searched in the electronic databases.

RESULTS

Four hundred and sixty cirrhotic patients with BSI were enrolled. Thirty-five patients with candidemia (7.6%) were identified. Nosocomial infection, intensive care unit (ICU) admission, antibiotics exposure ≥14 days, white cell count >10 K/mm3, and model for end-stage liver disease (MELD) score >24 were associated with candidemia. The 30-day mortality was 65.7% in the candidemia group and 37.9% in the bacteremia group (p = 0.001). Nosocomial infection, ICU admission, hepatoma, hepatic encephalopathy, international normalized ratio ≥1.2, platelet ≤150 K/mm3, estimated glomerular filtration rate <60 mL/min/1.73m2, and MELD score >24 were associated with 30-day mortality. Six studies were identified. The results were consistent with our findings regarding low incidence of candidemia, and relevant risk factors are listed.

CONCLUSION

Candidemia had low incidence but high mortality in hospitalized cirrhotic patients with BSI. New predictors were proposed for the occurrence of candidemia and 30-day mortality in these patients.

Fluoroquinolone-resistant strains in cirrhotic patients with spontaneous bacterial peritonitis: microbiological and molecular aspects

OBJECTIVES

This study aimed to determine the causative bacterial agents of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis and to define antibiotic-resistance patterns in addition to identifying the genetic mutations in the quinolone resistance determining regions (QRDRs).

PATIENTS AND METHODS

Twenty milliliters of ascetic fluid was obtained from 51 patients with SBP. The antibiotic-sensitivity patterns of different strains were determined by the Kirby-Bauer method. Extracted bacterial DNA was used to determine the mutations in four different genes in QRDRs (gyrA, gyrB, parC, and parE) by sequencing after gene amplification by PCR.

RESULTS

Gram-negative bacilli were detected in 60.7% of the patients. Escherichia coli was detected in 33.3% of the patients, and Staphylococcus aureus was detected in 21.6%. Gram-negative bacilli showed the best sensitivity to meropenem (90.3%), followed by amikacin (83.9%). Gram-positive cocci were sensitive to vancomycin and oxacillin at 90 and 80%, respectively. Fluoroquinolone resistance was detected in 27% of the bacterial strains. Mutations in the gyrA and parC genes were detected in quinolone-resistant strains (64.3 and 35.7%, respectively). Several mutations were found in the gyrA gene (Ser83Leu, Ser81Phe, and Ser-84Leu). Ser80Ile and Ser79Tyr mutations were detected in the parC gene. No mutation was detected in the parE gene.

CONCLUSION

Frequent use of antibiotics as prophylaxis against SBP leads to an increase in antibiotic resistance and changes the microbial pattern of causative agents. The gyrA gene mutation was the most common mutation detected in fluoroquinolone-resistant strains.

Variable Normalization of Naïve CD4+ Lymphopenia and Markers of Monocyte and T Cell Activation over the Course of Direct-Acting Anti-Viral Treatment of Chronic Hepatitis C Virus Infection

Chronic hepatitis C virus (HCV) infection is associated with naïve CD4+ T cell lymphopenia and long-standing/persistent elevation of cellular and soluble immune activation parameters, the latter heightened in the setting of HIV co-infection. The underlying mechanisms are not completely understood. However, we recently reported that accelerated peripheral cell death may contribute to naïve CD4+ T cell loss and that mechanistic relationships between monocyte activation, T cell activation, and soluble inflammatory mediators may also contribute. Chronic HCV infection can be cured by direct-acting anti-viral (DAA) therapy, and success is defined as sustained virological response (SVR, undetectable HCV RNA (ribonucleic acid) at 12 weeks after DAA treatment completion). However, there is no general consensus on the short-term and long-term immunological outcomes of DAA therapy. Here, we consolidate previous reports on the partial normalization of naïve CD4+ lymphopenia and T cell immune activation and the apparent irreversibility of monocyte activation following DAA therapy in HCV infected and HCV/HIV co-infected individuals. Further, advanced age and cirrhosis are associated with delayed or abrogation of immune reconstitution after DAA therapy, an indication that non-viral factors also likely contribute to host immune dysregulation in HCV infection.

Bacteraemia, sepsis and antibiotic resistance in Australian patients with cirrhosis: a population-based study

Objective

Multiple factors predispose patients with cirrhosis to sepsis and/or bacteraemia and this has a high mortality rate. Within different geographical regions there are marked differences in the prevalence of infection with multidrug-resistant organisms (MDR). This study examined risk factors for and outcomes of sepsis/bacteraemia in public hospital admissions with cirrhosis in the state of Queensland, Australia, over the last decade, along with the bacterial pathogens responsible and their antibiotic susceptibility profiles.

Design

A population-based retrospective cohort study of public hospital admissions was conducted from 1 January 2008 to 31 December 2017. Hospital admissions for patients with a diagnosis of cirrhosis were categorised by the presence or absence of sepsis/bacteraemia. Clinical and sociodemographic information including cirrhosis aetiology, complications and comorbidities, and in-hospital mortality were examined using bivariate and multivariate analyses. In patients with bacteraemia, the type and prevalence of bacteria and antibiotic resistance was assessed.

Results

Sepsis/bacteraemia was present in 3951 of 103 165 hospital admissions with a diagnosis of cirrhosis. Factors associated with sepsis/bacteraemia included disease aetiology, particularly primary sclerosing cholangitis (adj-OR 15.09, 95% CI 12.24 to 18.60), alcohol (adj-OR 2.90, 95% CI 2.71 to 3.09), Charlson Comorbidity Index ≥3 (adj-OR 3.54, 95% CI 3.19 to 3.93) and diabetes (adj-OR 1.87, 95% CI 1.74 to 2.01). Overall case-fatality rate among admissions with sepsis/bacteraemia was 27.7% (95% CI 26.3% to 29.1%) vs 3.7% (95% CI 3.6% to 3.8%) without sepsis/bacteraemia. In-hospital death was significantly associated with sepsis/bacteraemia (adj-OR 6.50, 95% CI 5.95 to 7.11). The most common organisms identified were Escherichia coli and Staphylococcus aureus, present in 22.9% and 18.1%, respectively, of the 2265 admissions with a positive blood culture. The prevalence of MDR bacteria was low (5.6%)

Conclusion

Morbidity and mortality related to sepsis/bacteraemia in patients with cirrhosis remains a critical clinical problem.

Bacteremia as a risk factor for variceal upper gastrointestinal tract bleeding in cirrhotic patients: a hospital-based study

Background

The presence of bacteremia as a complication of variceal bleeding in patients with liver cirrhosis had been investigated by many studies. The aim of this study was to assess the bacteremia as a risk factor for variceal upper gastrointestinal tract bleeding in cirrhotic patients. A cross-sectional study was conducted on 99 patients with chronic liver disease divided into three groups: group I included 35 patients presented with first attack of variceal bleeding, group II included 35 patients presented with recurrent attacks of variceal bleeding, and group III included 29 patients with no history of previous variceal bleeding as a control group. Routine laboratory tests were done, upper GI endoscopy, blood culture, and measurement of procalcitonin level in blood.

Results

Patients with recurrent variceal bleeding had statistically (p < 0.05) the highest percentage of positive blood culture followed by patients with first variceal bleeding and the control (60% vs 45.7% vs 24.1%) respectively. In addition to procalcitonin results, patients with recurrent variceal bleeding had statistically the highest values of PCT followed by patients with first variceal bleeding and the control (1.92 vs 0.325 vs 0.22 ng/ml) respectively. Multivariate regression analysis showed that procalcitonin and hemoglobin only was the significant predictors for variceal bleeding. Hemoglobin at cutoff value of ≤ 9.6 and procalcitonin (ng/dl) at cutoff value of > 1.76 is the most specific in predicting bleeding 86.21%, 86.21% (CI 95%) respectively.

Conclusion

Bacteremia and procalcitonin are risk factor for variceal bleeding in cirrhotic patients. Procalcitonin can be used as easily measurable and surrogate biomarker for bacteremia and variceal bleeding.

Management of portal hypertensive upper gastrointestinal bleeding: Report of the Coorg Consensus workshop of the Indian Society of Gastroenterology Task Force on Upper Gastrointestinal Bleeding

Portal hypertensive bleeding is a major complication of portal hypertension (PHT) with high morbidity and mortality. A lot of advances have been made in our understanding of screening, risk stratification, and management strategies for portal hypertensive bleeding including acute variceal bleeding leading to improved overall outcomes in patients with PHT. A number of guidelines on variceal bleeding have been published by various societies in the past few years. The Indian Society of Gastroenterology (ISG) Task Force on Upper Gastrointestinal Bleeding (UGIB) felt that it was necessary to bring out a standard practice guidance document for the use of Indian health care providers especially physicians, gastroenterologists, and hepatologists. For this purpose, an expert group meeting was convened by the ISG Task Force to deliberate on this matter and write a consensus guidance document for Indian practice. The delegates including gastroenterologists, hepatologists, radiologists, and surgeons from different parts of the country participated in the consensus development meeting at Coorg in 2018. A core group was constituted which reviewed all published literature on portal hypertensive UGIB with special reference to the Indian scenario and prepared unambiguous statements on different aspects for voting and consensus in the whole group. This consensus was produced through a modified Delphi process and reflects our current understanding and recommendations for the diagnosis and management of portal hypertensive UGIB in Indians. Intended for use by the health care providers especially gastroenterologists and hepatologists, these consensus statements provide an evidence-based approach to risk stratification, diagnosis, and management of patients with portal hypertensive bleeding.

Native Vertebral Osteomyelitis in Patients with Staphylococcus aureus Bacteremia

BACKGROUND

The purpose of the study was to assess the epidemiology, risk factors and outcomes of native vertebral osteomyelitis (NVO) in patients with Staphylococcus aureus bacteremia (SAB).

METHODS

A retrospective institutional review was conducted at Mayo Clinic, Minnesota. Patients aged ≥ 18 years with SAB who developed NVO from January 1, 2006 to December 31, 2020 were included and 3-month follow-up data were abstracted. Data pertaining to patient demographics, risk factors and outcomes were recorded using REDCap. A 1:2 nested case-control analysis was performed, and controls were matched according to age, sex and year of SAB diagnosis.

RESULTS

A total of 103 patients had NVO. A majority (60.2%) of patients was male, with a median age of 62.0 years. Thirty-one (30.1%) cases were caused by methicillin-resistant S. aureus (MRSA). The lumbar spine was most commonly (57.6%) and the most commonly reported comorbid conditions included diabetes mellitus (36.9%) and coronary artery disease (27.2%). Mortality at three-month follow-up was 18.6%. Nested case-control analysis revealed that injection drug use (IDU) and tobacco consumption were significant risk factors associated with NVO, while chronic hemodialysis and chronic liver disease (CLD) were associated with a decreased risk of NVO.

CONCLUSIONS

Atherosclerotic vascular disease was prominent in our contemporary cohort with NVO in the setting of SAB. Diabetes mellitus, tobacco consumption, older age and male sex likely contributed to this profile. Because IDU was associated with NVO, an increased number of cases should be anticipated among patients with IDU given the ongoing opioid epidemic in the United States.

Serum C-reactive protein and neutrophil-to-lymphocyte ratio as predictors of survival in cirrhotic patients with systemic inflammatory response syndrome and bacterial infection

BACKGROUND

Cirrhotic patients are prone to infections due to underlying immune dysfunction in them. We aimed to study the role of inflammatory markers, serum C-reactive protein (CRP) and neutrophil-to-lymphocyte ratio (NLR), in predicting infection, blood culture positivity, and short-term (1 month) mortality in hospitalized cirrhotic patients.

METHODS

This prospective study was done over a period of 14 months (October 2017 to November 2018). Patient data included age, gender, etiology of cirrhosis, reason for admission, and comorbidity. Laboratory tests included blood chemistry and blood cell counts, and blood and urine culture. The specific tests included were CRP and NLR. Survival of patients in the following 1 month was noted. Area under receiver operating characteristic curve (AUROC), sensitivity, specificity, predictive values, diagnostic accuracy were calculated and logistic regression analysis performed. A p-value < 0.05 was considered significant.

RESULTS

Two hundred and eight patients formed the study cohort. The median age was 51.5 years and male predominance was noted. Alcohol-related liver disease (49%) was the commonest etiology. The infection rate was 62%, culture positivity was 58.5%, and mortality was 30.8%. NLR and CRP were significantly higher in those with documented infection (culture positive or negative) and among nonsurvivors. Optimal cutoffs for NLR and CRP to predict infection were 5.86 and 33.7, respectively. The risk of having an infection was 7.5 times and about 15 times if NLR and CRP were above the cutoffs. The risk of 1-month mortality was 2-3 times higher if patients had NLR and CRP above the cutoffs. The combination of NLR and CRP (≥ 5.86 and ≥ 33.7, respectively) increased specificity and diagnostic accuracy for infection.

CONCLUSION

NLR and CRP were independently good predictors of infection and 1-month survival among the patients with cirrhosis of liver included in this study.

Taxonomy, virulence determinants and antimicrobial susceptibility of Aeromonas spp. isolated from bacteremia in southeastern China

Background

The study aimed to elucidate the species taxonomy, clinical manifestations, virulence gene profiles and antimicrobial susceptibilities of Aeromonas strains isolated from life-threatening bacteremia in southeastern China.

Methods

Clinical samples of Aeromonas causing bacteremia were isolated from a teaching hospital in Wenzhou from 2013 to 2018 and a retrospective cohort study was performed. Aeromonas strains were identified at species level by housekeeping gene gyrB. Virulence and drug resistance-associated genes were screened by polymerase chain reaction (PCR) and antimicrobial susceptibility testing (AST) was performed by the VITEK 2 Compact system.

Results

A total of 58 Aeromonas isolated from patients with bacteremia were collected during 6 years (2013–2018). 58 isolates were identified to five different species, where Aeromonas dhakensis appeared to be the predominant species (26/58), followed by Aeromonas veronii (13/58), Aeromonas caviae (10/58), Aeromonas hydrophila (7/58) and Aeromonas jandaei (2/58). 16 of 58 patients had poor prognosis. Poor prognosis was significantly associated with liver cirrhosis and inappropriate empirical antimicrobials therapy. The progression of bacteremia caused by Aeromonas was extremely fast, especially in A. dhakensis infections. Virulence genes aer, lip, hlyA, alt, ast, and act, were detected at ratios of 24.1% (14/58), 62.1% (36/58), 65.5% (38/58), 58.6% (34/58), 15.5% (9/58) and 65.5% (38/58), respectively. Antimicrobial susceptibility testing exhibited that 9 out of 58 isolates were identified as multi-drug resistant (MDR) organism. The bla_TEM gene was identified in all 9 MDR isolates. bla_SHV, bla_AQU-1, bla_MOX, bla_CepH, bla_CphA and aac(6′)-Ib-cr were detected in 4 isolates, 2 isolates, 1 isolate, 3 isolates, 8 isolates, and 3 isolates, respectively. The majority of Aeromonas strains maintained susceptible to 3rd generation cephalosporins, aminoglycosides, fluoroquinolones and furantoin.

Conclusions

The prevalence and dangerousness of Aeromonas infections, especially A. dhakensis, are underestimated in clinic. Continuous monitoring is essential to keep track of MDR Aeromonas due to the increasing prevalence recently and a more effective measure is required to control the spread of resistance determinants.

Continuous elevation of procalcitonin in cirrhosis combined with hepatic carcinoma: a case report

BACKGROUND

Serum levels of procalcitonin (PCT) are considered a useful biomarker for the diagnosis of bacterial infection or inflammation. There are few reports of high PCT levels in end-stage liver disease regardless of bacterial infection. Here, we present a case of extremely high PCT levels (> 100 ng/mL) in a patient with severe cirrhosis combined with hepatic carcinoma.

CASE PRESENTATION

A 65-year-old man developed end-stage cirrhosis with hepatic carcinoma. Radiographic imaging showed a massive hepatocellular carcinoma with multiple loci lack of indications of resection. Hence, transcatheter hepatic arterial chemoembolization was performed three times over a period of 4 months. Before and after interventional therapies, the biochemistry laboratory results were only slightly abnormal except for persistently high PCT concentrations (> 100 ng/mL), irrespective of the evidence for bacterial infection or sepsis.

CONCLUSIONS

This case suggests that continuously high levels of PCT (> 100 ng/mL) may be present in advanced liver disease, particularly in complex situations such as decompensated cirrhosis and liver cancer, in the absence of severe infection or sepsis. This knowledge could expand the significance of PCT in liver disease.

Compromised Ileal Mucus Barrier Due to Impaired Epithelial Homeostasis Caused by Notch1 Signaling in Cirrhotic Rats

BACKGROUND

In liver cirrhosis, intestinal mucus barrier is rarely studied.

AIMS

This study aimed to investigate whether mucus barrier in ileum is altered in cirrhotic rats and its underlying mechanisms.

METHODS

Thioacetamide was injected to induce liver cirrhosis in rats. Serum from portal vein blood, and ileum and liver tissues were obtained for further analysis. Goblet cell-like Ls174T cells were cultured for in vitro experiments.

RESULTS

The ileal mucus was thin, loose, and porous with small bubbles in cirrhotic rats. mRNA expressions of Muc2 and TFF3 were also down-regulated in cirrhotic rats. Bacteria located near to crypts and LPS were increased in the serum from portal vein in cirrhotic rats. Smaller theca area and few goblet cells were found in cirrhotic rats compared with control. Increased proliferation of ileal epithelia was observed in cirrhotic rats. Notch1, Dll1, and Hes1 expressions were enhanced, and KLF4 expression was suppressed in ileum of cirrhotic rats. In Ls174T cells, EDTA and NICD plasmid induced NICD and Hes1 expression and suppressed KLF4 concomitantly, and mucus expression almost vanished in these cells. NICD plasmid induced more proliferation in Ls174T cells. Oppositely, after DBZ treatment, NICD and Hes1 were inhibited along with augmentation of KLF4 and increased mucous expression in Ls174T cells, while proliferation of the cells was suppressed.

CONCLUSIONS

In cirrhotic rats, mucus barrier was impaired. This might be attributed to increased proliferation and decreased differentiation of epithelia, which might be mediated by Notch1-Hes1-KLF4 signaling.

Coexisting Cirrhosis Worsens Inpatient Outcomes in Patients With Infective Endocarditis: A Cross-Sectional Analysis of the National Inpatient Sample 2013-2014

Introduction

Cirrhosis is known to be an important prognostic factor in determining morbidity and mortality in preoperative cardiac risk assessment for cardiac surgery. Data is limited on outcomes in patients with infective endocarditis (IE) and comorbid liver cirrhosis. The objective of our study is to evaluate the clinical outcomes in patients suffering from IE both with and without underlying liver cirrhosis as well as to determine rates of in-hospital mortality and factors that contribute to this outcome.

Hypothesis

Liver cirrhosis worsens clinical outcomes in patients with IE.

Materials and methods

Patients with a principal diagnosis of IE with and without liver cirrhosis were identified by querying the Healthcare Cost and Utilization (HCUP) database, specifically the National Inpatient Sample for the years 2013 and 2014 using International Classification of Diseases, Ninth Revision (ICD-9) codes.

Results

During 2013 and 2014, a total of 17,952 patients were admitted with a diagnosis of IE, out of whom 780 had concurrent liver cirrhosis. There was increased in-hospital mortality [15.6% vs 10.2%, aOR = 1.57 (1.27-1.93)], acute kidney injury [41.4% vs 32.6%, aOR = 1.45 (1.24-1.69)], and hematologic complications [32.1 vs 14.7%, aOR = 2.87 (2.44-3.37)] in patients with IE with liver cirrhosis when compared to patients with IE without liver cirrhosis. Patients having IE without liver cirrhosis underwent an increased number of interventions, i.e. aortic (7.2 vs 3.7%, aOR = 0.51 (0.34-0.76)) and mitral (4.9% vs 3.4%, aOR = 0.39 (0.23-0.69)) valvular replacements as compared to those with liver cirrhosis, which may explain the increased mortality seen in patients with liver cirrhosis.

Conclusion

Liver cirrhosis is an important prognostic risk factor for in-hospital mortality in patients with IE. The coagulopathic state in addition to increased rates of bleeding complications and renal dysfunction make these patients poor surgical candidates thus contributing to higher mortality. Further research into the individual risk factors contributing to the increased mortality rates in patients with IE and cirrhosis is required.

Comparing Mortality Risk Predictive Ability of Different Scoring Systems in Cirrhotic Patients with Bacteremia

Patients with liver cirrhosis and bacteremia have substantially higher risk of mortality and morbidity. Our study aimed to investigate scoring systems that can predict the mortality risk in patients with cirrhosis and bacteremia. A single-center, retrospective cohort study was performed among adult patients who visited the emergency department from January 2015 to December 2018. All patients diagnosed with liver cirrhosis and bacteremia were enrolled and divided into survivor and nonsurvivor groups for comparison based on their 30-day in-hospital mortality event. The Pitt bacteremia score (PBS), model for end-stage liver disease (MELD) score, Child–Pugh score, and quick sequential Organ Failure Assessment (qSOFA) score were calculated and compared using the area under the receiver operating characteristic (AUROC) curves. A total of 127 patients (survivor: 86; nonsurvivor: 41) were eligible for this study. Compared with the nonsurvivor group, patients in the survivor group had significantly lower MELD score (22 ± 7 vs. 29 ± 5, p < 0.001), lower proportion of high qSOFA (score ≥ 2) (23.3% vs. 51.2%, p < 0.01), and high PBS (score ≥ 4) (7.0% vs. 34.1%, p < 0.001) category. There was also a significantly different distribution in Child–Pugh classification between the two groups (p < 0.01). The survivor group had significantly lower proportion of acute-on-chronic liver failure (27.9% vs. 68.3%, p < 0.001) and fewer number of organ failures (p < 0.001). In comparison of the discriminative ability in mortality risk prediction, PBS (AUROC = 0.83, 95% CI = 0.75–0.90, p < 0.001) and MELD scores (AUROC = 0.78, 95% CI = 0.70–0.86, p < 0.001) revealed a better predictive ability than Child–Pugh (AUROC = 0.69, 95% CI = 0.59–0.70, p < 0.01) and qSOFA scores (AUROC = 0.65, 95% CI = 0.54–0.75, p < 0.01). PBS and MELD scores both demonstrated a superior ability of predicting mortality risk in cirrhotic patients with bacteremia.

Intestinal permeability and bacterial translocation in patients with liver disease, focusing on alcoholic aetiology: methods of assessment and therapeutic intervention

Increased bacterial translocation (BT) across the gut barrier due to greater intestinal permeability (IP) is seen across a range of conditions, including alcohol-related liver disease (ArLD). The phenomenon of BT may contribute to both the pathogenesis and the development of complications in ArLD. There are a number of methods available to assess IP and in this review we look at their various advantages and limitations. The knowledge around BT and IP in ArLD is also reviewed, as well as the therapeutic strategies currently in use and in development.

Extended Infusion of β-Lactams for Bloodstream Infection in Patients With Liver Cirrhosis: An Observational Multicenter Study

BACKGROUND

We analyzed the impact of continuous/extended infusion (C/EI) vs intermittent infusion of piperacillin-tazobactam (TZP) and carbapenems on 30-day mortality of patients with liver cirrhosis and bloodstream infection (BSI).

METHODS

The BICRHOME study was a prospective, multicenter study that enrolled 312 cirrhotic patients with BSI. In this secondary analysis, we selected patients receiving TZP or carbapenems as adequate empirical treatment. The 30-day mortality of patients receiving C/EI or intermittent infusion of TZP or carbapenems was assessed with Kaplan-Meier curves, Cox-regression model, and estimation of the average treatment effect (ATE) using propensity score matching.

RESULTS

Overall, 119 patients received TZP or carbapenems as empirical treatment. Patients who received C/EI had a significantly lower mortality rate (16% vs 36%, P = .047). In a Cox-regression model, the administration of C/EI was associated with a significantly lower mortality (hazard ratio [HR], 0.41; 95% confidence interval [CI], 0.11-0.936; P = .04) when adjusted for severity of illness and an ATE of 25.6% reduction in 30-day mortality risk (95% CI, 18.9-32.3; P < .0001) estimated with propensity score matching. A significant reduction in 30-day mortality was also observed in the subgroups of patients with sepsis (HR, 0.21; 95% CI, 0.06-0.74), acute-on-chronic liver failure (HR, 0.29; 95% CI, 0.03-0.99), and a model for end-stage liver disease score ≥25 (HR, 0.26; 95% CI, 0.08-0.92). At competing risk analysis, C/EI of beta-lactams was associated with significantly higher rates of hospital discharge (subdistribution hazard [95% CI], 1.62 [1.06-2.47]).

CONCLUSIONS

C/EI of beta-lactams in cirrhotic patients with BSI may improve outcomes and facilitate earlier discharge.

Comparing the Prognosis of Patient with Alcohol and Nonalcohol-Associated Cirrhosis with Bacteremia

Aims

Patients with liver cirrhosis are more susceptible to bacteremia and more likely to have a poor prognosis in comparison to healthy individuals. Studies on the role of alcohol in cirrhotic patients with bacteremia are limited. Our study aimed to investigate the clinical characteristics and prognostic differences between the patients with alcohol and non-alcohol-associated cirrhosis with bacteremia.

Methods

A single-center, retrospective cohort study was conducted among adult patients who presented to the emergency department from January 2015 to December 2018. All patients diagnosed with liver cirrhosis and bacteremia were enrolled and divided into alcohol-associated and non-alcohol-associated groups according to the etiology of their cirrhosis. We compared their clinical characteristics, laboratory results, microbiological data, and infection source as well as outcome measurements between the two groups.

Results

A total of 112 cirrhotic patients with bacteremia (alcohol-associated: 67; non-alcohol-associated: 45) were eligible for this study. In comparison with the non-alcohol-associated group, patients in the alcohol-associated group had a significantly higher rate of intensive care unit transfer (41.8% vs. 22.2%, P = 0.04), septic shock occurrence (56.7% vs. 35.6%, P = 0.04) and 30-day mortality risk (37.3% vs. 15.6%, P = 0.02). Moreover, alcohol-associated cirrhosis and Model for End-Stage Liver Disease score were independent predictors of 30-day mortality in cirrhotic patients with bacteremia.

Conclusions

The etiology of liver cirrhosis influences the outcomes of patients with bacteremia as well as the severity of their cirrhosis.

Epidemiological Trend of Sepsis in Patients with Hospital Admissions Related to Hepatitis C in Spain (2000-2015): A Nationwide Study

Background: Hepatitis C virus (HCV) infection predisposes patients to other infectious diseases, such as sepsis. We aimed to analyze epidemiological trends of sepsis-related admissions, deaths, and costs in hospital admissions with chronic hepatitis C who had a hospital admission in Spain. Methods: We performed a retrospective study of all hospitalizations involving chronic hepatitis C in the Spanish Minimum Basic Data Set (MBDS) between 2000 and 2015. This period was divided into four calendar periods (2000–2004, 2005–2007, 2008–2011, and 2012–2015). Results: We selected 868,523 hospital admissions of patients with chronic hepatitis C over 16 years in the Spanish MBDS. Among them, we found 70,976 (8.17%) hospital admissions of patients who developed sepsis, of which 13,915 (19.61%) died during admission. We found an upward trend, from 2000–2003 to 2012–2015, in the rate of sepsis-related admission (from 6.18% to 10.64%; p < 0.001), the risk of sepsis-related admission (from 1.31 to 1.55; p < 0.001), and the sepsis-related cost per hospital admission (from 7198€ to above 9497€; p < 0.001). However, we found a downward trend during the same study period in the sepsis case-fatality rate (from 21.99% to 18.16%; p < 0.001), the risk of sepsis-related death (from 0.81 to 0.56; p < 0.001), and the length of hospital stay (LOHS) (from 16.9 to 13.9; p < 0.001). Moreover, the rate of bacterial Gram-positive and candidiasis infections decreased, while Gram-negative microorganisms increased from 2000–2003 to 2012–2015. Conclusions: Sepsis, in chronic hepatitis C patients admitted to the hospital, has increased the period 2000–2015 and has been an increasing burden for the Spanish public health system. However, there has also been a significant reduction in lethality and LOHS during the study period. In addition, the most prevalent specific microorganisms have also changed in this period.

Microbial Etiology of Pyogenic Vertebral Osteomyelitis According to Patient Characteristics

Background

It is difficult to select an appropriate empirical antibiotic treatment regimen for patients with culture-negative pyogenic vertebral osteomyelitis (PVO). Having knowledge of the distribution of microorganisms according to patient characteristics can help clinicians make informed choices regarding empirical antibiotics. The aim of this study was to determine the microbial distribution among individuals with PVO according to their demographic and clinical characteristics.

Methods

We reviewed the medical records of patients admitted to our hospital with culture-confirmed PVO between January 2005 and December 2017 and collected data on demographics, underlying diseases, and radiographic and microbiological results. Statistical analysis was performed to identify associations between specific bacteria and specific patient characteristics.

Results

A total of 586 patients were included in the study. The prevalence of Staphylococcus aureus infections was higher in young patients than in old patients, while gram-negative bacterial infections and Enterococcus were more prevalent in older patients. Gram-negative bacterial infections were more common in women than in men (32.1% vs 16.4%; P < .05), in patients with cirrhosis than in those without (32.7% vs 21.1%; P < .05), and in patients with a solid tumor than in those without (31.0% vs 20.7%; P < .05). Methicillin-resistant S. aureus infections were more prevalent in patients with chronic renal disease than in those without (34.4% vs 14.7%; P < .05).

Conclusions

The microbial etiology of PVO varies according to patient characteristics. Patient characteristics should thus be considered when choosing empirical antibiotics in patients with culture-negative PVO.

Afebrile Bacteremia in Adult Emergency Department Patients with Liver Cirrhosis: Clinical Characteristics and Outcomes

Cirrhotic patients with bacteremia are at an increased risk of organ failure and mortality. In addition, they can develop serious infection without fever because of their impaired immune response. Our study aimed to investigate the clinical characteristics and outcomes in afebrile bacteremic patients with liver cirrhosis. A single-center, retrospective cohort study was performed on adult patients who visited the emergency department from January 2015 to December 2018. All patients with bacteremia and diagnosis of liver cirrhosis were enrolled and classified as either afebrile or febrile. In total, 104 bacteremic patients with liver cirrhosis (afebrile: 55 patients and, febrile: 49) were included in the study. Compared with the febrile group, patients in the afebrile group showed a significantly higher rate of inappropriate antibiotics administration (43.6% vs. 20.4%, p = 0.01). They were also at an increased risk of 30-day mortality (40% vs. 18.4%, p = 0.02), intensive care unit transfer (38.2% vs. 18.4%, p = 0.03) and endotracheal intubation (27.3% vs. 10.2%, p = 0.03). The afebrile state was also an independent risk factor associated with 30-day mortality in cirrhotic patients with bacteremia. Clinicians should perform a prudent evaluation in cirrhotic patients and carefully monitor for possible signs of serious infection even in the absence of fever.

Risk factors for candidaemia in hospitalized patients with liver cirrhosis: a multicentre case-control-control study

OBJECTIVES

The aim of this study was to evaluate the risk factors for candidaemia in patients with liver cirrhosis.

METHODS

This was a case-control-control (1:2:2) study performed in four Italian tertiary centres from 2006 to 2015. Cases were patients with liver cirrhosis developing candidaemia. For every case of candidaemia we enrolled two additional patients undergoing blood cultures for suspected infection yielding isolation of a bacterial pathogen (control A) and two additional patients undergoing blood cultures for suspected infection yielding negative results (control B). Patients were matched according to age, sex and model for end stage liver disease at hospital admission.

RESULTS

During the study period 90 cases, 180 controls A and 180 controls B were included. At multivariate analysis assessed by means of multinomial conditional regression models, factors independently associated with candidaemia were previous (<30 days) acute-on-chronic liver failure (relative risk ratio (RRR) 2.22 (95% confidence interval (CI) 1.09-4.54), p = 0.046), previous(<30 days) gastrointestinal endoscopy (RRR 2.38 (95% CI 1.19-4.78) p = 0.014), previous(<30 days) antibiotic treatment for at least 7 days (RRR 2.74 (95% CI 1.00-7.48), p = 0.049), presence of central venous catheter (RRR 2.77 (95% CI 1.26-6.09, p = 0.011), total parenteral nutrition (RRR 3.90 (95% CI 1.62-9.40), p = 0.002) at infection onset and length of in-hospital stay >15 days (RRR 4.63 (95% CI 2.11-10.18), p <0.001] Conversely, rifaximin treatment was associated with lower rate of candidaemia (RRR 0.38 (95% CI 0.19-0.77), p = 0.007). Multivariable analysis for 30-day mortality showed that patients with isolation of Candida spp. from blood cultures had worse outcome when compared with controls even though the difference did not reach a statistical significance (hazard ratio 1.64 (95% 0.97-2.75) p = 0.06).

CONCLUSIONS

We identified previous antibiotic use, gastrointestinal endoscopy or acute-on-chronic liver failure and presence of central venous catheter especially for parenteral nutrition as independent factors associated with candidaemia. Surprisingly, chronic rifaximin use was a protective factor.

Bacterial Infections in Patients with Liver Cirrhosis in an Internal Medicine Department

BACKGROUND AND AIMS

Liver cirrhosis (LC) is the end stage of multiple processes that lead to hepatic failure and is the 10th most common cause of death in the Western world. Bacterial infections are one of the most important clinical problems in patients with LC, as their underlying immune status is compromised. Approximately 60% of bacterial infections in cirrhotic patients are community acquired (CA) and 40% are nosocomial. The most common infections in cirrhotic patients are spontaneous bacterial peritonitis (SBP) (25%), urinary tract infection (UTI) (20%), pneumonia (15%), bacteremia (12%), and cellulitis (2-11%). The aim of this study was to evaluate the most frequent infections in patients with LC and describe the evolution of the microbiology in these patients.

MATERIAL AND METHODS

This is a retrospective analysis of 4 interspersed years (2008, 2010, 2012, and 2014) that included 372 patients. Demographic characteristics were evaluated, including gender, age, type of infection, bacteria resistance profile, antibiotic use, Child-Pugh-Turcotte and Model for End-Stage Liver Disease scores, and mortality rate.

RESULTS

The mean age of all patients enrolled in this study was 64.5 ± 12.2 years. Male patients were significantly more prevalent than female ones (72 vs. 28%). In the 4 analyzed years, the following numbers of infections occurred: 71 infections (49% CA and 51% nosocomial) in 2008; 86 infections (60.5% CA and 39.5% nosocomial) in 2010; 99 infections (56.6% CA and 43.4% nosocomial) in 2012; and 116 infections (70.7% CA and 29.3% nosocomial) in 2014. The most frequent infections were UTI (32.5%), respiratory tract infection (29.3%), SBP (26.1%), and cellulitis (6.2%). A microbiological agent was identified in 32.4, 59.3, 53.5, and 61.2% of infections in 2008, 2010, 2012, and 2014, respectively, with a predominance of gram-negative bacilli. In all series, a third-generation cephalosporin was the most frequent antibiotic used empirically. The majority of patients was in stage B (42.7%) of the Child-Pugh-Turcotte score, followed by stage C (39.3%) and stage A (18%). Mortality increased significantly over the years, from 7% in 2008 to 25% in 2014 (p = 0.016).

CONCLUSIONS

The present study showed a high prevalence of bacterial infections in patients with LC. A high rate of suspicion is needed for an infectious process in these patients, and an appropriate antibiotic treatment can decrease the morbidity and mortality in cirrhotic patients.

Microbial Infections as a Trigger for Acute-on-Chronic Liver Failure: A Review

Microbial infection is an important cause of acute-on-chronic liver failure (ACLF), which is a syndrome that results in multiple organ dysfunction or failure and is accompanied by an increased short-term risk of mortality. Early detection and treatment of microbial infection can effectively reduce the mortality of patients with ACLF. However, antimicrobial resistance has recently increased due to the increased use of antimicrobial agents. Therefore, it is important to choose appropriate antibiotics and antifungal agents for early prevention or treatment of patients with microbial infection and ACLF to reduce the occurrence of drug resistance and to reduce patient mortality. This review summarizes the current status in the understanding of the epidemiology, pathogenesis, early diagnosis, treatment, and strategies for prevention of microbial infection in patients with ACLF.

Causes and Consequences of Innate Immune Dysfunction in Cirrhosis

Liver cirrhosis is an increasing health burden and public health concern. Regardless of etiology, patients with cirrhosis are at risk of a range of life-threatening complications, including the development of infections, which are associated with high morbidity and mortality and frequent hospital admissions. The term Cirrhosis-Associated Immune Dysfunction (CAID) refers to a dynamic spectrum of immunological perturbations that develop in patients with cirrhosis, which are intimately linked to the underlying liver disease, and negatively correlated with prognosis. At the two extremes of the CAID spectrum are systemic inflammation, which can exacerbate clinical manifestations of cirrhosis such as hemodynamic derangement and kidney injury; and immunodeficiency, which contributes to the high rate of infection in patients with decompensated cirrhosis. Innate immune cells, in particular monocytes/macrophages and neutrophils, are pivotal effector and target cells in CAID. This review focuses on the pathophysiological mechanisms leading to impaired innate immune function in cirrhosis. Knowledge of the phenotypic manifestation and pathophysiological mechanisms of cirrhosis associated immunosuppression may lead to immune targeted therapies to reduce susceptibility to infection in patients with cirrhosis, and better biomarkers for risk stratification, and assessment of efficacy of novel immunotherapies.

Bloodstream infection due to Escherichia coli in liver cirrhosis patients: clinical features and outcomes

OBJECTIVES

The study aimed to investigate the clinical characteristics and antibiotic management, as well as independent indicators for survival within 30 days for Escherichia coli bloodstream infection (BSI) in liver cirrhosis.

RESULTS

Hospital-acquired BSI accounted for 60.07%, with prolonged hospital stay (P = 0.000). The prevalence of Extended Spectrum Beta-Lactamases (ESBL) producing bacteria was 48.26%, which correlated with ICU admission (P = 0.015) and high model for end-stage liver disease (MELD) score at onset of BSI (P = 0.035). Moreover, ESBL producing pathogens showed a high resistant to the common antibiotic families and 27.5% pathogens were confirmed as multidrug-resistant (MDR). MDR infection was significantly correlated with ESBL production, ICU admission, inappropriate empiric therapy, resistance to firstly selected antibiotic, and infection duration (P < 0.05 for all). In addition, appropriate empiric therapy within 48 h (HR = 2.581, 95% CI = 1.166-5.715), ICU admission (HR = 4.434, 95% CI = 2.130-8.823), HE (HR = 2.379, 95% CI = 1.115-5.073) and final MELD (HR = 1.074, 95% CI = 1.044-1.106) were independent indicators for 30-day mortality.

MATERIALS AND METHODS

The clinical data were collected from 288 eligible patients, and compared according to survival status and sites of infection acquisition. Drug resistance was recorded according to ESBL. In addition, cox regression analysis model was applied to evaluate the risk factors for 30-day mortality.

CONCLUSIONS

ESBL production can promote resistance to antibiotics in Escherichia coli. Antibiotic regimens, ICU admission, HE and MELD score can help identify the risk individuals who will benefit from the improved therapeutic regimens.

Management of bacterial and fungal infections in end stage liver disease and liver transplantation: Current options and future directions

Patients with liver cirrhosis are susceptible to infections due to various mechanisms, including abnormalities of humoral and cell-mediated immunity and occurrence of bacterial translocation from the intestine. Bacterial infections are common and represent a reason for progression to liver failure and increased mortality. Fungal infections, mainly caused by Candida spp., are often associated to delayed diagnosis and high mortality rates. High level of suspicion along with prompt diagnosis and treatment of infections are warranted. Bacterial and fungal infections negatively affect the outcomes of liver transplant candidates and recipients, causing disease progression among patients on the waiting list and increasing mortality, especially in the early post-transplant period. Abdominal, biliary tract, and bloodstream infections caused by Gram-negative bacteria [e.g., Enterobacteriaceae and Pseudomonas aeruginosa (P. aeruginosa)] and Staphylococcus spp. are commonly encountered in liver transplant recipients. Due to frequent exposure to broad-spectrum antibiotics, invasive procedures, and prolonged hospitalizations, these patients are especially at risk of developing infections caused by multidrug resistant bacteria. The increase in antimicrobial resistance hampers the choice of an adequate empiric therapy and warrants the knowledge of the local microbial epidemiology and the implementation of infection control measures. The main characteristics and the management of bacterial and fungal infections in patients with liver cirrhosis and liver transplant recipients are presented.

Bacteremia in Patients With Liver Cirrhosis: Prevalence and Predictors of Multidrug Resistant Organisms

GOALS

The objective of this study was to assess the prevalence and predictors of multidrug resistant organisms (MDRO) in cirrhotic patients with bacteremia at a large tertiary center in the United States.

BACKGROUND

The epidemiology of bacteremia in patients with liver cirrhosis has not been well studied in the United States.

STUDY

This case-case control study included 180 adults with liver cirrhosis hospitalized from 2011 to 2015. Case group 1 were patients with bacteremia due to a MDRO (n=30). Case group 2 were patients with bacteremia due to a non-MDRO (n=60). Control group comprised patients without bacteremia (n=90). MDRO was defined as bacteria that was nonsusceptible to ≥1 agent in ≥3 antimicrobial categories.

RESULTS

Of the 90 bacteremia episodes, 44% were because of gram-positive bacteria, 50% were because of gram-negative bacteria, and 6% were polymicrobial. MDROs caused 30 of 90 (33%) bacteremia episodes, including methicillin-resistant Staphylococcus species [12% (11/90)], fluoroquinolone-resistant Enterobacteriaceae [10% (9/90)], and Enterococcus faecium [3% (3/90)]. Eight percent of Enterobacteriaceae produced extended-spectrum β-lactamases. Four independent predictors of MDROs were identified: nonwhite race [adjusted odds ratio (aOR), 3.35; 95% confidence interval (CI), 1.19-9.38], biliary cirrhosis (aOR, 11.75; 95% CI, 2.08-66.32), blood cultures obtained >48 hours after hospital admission (aOR, 6.02; 95% CI, 1.70-21.40), and recent health care exposure (aOR, 9.81; 95% CI, 2.15-44.88).

CONCLUSIONS

A significant proportion of bacteremia in cirrhotic patients was due to MDROs at a large US tertiary care center. Local epidemiology data and identification of risk factors associated with MDROs may help with optimal empiric antibiotic selection.

Echinocandins for management of invasive candidiasis in patients with liver disease and liver transplantation

Candida species remains one of the most important causes of opportunistic infections worldwide. Invasive candidiasis (IC) is associated with considerable morbidity and mortality in liver disease (LD) patients if not treated promptly. Echinocandins are often recommended as a first-line empirical treatment for managing IC and can especially play a critical role in managing IC in LD patients. However, advanced LD patients are often immunocompromised and critically ill. Hence altered pharmacokinetics, drug interactions as well as tolerance issues of antifungal treatments are a concern in these patients. This comprehensive review examines the epidemiology, risk factors and diagnosis of IC in patients with LD and evaluates differences between three available echinocandins for treating this group of patients.

Bacteremia in cirrhotic patients with upper gastrointestinal bleeding

BACKGROUND/AIMS

Increased risk of bacterial infection is common in cirrhotic patients with upper gastrointestinal bleeding (UGIB). Our study aimed to explore the association of the bacteremia with in-hospital mortality and risk factors of bacteremia in these patients.

MATERIALS AND METHODS

In our retrospective cohort study, we collected data for cirrhotic patients with UGIB admitted to our hospital between August 2010 and December 2010. The primary outcome was in-hospital mortality. The secondary outcome was bacteremia. A multivariate logistic regression analysis was performed to determine risk factors for mortality and bacteremia.

RESULTS

A total of 202 patients with cirrhosis presenting with UGIB at the emergency department (ED) were enrolled. Bacteremia was associated with a higher mortality rate (adjusted odds ratio [OR]: 9.7; 95% confidence interval [CI]: 1.9-50.6, p=0.007), whereas shock (systolic blood pressure <90 mmHg at ED triage) and bandemia (>0% immature neutrophils of band form) were associated with bacteremia in cirrhotic patients with UGIB (adjusted OR: 5.3; 95% CI: 2.3-12.7, p<0.0001 and adjusted OR: 4.0; 95% CI: 1.6-9.9, p=0.0003, respectively).

CONCLUSION

Bacteremia in cirrhotic patients with UGIB is one of the major risk factors leading to in-hospital mortality. On the basis of our findings, prevention of bacteremia in cirrhotic patients with UGIB, especially in those with shock and bandemia, is important; thus, adequate antibiotic treatment is suggested.