The Spread of Multi Drug Resistant Infections Is Leading to an Increase in the Empirical Antibiotic Treatment Failure in Cirrhosis: A Prospective Survey

Merli, Manuela; Lucidi, C.; Gregorio, V. Di; Falcone, Marco; Giannelli, V.; Lattanzi, Barbara; Giusto, M.; Ceccarelli, Giancarlo; Farcomeni, Alessio; Riggio, Oliviero; Venditti, Mario

doi:10.1371/journal.pone.0127448

Cited by 88 publications

(101 citation statements)

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“…It is a continuous challenge because of the progressive evolution of pathogens and their antibiotic resistances. An increase in the prevalence of multiresistant pathogens has been documented in the last decades in hospital‐acquired (HA) and in HCA infections in several countries . This microbiological pattern explains the increasing rate of therapeutic failure and the poor prognosis when these patients are treated with first‐line standard antibiotic treatment .…”

Section: Discussionmentioning

confidence: 99%

“…The most likely explanation for this persistent high mortality is the growing spread of multiresistant pathogens with a consequent reduction in the rate of treatment success with empirical standard antibiotic therapies. This problem has been raised by several researchers in the last decade …”

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confidence: 99%

“…The choice of an appropriate and effective empirical antibiotic regimen is also crucial. Several studies have demonstrated that antibiotic treatment failure is related to a poorer outcome in patients with cirrhosis …”

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confidence: 99%

“…The growing evidence of a very high rate of antibiotic resistance (14%‐50% in different countries) in health‐care–associated (HCA) infections, and their poor prognosis has sparked off a debate about the possible advantages or disadvantages of using a broader spectrum antibiotic treatment in these infections. To our knowledge, no controlled trials are available in this setting.…”

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An empirical broad spectrum antibiotic therapy in health‐care–associated infections improves survival in patients with cirrhosis: A randomized trial

et al. 2016

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Early diagnosis and appropriate treatment of infections in cirrhosis are crucial because of their high morbidity and mortality. Multidrug-resistant (MDR) infections are on the increase in health care settings. Health-care-associated (HCA) infections are still frequently treated as community-acquired with a detrimental effect on survival. We aimed to prospectively evaluate in a randomized trial the effectiveness of a broad spectrum antibiotic treatment in patients with cirrhosis with HCA infections. Consecutive patients with cirrhosis hospitalized with HCA infections were enrolled. After culture sampling, patients were promptly randomized to receive a standard or a broad spectrum antibiotic treatment (NCT01820026). The primary endpoint was in-hospital mortality. Efficacy, side effects, and the length of hospitalization were considered. Treatment failure was followed by a change in antibiotic therapy. Ninety-six patients were randomized and 94 were included. The two groups were similar for demographic, clinical, and microbiological characteristics. The prevalence of MDR pathogens was 40% in the standard versus 46% in the broad spectrum group. In-hospital mortality showed a substantial reduction in the broad spectrum versus standard group (6% vs. 25%; P 5 0.01). In a post-hoc analysis, reduction of mortality was more evident in patients with sepsis. The broad spectrum showed a lower rate of treatment failure than the standard therapy (18% vs. 51%; P 5 0.001). Length of hospitalization was shorter in the broad spectrum (12.3 6 7 days) versus standard group (18 6 15 days; P 5 0.03). Five patients in each group developed a second infection during hospitalization with a similar prevalence of MDR (50% broad spectrum vs. 60% standard). Conclusions: A broad spectrum antibiotic therapy as empirical treatment in HCA infections improves survival in cirrhosis. This treatment was significantly effective, safe, and cost saving. (HEPATOLOGY 2016;63:1632-1639 B acterial infections are a frequent and lifethreatening complication in chronic liver disease; despite the improvement in diagnostic and therapeutic measures, infection-related morbidity and mortality still play a prominent role in these patients. (1)(2)(3)(4) The most likely explanation for this persistent high mortality is the growing spread of multiresistant pathogens with a consequent reduction in the rate of treatment success with empirical standard antibiotic therapies. This problem has been raised by several researchers in the last decade. (5)(6)(7)(8) A timely initiation of antibiotic treatment is strongly recommended in these patients, particularly in the case of severe infections. This recommendation arises from the observation that a delay in starting empirical antibiotics is associated with an

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An empirical broad spectrum antibiotic therapy in health‐care–associated infections improves survival in patients with cirrhosis: A randomized trial

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“…The spread of these strains in fact is a leading cause of failure of antimicrobial empirical treatment in LC. 42 We recently analyzed 162 cirrhotic patients with BSI hospitalized at our hospital from 2008 to 2012. 38 GNB, which caused 64% of episodes, were classified as MDR and XDR in 25% and 21% of cases, according to the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and consensus definitions.…”

Section: Etiologymentioning

confidence: 99%

Bloodstream infections in patients with liver cirrhosis

et al. 2016

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Bloodstream infections are a serious complication in patients with liver cirrhosis. Dysregulated intestinal bacterial translocation is the predominant pathophysiological mechanism of infections in this setting. For this reason enteric Gram-negative bacteria are commonly encountered as the first etiological cause of infection. However, through the years, the improvement in the management of cirrhosis, the recourse to invasive procedures and the global spread of multidrug resistant pathogens have importantly changed the current epidemiology. Bloodstream infections in cirrhotic patients are characterized by high mortality rate and complications including metastatic infections, infective endocarditis, and endotipsitis (or transjugular intrahepatic portosystemic shunt-related infection). For this reason early identification of patients at risk for mortality and appropriated therapeutic management is mandatory. Liver cirrhosis can significantly change the pharmacokinetic behavior of antimicrobials. In fact hypoproteinaemia, ascitis and third space expansion and impairment of renal function can be translated in an unpredictable drug exposure.

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