Medicina Interna, IRCCS San Donato, Università degli studi di Milano, San Donato Milanese, Milano, Italy.
Unità di Gastroenterologia e Microbiologia, Ospedale Predabissi, Melegnano, Italy.
Liver Int. 2017 Jan;37(1):71-79. doi: 10.1111/liv.13195. Epub 2016 Jul 22.
BACKGROUND & AIMS: Bacterial strains resistant to antibiotics are a serious clinical challenge. We assessed the antibiotic susceptibility of bacteria isolated from infections in patients with cirrhosis by a multicentre investigation.
Three hundred and thirteen culture-positive infections (173 community acquired [CA] and 140 hospital acquired [HA]) were identified in 308 patients. Urinary tract infections, spontaneous bacterial peritonitis and bacteremias were the most frequent. Quinolone-resistant Gram-negative isolates were 48%, 44% were extended-spectrum beta-lactamase producers and 9% carbapenem resistant. In 83/313 culture-positive infections (27%), multidrug-resistant agents (MDRA) were isolated. This prevalence did not differ between CA and HA infections. MDRA were identified in 17 of 37 patients on quinolone prophylaxis, and in 46 of 166 not on prophylaxis (45% vs 27%; P<.03). In 287 cases an empiric antibiotic therapy was undertaken, in 37 (12.9%) this therapy failed. The in-hospital mortality rate of this subset of patients was significantly higher compared to patients who received an effective broad(er)-spectrum therapy (P=.038). During a 3-month follow-up, 56/203 culture-positive patients (27.6%) died, 24/63 who have had MDRA-related infections (38%) and 32/140 who have had antibiotic-susceptible infections (22.8%) (P=.025). Multivariate analysis disclosed MDRA infection, age, hepatocellular carcinoma, bilirubin, international normalized ratio and the occurrence of portal hypertension-related complications independent predictors of death.
Infection by MDRA is frequent in patients with cirrhosis and the prognosis is severe, especially in patients unresponsive to empiric antibiotic therapy.
对抗生素耐药的细菌菌株是一个严重的临床挑战。我们通过一项多中心研究评估了肝硬化患者感染分离细菌的抗生素敏感性。
在 308 名患者中确定了 313 例培养阳性感染（173 例社区获得性[CA]和 140 例医院获得性[HA]）。尿路感染、自发性细菌性腹膜炎和菌血症是最常见的。耐喹诺酮的革兰氏阴性分离株为 48%，44%为扩展谱β-内酰胺酶产生菌，9%为碳青霉烯类耐药菌。在 313 例培养阳性感染中的 83 例（27%）中分离出了多药耐药菌（MDRA）。CA 和 HA 感染之间的这种患病率没有差异。在接受喹诺酮预防的 37 名患者中有 17 例分离出 MDRA，而在未接受预防的 166 名患者中有 46 例（45%比 27%；P<.03）。在 287 例情况下进行了经验性抗生素治疗，其中 37 例（12.9%）治疗失败。这组患者的院内死亡率明显高于接受有效广谱治疗的患者（P=.038）。在 3 个月的随访期间，203 例培养阳性患者中有 56 例（27.6%）死亡，24 例（38%）与 MDRA 相关感染的患者和 32 例（22.8%）与抗生素敏感感染的患者（P=.025）。多变量分析显示，MDRA 感染、年龄、肝细胞癌、胆红素、国际标准化比值和门静脉高压相关并发症的发生是死亡的独立预测因素。
肝硬化患者感染 MDRA 很常见，预后严重，特别是对经验性抗生素治疗无反应的患者。
