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Original Article

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

Lameirão Gomes C. · Violante Silva R. · Carrola P. · Presa J.

Author affiliations

Liver Unit, Internal Medicine Department, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal

Corresponding Author

Cristina Lameirão Gomes

Centro Hospitalar de Trás-os-Montes e Alto Douro

Av. Da Noruega, Lordelo

Vila Real 5000-508 (Portugal)

E-Mail cristinasofiagomes@hotmail.com

Keywords: Liver cirrhosisBacterial infectionsChild-Pugh-Turcotte scoreModel for End-Stage Liver Disease score

Related Articles for ""
GE Port J Gastroenterol 2019;26:324–332
https://doi.org/10.1159/000494568

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Abstract

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.

© 2018 Sociedade Portuguesa de Gastrenterologia Published by S. Karger AG, Basel

Infeções bacterianas em doentes com cirrose hepática num serviço de medicina interna

Palavras Chave

Cirrose hepática · Infeções bacterianas · Child-Pugh-Turcotte score · Model for End-Stage Liver Disease score ·

Resumo

Introdução: A cirrose hepática (CH) é o estágio final de múltiplos processos que conduzem à insuficiência hepática e corresponde à 10ª causa de morte mais comum no mundo Ocidental. As infeções bacterianas são uma complicação frequente nos doentes com CH, devido ao seu estado de imunossupressão. Aproximadamente 60% das infeções bacterianas em cirróticos são adquiridas na comunidade (AC) e 40% são nosocomiais. As infeções bacterianas mais comuns em cirróticos são Peritonite Bacteriana Espontânea (PBE) (25%), Infeção do Trato Urinário (ITU) (20%), Pneumonia (15%), Bacteriemia (12%) e Celulite (2–11%). O objetivo deste estudo é avaliar as infeções mais frequentes em doentes com CH e descrever a evolução da microbiologia nos mesmos. Material e Métodos: Análise retrospetiva de quatro anos intercalados (2008, 2010, 2012 e 2014) que incluiu trezentos e setenta e dois doentes. Características demográficas: género, idade, tipo de infeção, perfil de resistência bacteriana, uso de antibióticos, scores Child-Pugh-Turcotte e Model for End-Stage Liver Disease e taxa de mortalidade. Resultados: A idade média dos doentes incluídos neste estudo foi de 64.5 ± 12.2 anos. Os homens foram, significativamente, mais prevalentes que as mulheres (72 vs. 28%). Nos quatro anos intercalados, ocorreram: 71 infeções (49% AC e 51% nosocomiais) em 2008; 86 infeções (60.5% AC e 39.5% nosocomiais) em 2010; 99 infeções (56.6% AC e 43.4% nosocomiais) em 2012 e 116 infeções (70.7% AC e 29.3% nosocomiais) em 2014. As infeções mais frequentes foram a ITU (32.5%), Infeção do Trato Respiratório (29.3%), PBE (26.1%) e Celulite (6.2%). Identificou-se o agente microbiológico em 32.4, 59.3, 53.5 e 61.2% das infeções em 2008, 2010, 2012 e 2014, respetivamente, com predomínio de bacilos Gram-negativos. Em todas as séries, as cefalosporinas de terceira geração foram o antibiótico mais utilizado empiricamente. A grande maioria dos doentes encontra-se no estadio B (42,7%) do score Child-Pugh-Turcotte, seguido de C (39.3%) e A (18%). A mortalidade aumentou, significativamente, de 7% em 2008 para 25% em 2014 (p = 0.016). Conclusões: O presente estudo mostrou uma elevada prevalência de infeções bacterianas em doentes com CH. É necessário uma alta suspeita clínica para infeção nestes doentes, pois o tratamento antibiótico precoce e apropriado pode diminuir a morbilidade e a mortalidade.



Related Articles:

References

  1. Pop A, Andreica V. Infections and liver cirrhosis: a dangerous liaison. HVM Bioflux. 2015;7:264–70.
  2. Ge PS, Runyon BA. Treatment of Patients with Cirrhosis. N Engl J Med. 2016 Aug;375(8):767–77.
    External Resources
  3. Bartoletti M, Giannella M, Lewis RE, Viale P. Bloodstream infections in patients with liver cirrhosis. Virulence. 2016 Apr;7(3):309–19.
    External Resources
  4. Fernández J, Navasa M, Gómez J, Colmenero J, Vila J, Arroyo V, et al. Bacterial infections in cirrhosis: epidemiological changes with invasive procedures and norfloxacin prophylaxis. Hepatology. 2002 Jan;35(1):140–8.
    External Resources
  5. Carrola P, Militão I, Presa J. Infeções bacterianas no doente com cirrose hepática. GE J Port Gastrenterol. 2013;20(2):58–65.
    External Resources
  6. Bunchorntavakul C, Chamroonkul N, Chavalitdhamrong D. Bacterial infectons in cirrhosis: A critical review and practical guidance. World J Hepatol. 2016 Feb;8(6):307–321.
    External Resources
  7. Fernandez J, Arroyo V. Bacterial infections in cirrhosis: A growing problem with significant implications. Clin Liver Dis (Hoboken). 2013;2(3):102–5.
    External Resources
  8. Taneja SK, Dhiman RK. Prevention and management of bacterial infections in cirrhosis. Int J Hepatol. 2011;2011:784540.
    External Resources
  9. Jalan R, Fernandez J, Wiest R, Schnabl B, Moreau R, Angeli P, et al. Bacterial infections in cirrhosis: a position statement based on the EASL Special Conference 2013. J Hepatol. 2014 Jun;60(6):1310–24.
    External Resources
  10. Oliveira A, Branco JC, Barosa R, Rodrigues JA, Ramos L, Martins A, et al. Clinical and microbiological characteristics associated with mortality in spontaneous bacterial peritonitis: a multicenter cohort study. Eur J Gastroenterol Hepatol. 2016 Oct;28(10):1216–22.
    External Resources
  11. Vitalis Z, Papp M. Bacterial infections in cirrhosis. In: Blackwell RM, Tyson AP, editors. Cirrhosis. Nova Science Publishers; 2014. pp. 63–87.
  12. Hung TH, Tseng CW, Hsieh YH, Tseng KC, Tsai CC, Tsai CC. High mortality of pneumonia in cirrhotic patients with ascites. BMC Gastroenterol. 2013 Feb;13(1):25.
    External Resources
  13. Cheruvattath R, Balan V. Infections in Patients With End-stage Liver Disease. J Clin Gastroenterol. 2007 Apr;41(4):403–11.
    External Resources
  14. Lagadinou M, Gogos CA. Bacterial infections in cirrhotic patients: a retrospective epidemiologic study in a Greek university hospital. Clin Hepatol Hepat Rep. 2015;2(1):1.
    External Resources
  15. Gustot T, Durand F, Lebrec D, Vincent JL, Moreau R. Severe sepsis in cirrhosis. Hepatology. 2009 Dec;50(6):2022–33.
    External Resources
  16. Sevastianos VA, Dourakis SP. Pathogenesis, diagnosis and therapy of Infections complicating patients with chronic liver disease. Ann Gastroenterol. 2003;16(4):300–15.
  17. Bassetti M, Carnelutti A, Peghin M. Patient specific risk stratification for antimicrobial resistance and possible treatment strategies in gram-negative bacterial infections. Expert Rev Anti Infect Ther. 2017 Jan;15(1):55–65.
    External Resources
  18. Anastasiou J, Williams R. When to use antibiotics in the cirrhotic patient? The evidence base. Ann Gastroenterol. 2013;26(2):128–31.
    External Resources
  19. Fagiuoli S, Colli A, Bruno R, Burra P, Craxi A, Gaeta GB, et al. Management of infections in cirrhotic patients: report of a consensus conference. Dig Liver Dis. 2014 Mar;46(3):204–12.
    External Resources

Article / Publication Details

First-Page Preview
Abstract of Original Article

Received: June 04, 2018
Accepted: October 12, 2018
Published online: December 17, 2018
Issue release date: September - October

Number of Print Pages: 9
Number of Figures: 0
Number of Tables: 6

ISSN: 2341-4545 (Print)
eISSN: 2387-1954 (Online)

For additional information: https://www.karger.com/PJG

References

  1. Pop A, Andreica V. Infections and liver cirrhosis: a dangerous liaison. HVM Bioflux. 2015;7:264–70.
  2. Ge PS, Runyon BA. Treatment of Patients with Cirrhosis. N Engl J Med. 2016 Aug;375(8):767–77.
    External Resources
  3. Bartoletti M, Giannella M, Lewis RE, Viale P. Bloodstream infections in patients with liver cirrhosis. Virulence. 2016 Apr;7(3):309–19.
    External Resources
  4. Fernández J, Navasa M, Gómez J, Colmenero J, Vila J, Arroyo V, et al. Bacterial infections in cirrhosis: epidemiological changes with invasive procedures and norfloxacin prophylaxis. Hepatology. 2002 Jan;35(1):140–8.
    External Resources
  5. Carrola P, Militão I, Presa J. Infeções bacterianas no doente com cirrose hepática. GE J Port Gastrenterol. 2013;20(2):58–65.
    External Resources
  6. Bunchorntavakul C, Chamroonkul N, Chavalitdhamrong D. Bacterial infectons in cirrhosis: A critical review and practical guidance. World J Hepatol. 2016 Feb;8(6):307–321.
    External Resources
  7. Fernandez J, Arroyo V. Bacterial infections in cirrhosis: A growing problem with significant implications. Clin Liver Dis (Hoboken). 2013;2(3):102–5.
    External Resources
  8. Taneja SK, Dhiman RK. Prevention and management of bacterial infections in cirrhosis. Int J Hepatol. 2011;2011:784540.
    External Resources
  9. Jalan R, Fernandez J, Wiest R, Schnabl B, Moreau R, Angeli P, et al. Bacterial infections in cirrhosis: a position statement based on the EASL Special Conference 2013. J Hepatol. 2014 Jun;60(6):1310–24.
    External Resources
  10. Oliveira A, Branco JC, Barosa R, Rodrigues JA, Ramos L, Martins A, et al. Clinical and microbiological characteristics associated with mortality in spontaneous bacterial peritonitis: a multicenter cohort study. Eur J Gastroenterol Hepatol. 2016 Oct;28(10):1216–22.
    External Resources
  11. Vitalis Z, Papp M. Bacterial infections in cirrhosis. In: Blackwell RM, Tyson AP, editors. Cirrhosis. Nova Science Publishers; 2014. pp. 63–87.
  12. Hung TH, Tseng CW, Hsieh YH, Tseng KC, Tsai CC, Tsai CC. High mortality of pneumonia in cirrhotic patients with ascites. BMC Gastroenterol. 2013 Feb;13(1):25.
    External Resources
  13. Cheruvattath R, Balan V. Infections in Patients With End-stage Liver Disease. J Clin Gastroenterol. 2007 Apr;41(4):403–11.
    External Resources
  14. Lagadinou M, Gogos CA. Bacterial infections in cirrhotic patients: a retrospective epidemiologic study in a Greek university hospital. Clin Hepatol Hepat Rep. 2015;2(1):1.
    External Resources
  15. Gustot T, Durand F, Lebrec D, Vincent JL, Moreau R. Severe sepsis in cirrhosis. Hepatology. 2009 Dec;50(6):2022–33.
    External Resources
  16. Sevastianos VA, Dourakis SP. Pathogenesis, diagnosis and therapy of Infections complicating patients with chronic liver disease. Ann Gastroenterol. 2003;16(4):300–15.
  17. Bassetti M, Carnelutti A, Peghin M. Patient specific risk stratification for antimicrobial resistance and possible treatment strategies in gram-negative bacterial infections. Expert Rev Anti Infect Ther. 2017 Jan;15(1):55–65.
    External Resources
  18. Anastasiou J, Williams R. When to use antibiotics in the cirrhotic patient? The evidence base. Ann Gastroenterol. 2013;26(2):128–31.
    External Resources
  19. Fagiuoli S, Colli A, Bruno R, Burra P, Craxi A, Gaeta GB, et al. Management of infections in cirrhotic patients: report of a consensus conference. Dig Liver Dis. 2014 Mar;46(3):204–12.
    External Resources
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This article is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License (CC BY-NC-ND). Usage and distribution for commercial purposes as well as any distribution of modified material requires written permission. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
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