Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain.
Hepatology. 2012 May;55(5):1551-61. doi: 10.1002/hep.25532. Epub 2012 Apr 4.
Epidemiology, risk factors, and clinical effect of infections by multiresistant bacteria in cirrhosis are poorly known. This work was a prospective evaluation in two series of cirrhotic patients admitted with infection or developing infection during hospitalization. The first series was studied between 2005 and 2007 (507 bacterial infections in 223 patients) and the second between 2010 and 2011 (162 bacterial infections in 110 patients). In the first series, 32% of infections were community acquired (CA), 32% healthcare associated (HCA), and 36% nosocomial. Multiresistant bacteria (92 infections; 18%) were isolated in 4%, 14%, and 35% of these infections, respectively (P < 0.001). Extended-spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E; n = 43) was the main multiresistant organism identified, followed by Pseudomonas aeruginosa (n = 17), methicillin-resistant Staphylococcus aureus (n = 14), and Enterococcus faecium (n = 14). The efficacy of currently recommended empirical antibiotic therapy was very low in nosocomial infections (40%), compared to HCA and CA episodes (73% and 83%, respectively; P < 0.0001), particularly in spontaneous bacterial peritonitis, urinary tract infection, and pneumonia (26%, 29%, and 44%, respectively). Septic shock (26% versus 10%; P < 0.0001) and mortality rate (25% versus 12%; P = 0.001) were significantly higher in infections caused by multiresistant strains. Nosocomial origin of infection (hazard ratio [HR], 4.43), long-term norfloxacin prophylaxis (HR, 2.69), recent infection by multiresistant bacteria (HR, 2.45), and recent use of β-lactams (HR, 2.39) were independently associated with the development of multiresistant infections. Results in the second series were similar to those observed in the first series.
Multiresistant bacteria, especially ESBL-producing Enterobacteriaceae, are frequently isolated in nosocomial and, to a lesser extent, HCA infections in cirrhosis, rendering third-generation cephalosporins clinically ineffective. New antibiotic strategies tailored according to the local epidemiological patterns are needed for the empirical treatment of nosocomial infections in cirrhosis.
本研究旨在评估肝硬化患者感染多耐药菌的流行病学、危险因素和临床影响。
本研究为前瞻性研究，纳入了 2005 年至 2007 年（223 例患者 507 例细菌感染）和 2010 年至 2011 年（110 例患者 162 例细菌感染）住院期间发生感染或出现感染的肝硬化患者。第一组 32%的感染为社区获得性（CA），32%为医源性（HCA），36%为医院获得性。在第一组中，4%、14%和 35%的感染分别分离出多耐药菌（92 例；18%）（P<0.001）。产超广谱β-内酰胺酶的肠杆菌科细菌（ESBL-E；n=43）是主要的多耐药菌，其次是铜绿假单胞菌（n=17）、耐甲氧西林金黄色葡萄球菌（n=14）和粪肠球菌（n=14）。与 HCA 和 CA 感染（分别为 73%和 83%）相比，医院获得性感染（40%）中目前推荐的经验性抗生素治疗的疗效非常低（P<0.0001），尤其是在自发性细菌性腹膜炎、尿路感染和肺炎中（分别为 26%、29%和 44%）。感染多耐药菌的患者发生感染性休克（26%对 10%；P<0.0001）和死亡率（25%对 12%；P=0.001）明显更高。感染的医院来源（风险比[HR]，4.43）、长期诺氟沙星预防（HR，2.69）、近期多耐药菌感染（HR，2.45）和近期使用β-内酰胺类药物（HR，2.39）与多耐药菌感染的发生独立相关。第二组的结果与第一组相似。
多耐药菌，尤其是产 ESBL 的肠杆菌科细菌，在肝硬化患者的医院获得性和医源性感染中经常分离出来，使第三代头孢菌素在临床上无效。需要根据当地的流行病学模式制定新的抗生素策略，以对肝硬化患者的医院获得性感染进行经验性治疗。
