Treatment of Hospital-Acquired Infections in Patients with Cirrhosis – New Challenges

Abstract

Background

Hospital acquired infections (HAI) in the cirrhotic patients contribute to hepatic decompensation. With emergence of bacterial drug resistance, designing the treatment protocol of HA infection has become the foremost challenge.

Purpose

To analyze the resistance pattern of organisms isolated from hospital-acquired (HA) infections and determine appropriate antibiotics treatment protocols for these infections.

Study Design

A prospective hospital based observational study was undertaken.

Patients and Methods

The present study was conducted over 18 months at Kasturba Medical College, Mangalore, Karnataka, India. Patients with suspected HA infections were subjected to clinical, hematological and microbiological evaluation. Antibiotic sensitivity evaluation was undertaken for the bacteria isolated from these patients.

Results

During the study period, 398 patients with cirrhosis were 472 times admitted to the hospital for treatment. Out of these patients, 40 patients were diagnosed with 50 HA infections. Fifty five different organisms were isolated from these infections. It was found that these 55 bacteria isolates comprised 30 (54.54%) gram-negative (GN) and 25 (45.45%) gram-positive (GP) bacteria. Quite seriously, extended-spectrum beta-lactamase (ESBL) producers and methicillin-resistant Staphylococcus aureus (MRSA) were detected in 40% and 58% of GN and GP infections respectively. A total of 36 (65.4%) and (14.5%) 8 out of 55 isolated organisms exhibited multi–drug resistance (MDR) and extensive drug resistance (XDR) behavior, respectively.

Conclusion

Cirrhosis patients with HA infection possess higher prevalence of MDR and XDR infections. In such sick patients, cephalosporin and quinolones are not the appropriate empirical antibiotics. Herein, we propose a tigecycline with carbapenem like meropenem and vancomycin based empirical antibiotics protocol to be prescribed for such patients. De-escalation is advised after the culture sensitivity report is obtained.

Keywords:

• drug resistance
• antibiotic sensitivity
• nosocomial infections
• tigecycline

Abbreviations

NI, nosocomial infections; HA infections, hospital-acquired infections; GN, Gram negative; GP, Gram positive; ESBL, extended-spectrum beta-lactamase; ESBLE, ESBL-producing Enterobacteriaceae; MRSA, methicillin-resistant Staphylococcus aureus; MDR, multi–drug resistance; XDR, extensive drug resistance; PDR, pan drug resistance; VRE, vancomycin resistant enterococci; VSE, vancomycin sensitive enterococci; CA infections, community-acquired infections; PPI, proton-pump inhibitors; MELD, model for end stage liver disease; INR, international normalized ratio; AFI, ascitic fluid infections; RTI, respiratory tract infection; UTI, urinary tract infection; SB, spontaneous bacteremia; EASL, European association for study of liver; AKI, acute kidney injury; SIRS, systemic inflammatory response syndrome; ACLF, acute-on-chronic liver failure; CTP, Child Turcotte Pugh.

Ethics Statement

The study was approved by the institutional ethics committee (KmcMG/ETHICS/01/2017) at Kasturba Medical College Hospital, Mangalore. The study was conducted in accordance to the Declaration of Helsinki.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Disclosure

The authors declare no conflicts of interest in this work.