• Javier Fernández, Verónica Prado, Jonel Trebicka, Alex Amoros, Thierry Gustot, Reiner Wiest, Carme Deulofeu, Elisabet Garcia, Juan Acevedo, Valentin Fuhrmann, François Durand, Cristina Sánchez, Maria Papp, Paolo Caraceni, Victor Vargas, Rafael Bañares, Salvatore Piano, Martin Janicko, Agustin Albillos, Carlo Alessandria, German Soriano, Tania M Welzel, Wim Laleman, Alexander Gerbes, Andrea De Gottardi, Manuela Merli, Minneke Coenraad, Faouzi Saliba, Marco Pavesi, Rajiv Jalan, Pere Ginès, Paolo Angeli, Vicente Arroyo, and European Foundation for the Study of Chronic Liver Failure (EF-Clif).
• Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain; European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain. Electronic address: Jfdez@clinic.ub.es.
• J. Hepatol. 2019 Mar 1; 70 (3): 398-411.

Background & AimsAntibiotic resistance has been increasingly reported in patients with decompensated cirrhosis in single-center studies. Prospective investigations reporting broad epidemiological data are scarce. We aimed to analyze epidemiological changes in bacterial infections in patients with decompensated cirrhosis.MethodsThis was a prospective evaluation of 2 series of patients hospitalized with decompensated cirrhosis. The Canonic series included 1,146 patients from Northern, Southern and Western Europe in 2011. Data on epidemiology, clinical characteristics of bacterial infections, microbiology and empirical antibiotic schedules were assessed. A second series of 883 patients from Eastern, Southern and Western Europe was investigated between 2017-2018.ResultsA total of 455 patients developed 520 infections (39.7%) in the first series, with spontaneous bacterial peritonitis, urinary tract infections and pneumonia the most frequent infections. Nosocomial episodes predominated in this series. Nearly half of the infections were culture-positive, of which 29.2% were caused by multidrug-resistant organisms (MDROs). MDR strains were more frequently isolated in Northern and Western Europe. Extended-spectrum beta-lactamase-producing Enterobacteriaceae were the most frequent MDROs isolated in this series, although prevalence and type differed markedly among countries and centers. Antibiotic resistance was associated with poor prognosis and failure of antibiotic strategies, based on third-generation cephalosporins or quinolones. Nosocomial infection (odds ratio [OR] 2.74; p < 0.001), intensive care unit admission (OR 2.09; p = 0.02), and recent hospitalization (OR 1.93; p = 0.04) were identified as independent predictors of MDR infection. The prevalence of MDROs in the second series (392 infections/284 patients) was 23%; 38% in culture-positive infections. A mild increase in the rate of carbapenem-resistant Enterobacteriaceae was observed in this series.ConclusionsMDR bacterial infections constitute a prevalent, growing and complex healthcare problem in patients with decompensated cirrhosis and acute-on-chronic liver failure across Europe, negatively impacting on prognosis. Strategies aimed at preventing the spread of antibiotic resistance in cirrhosis should be urgently evaluated.Lay SummaryInfections caused by bacteria resistant to the main antibiotic families are prevalent in patients with cirrhosis. This study demonstrates that this healthcare problem is increasing and extends through all European regions. Infections caused by these difficult to treat bacteria resolve less frequently and often cause the death of the patient. The type of resistant bacteria varies markedly among different hospitals.Copyright © 2018 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

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