1
|
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: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
Collapse
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
| |
Collapse
|
2
|
Niyas VK, Keri VC, Kumar P. Endotipsitis: An Underdiagnosed Complication of Transjugular Intrahepatic Portosystemic Shunts. J Clin Exp Hepatol 2022; 12:222-224. [PMID: 35068804 PMCID: PMC8766577 DOI: 10.1016/j.jceh.2021.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 02/28/2021] [Indexed: 01/03/2023] Open
Abstract
Recurrent hematemesis and ascites due to portal hypertension are treated by Transjugular Intrahepatic Portosystemic Shunt (TIPS) to decompress the portal system. Many causes can be attributed to fever in such patients, one of them being, endotipsitis. Awareness among the clinicians about the existence of such a condition needs to be enhanced to avoid underdiagnosis. The diagnosis of endotipsitis, a primary vegetative infection of the TIPS, requires a high index of suspicion. Here we describe one such case that presented with prolonged fever and sustained bacteremia with a history of TIPS thrombosis. After ruling out all possible causes of fever a diagnosis of probable endotipsitis was made and treated successfully with prolonged targeted antimicrobial therapy without further relapses. Only a handful of cases have been described in literature, and there is an urgent need to develop standard management guidelines. Because definitive treatment, which involves removal of the shunt requires liver transplantation, which is not practically feasible always.
Collapse
Affiliation(s)
- Vettakkara K.M. Niyas
- Infectious Diseases, Department of Medicine and Microbiology, All India Institute of Medical Sciences, New Delhi, India
| | - Vishakh C. Keri
- Infectious Diseases, Department of Medicine and Microbiology, All India Institute of Medical Sciences, New Delhi, India,Address for correspondence:
| | - Prabhat Kumar
- Department of Medicine, A.B.V.I.M.S & Dr RML Hospital, New Delhi, India
| |
Collapse
|
3
|
Lattanzi B, D’Ambrosio D, Merli M. Hepatic Encephalopathy and Sarcopenia: Two Faces of the Same Metabolic Alteration. J Clin Exp Hepatol 2019; 9:125-130. [PMID: 30765945 PMCID: PMC6363954 DOI: 10.1016/j.jceh.2018.04.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 04/25/2018] [Indexed: 12/12/2022] Open
Abstract
Sarcopenia is an important burden in liver cirrhosis representing a negative prognostic factor for mortality. Moreover, sarcopenia is an independent predictor of complications in patients with liver cirrhosis, including Hepatic Encephalopathy (HE). An association between sarcopenia and HE in liver cirrhosis has been reported in recent studies, indeed both these complications often affect patients with advanced liver cirrhosis and may exert a synergic effect in deteriorating patients' outcome. Episodes of HE occur more often in patients with muscle depletion. The rationale for these finding is based on the role played by muscle in ammonia detoxification due to the inability of urea synthesis in the cirrhotic liver. Consequently, muscle depletion may have relevant implications in favoring hyperammonemia and HE. At the same time hyperammonemia has been found to impair muscle protein synthesis through myostatin down-regulation. From this point of view, modulation of diet and amelioration of nutritional status and muscle mass can be considered a potential goal to prevent this vicious circle and improve the cognitive impairment in cirrhotic patients.
Collapse
Affiliation(s)
| | | | - Manuela Merli
- Address for correspondence: Manuela Merli, Department of Clinical Medicine, Gastroenterology Unit, La Sapienza University of Rome, Italy. Tel.: +39 0649972002; fax: +39 0649972002.
| |
Collapse
|
4
|
Abstract
Small intestinal bacterial overgrowth (SIBO) is defined by increased density and/or abnormal composition of microbiota in the small bowel. SIBO is often encountered in patients with cirrhosis as a result of impaired intestinal motility and delayed transit time, both of which are exacerbated by more severe liver disease. Additional risk factors for SIBO commonly encountered in cirrhotic patients include coexisting diabetes, autonomic neuropathy, and/or alcoholic use. Diagnosis of SIBO is performed by breath testing or jejunal aspiration, the gold standard. In cirrhotic patients, the presence of SIBO can lead to profound clinical consequences. Increased intestinal permeability in these patients predisposes to bacterial translocation into the systemic circulation. As a result, SIBO is implicated as a significant risk factor in the pathogenesis of both spontaneous bacterial peritonitis and hepatic encephalopathy in cirrhotics. Antibiotics, especially rifaximin, are the best studied and most effective treatment options for SIBO. However, prokinetics, probiotics, nonselective beta-blockers, and treatment of underlying liver-related pathophysiology with transjugular intrahepatic portosystemic shunt placement or liver transplantation are also being investigated. This review will discuss the risk factors, diagnosis, manifestations in cirrhosis, and treatment options of SIBO.
Collapse
Key Words
- 51Cr-EDTA, 51Cr-Ethylenediaminetetraacetic Acid
- CFUs, Colony-Forming Units
- CP, Child-Pugh Score
- FODMAPS, Fermentable Oligosaccharides, Disaccharides, Monosaccharides, and Polyols
- GI, Gastrointestinal
- HBV, Hepatitis B Virus
- HE, Hepatic Encephalopathy
- IBS, Irritable Bowel Syndrome
- MHE, Minimal Hepatic Encephalopathy
- MMC, Migrating Motor Complex
- OCTT, Orocecal Transit Time
- PH, Portal Hypertension
- PPI, Proton Pump Inhibitor
- SBP, Spontaneous Bacterial Peritonitis
- SBRT, Small Bowel Residence Time
- SBTT, Small Bowel Transit Time
- SIBO, Small Intestinal Bacterial Overgrowth
- TIPS, Transjugular Intrahepatic Portosystemic Shunt
- bacterial translocation
- cirrhosis
- liver disease
- mL, Milliliter
- ppm, Parts Per Million
- small intestinal bacterial overgrowth
Collapse
Affiliation(s)
- Gaurav Ghosh
- Department of Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medicine, 525 E. 68th Street, M-532, New York, NY, 10065, USA
| | - Arun B. Jesudian
- Division of Gastroenterology and Hepatology, NewYork-Presbyterian Hospital/Weill Cornell Medicine, 1305 York Avenue, 4th Floor, New York, NY, 10065, USA,Address for correspondence: Arun B. Jesudian, 1305 York Avenue, 4th Floor, New York, NY, 10065, USA
| |
Collapse
|
5
|
Sonavane AD, Amarapurkar DN, Rathod KR, Punamiya SJ. Long Term Survival of Patients Undergoing TIPS in Budd-Chiari Syndrome. J Clin Exp Hepatol 2019; 9:56-61. [PMID: 30765940 PMCID: PMC6363956 DOI: 10.1016/j.jceh.2018.02.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Accepted: 02/20/2018] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND There has been significant improvement in understanding the etiology and management of Budd-Chiari Syndrome (BCS). Patients with chronic or acute-on-chronic BCS need radiological interventions in the form of angioplasty, hepatic vein/inferior vena cava stenting or Transjugular Intrahepatic Portosystemic Shunt (TIPS). Data regarding the long term follow up of patients undergoing TIPS is limited. We thus prospectively followed-up BCS patients who underwent TIPS at our center. METHODS This study included 42 patients with BCS who underwent TIPS with a covered stent between 2004 and 2014. We analyzed the etiology, symptoms, severity, laboratory parameters and imaging pre and post TIPS. All patients underwent surveillance for hepatocellular carcinoma. RESULTS Patients demographics included 26 males and 16 females with a mean age of 40.5 years (19-68 years). The mean Model for End-Stage Liver Disease score of the entire cohort was 15.38 (range: 9-25). Thirty-four patients were grouped into Rotterdam Class 2 and remaining into Class 3. There was significant improvement in ascites, gastrointestinal bleed, renal function and transaminase levels post TIPS. There were 11 deaths over the follow-up period - 4 within one month, 2 within six months and the rest after 3 years following TIPS. Median duration from clinical presentation to TIPS was 2.1 weeks and median survival till follow-up was 45.5 months (0-130 months). 33/42 patients underwent TIPS prior to 2013, and their median survival till follow-up was 55 months. Six out of eleven deaths that occurred within six months post-TIPS were before 2006; when the technique of TIPS creation was evolving. The cumulative 1 year, 5 years and 10 years OLT-free survival was 86%, 81% and 76%, respectively. Two patients underwent a liver transplant at 4 and 7 years after TIPS. CONCLUSION Our results validate the role of TIPS in the management of patients with BCS. With the accessibility of TIPS, the requirement for liver transplantation has become rare.
Collapse
Key Words
- AT III, Antithrombin III
- BCS, Budd-Chiari Syndrome
- Budd Chiari syndrome
- CT, Computerized Tomography
- CTP, Child-Turcotte-Pugh
- HV, Hepatic Vein
- INR, International Normalized Ratio
- IVC, Inferior Vena Cava
- JAK-2, Janus Kinase 2
- MELD, Model for End-Stage Liver Disease
- MRI, Magnetic Resonance Imaging
- MTHFR, Methylene Tetrahydrofolate Reductase
- OLT, Orthotopic Liver Transplantation
- SD, Standard Deviation
- TIPS, Transjugular Intrahepatic Portosystemic Shunt
- TIPS-BCS PI score, BCS-TIPS Prognostic Index score
- long term survival
- orthotopic liver transplantation free survival
- transjugular intrahepatic portosystemic shunt
Collapse
Affiliation(s)
- Amey D. Sonavane
- Post-graduate Resident, Department of Gastroenterology, Bombay Hospital and Institute of Medical Sciences, Mumbai, India,Address for correspondence: Amey D. Sonavane, C-1804, Azziano, Rustomjee Urbania, Majiwada, Thane (West), Maharashtra 400601, India.
| | - Deepak N. Amarapurkar
- Consultant Gastroenterologist, Department of Gastroenterology, Bombay Hospital and Institute of Medical Sciences, Mumbai, India
| | - Krantikumar R. Rathod
- Consultant, Department of Vascular and Interventional Radiology, Bombay Hospital and Institute of Medical Sciences, Mumbai, India
| | - Sundeep J. Punamiya
- Consultant, Department of Vascular and Interventional Radiology, Tan Tock Seng Hospital, Singapore
| |
Collapse
|