Bacterial infections in patients with acute variceal bleeding in the era of antibiotic prophylaxis

Javier Martínez, Virginia Hernández-Gea, Enrique Rodríguez-de-Santiago, Luis Téllez, Bogdan Procopet, Álvaro Giráldez, Lucio Amitrano, Candid Villanueva, Dominique Thabut, Luis Ibañez-Samaniego, Gilberto Silva-Junior, Joan Genescà, Christophe Bureau, Jonel Trebicka, Rafael Bañares, Aleksander Krag, Elba Llop, Wim Laleman, Jose María Palazon, Jose CastelloteSusana Rodrigues, Lise L. Gluud, Carlos Noronha-Ferreira, Nuria Cañete, Manuel Rodríguez, Arnulf Ferlitsch, Remy Schwarzer, Jose Luis Mundi, Henning Gronbaek, Manuel Hernández-Guerra, Romano Sassatelli, Alessandra Dell'Era, Marco Senzolo, Juan G. Abraldes, Manuel Romero-Gomez, Alexander Zipprich, Meritxell Casas, Helena Masnou, Massimo Primignani, Frederik Nevens, Jose Luis Calleja, Christian Jansen, Marie Angèle Robic, Irene Conejo, Maria Vega Catalina, Marika Rudler, Edilmar Alvarado, Valeria Perez-Campuzano, Maria Anna Guardascione, Petra Fischer, Petra Fischer, Jaime Bosch, Juan Carlos Garcia-Pagan, Agustín Albillos, International Variceal Bleeding Observational Study Group and Baveno Cooperation

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Background & Aims: Antibiotic prophylaxis reduces the risk of infection and mortality in patients with cirrhosis and acute variceal bleeding (AVB). This study examines the incidence of, and risk factors for, bacterial infections during hospitalization in patients with AVB on antibiotic prophylaxis. Methods: A post hoc analysis was performed using the database of an international, multicenter, observational study designed to examine the role of pre-emptive transjugular intrahepatic portosystemic shunts in patients with cirrhosis and AVB. Data were collected on patients with cirrhosis hospitalized for AVB (n = 2,138) from a prospective cohort (October 2013-May 2015) at 34 referral centers, and a retrospective cohort (October 2011-September 2013) at 19 of these centers. The primary outcome was incidence of bacterial infection during hospitalization. Results: A total of 1,656 patients out of 1,770 (93.6%) received antibiotic prophylaxis; third-generation cephalosporins (76.2%) and quinolones (19.0%) were used most frequently. Of the patients on antibiotic prophylaxis, 320 patients developed bacterial infection during hospitalization. Respiratory infection accounted for 43.6% of infections and for 49.7% of infected patients, and occurred early after admission (median 3 days, IQR 1-6). On multivariate analysis, respiratory infection was independently associated with Child-Pugh C (odds ratio [OR] 3.1; 95% CI 1.4-6.7), grade III-IV encephalopathy (OR 2.8; 95% CI 1.8-4.4), orotracheal intubation for endoscopy (OR 2.6; 95% CI 1.8-3.8), nasogastric tube placement (OR 1.7; 95% CI 1.2-2.4) or esophageal balloon tamponade (OR 2.4; 95% CI 1.2-4.9). Conclusion: Bacterial infections develop in almost one-fifth of patients with AVB despite antibiotic prophylaxis. Respiratory infection is the most frequent, is an early event after admission, and is associated with advanced liver failure, severe hepatic encephalopathy and use of nasogastric tube, orotracheal intubation for endoscopy or esophageal balloon tamponade. Lay summary: Bacterial infections develop during hospitalization in close to 20% of patients with acute variceal bleeding despite antibiotic prophylaxis. Respiratory bacterial infections are the most frequent and occur early after admission. Respiratory infection is associated with advanced liver disease, severe hepatic encephalopathy and a need for a nasogastric tube, orotracheal intubation for endoscopy or esophageal balloon tamponade.

TidsskriftJournal of Hepatology
Udgave nummer2
Sider (fra-til)342-350
StatusUdgivet - aug. 2021

Bibliografisk note

Funding Information:
Supported by grants from the Spanish Ministry of Science and Innovation ( SAF-2016-75767-R to JC.G-P, SAF 2017-86343-R awarded to A.A, Instituto de Salud Carlos III PIE 15/00027 to JC.G-P, PI17/00398 to V.H.G, PI18/01901 to R.B and PI20/01302 to A.A, and Commissioner for Universities and Research of the Generalitat de Catalunya ( AGAUR SGR 2017 awarded to JC.G-P). CIBEREHD is funded by the Instituto de Salud Carlos III with grants cofinanced by the European Development Regional Fund “A way to achieve Europe” (EDRF).

Funding Information:
Juan Carlos Garcia-Pagan has consultant fees for GORE, Shionogi and Cook grants from GORE and Novartis. Álvaro Giráldez has served as speaker for Gore.


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