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

Published on Aug 1, 2021in Journal of Hepatology20.582
· DOI :10.1016/J.JHEP.2021.03.026
Javier Martínez30
Estimated H-index: 30
(University of Alcalá),
Virginia Hernández-Gea27
Estimated H-index: 27
(University of Barcelona)
+ 50 AuthorsBaveno Cooperation1
Estimated H-index: 1
BACKGROUND AND AIMS Antibiotic prophylaxis reduces the risk of infection and mortality in cirrhotic patients with acute variceal bleeding (AVB). This study examines the incidence and risk factors of bacterial infections during hospitalization in patients with AVB on antibiotic prophylaxis. METHODS Post-hoc analysis of the database of an international, multicenter, observational study designed to examine the role of preemptive TIPS in patients with cirrhosis and AVB. Data collected on patients with cirrhosis hospitalized for AVB (n=2138) from a prospective cohort (October 2013-May 2015) at 34 referral centers, and retrospective cohort (October 2011-September 2013) at 19 of these centers. The primary outcome was incidence of bacterial infection during hospitalization. RESULTS 1656 patients out of 1770 (93.6%) received antibiotic prophylaxis, the most frequently used being third-generation cephalosporins (76.2%) and quinolones (19.0%). Of these, 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 (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 (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 infection is the most frequent and occurs 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.
📖 Papers frequently viewed together
20202.74PLOS ONE
12 Authors (Te-Sheng Chang, ..., Yen-Hua Huang)
7 Citations
#1Dipayan Chaudhuri (McMaster University)H-Index: 6
#1Dipayan Chaudhuri (McMaster University)H-Index: 2
Last. Kwadwo KyeremantengH-Index: 17
view all 8 authors...
Background and Aim: Prophylactic endotracheal intubation for airway protection prior to endoscopy for the management of severe upper gastrointestinal bleeding (UGIB) is controversial. The aim of this meta-analysis is to examine the clinical outcomes and costs related to prophylactic endotracheal intubation compared to no intubation in UGIB. Methods: EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials were used to identify studies through June 2017. Data regarding mortality, t...
4 CitationsSource
#1Katerina M. Marcoulides (UF: University of Florida)H-Index: 8
#2Tenko Raykov (MSU: Michigan State University)H-Index: 36
A procedure that can be used to evaluate the variance inflation factors and tolerance indices in linear regression models is discussed. The method permits both point and interval estimation of thes...
20 CitationsSource
#1Javier FernándezH-Index: 7
#1Javier FernándezH-Index: 13
Last. Vicente ArroyoH-Index: 128
view all 15 authors...
Bacterial infection is a frequent trigger of acute-on-chronic liver failure (ACLF), syndrome that could also increase the risk of infection. This investigation evaluated prevalence and characteristics of bacterial and fungal infections causing and complicating ACLF, predictors of follow-up bacterial infections and impact of bacterial infections on survival. Patients 407 patients with ACLF and 235 patients with acute decompensation (AD). Results 152 patients (37%) presented bacterial infections a...
177 CitationsSource
#1Paolo AngeliH-Index: 80
#2Mauro BernardiH-Index: 89
Last. Pere GinèsH-Index: 117
view all 9 authors...
Summary The natural history of cirrhosis is characterised by an asymptomatic compensated phase followed by a decompensated phase, marked by the development of overt clinical signs, the most frequent of which are ascites, bleeding, encephalopathy, and jaundice. The following Clinical Practice Guidelines (CPGs) represent the first CPGs on the management of decompensated cirrhosis. In this context, the panel of experts, having emphasised the importance of initiating aetiologic treatment for any deg...
662 CitationsSource
#1Virginia Hernández-Gea (University of Barcelona)H-Index: 27
#2Bogdan ProcopetH-Index: 20
Last. Juan Carlos García-Pagán (University of Barcelona)H-Index: 100
view all 50 authors...
OBJECTIVE Patients admitted with acute variceal bleeding (AVB) and Child Pugh C score (CP-C) or Child Pugh B plus active bleeding at endoscopy (CP-B+AB) are at high risk for treatment failure, rebleeding and mortality. Preemptive TIPS (p-TIPS) has been shown to improve survival in these patients but its use in clinical practice has been challenged and not routinely incorporated. The present study aimed to further validate the role of preemptive TIPS in a large number of high-risk patients. DESIG...
78 CitationsSource
#1Dominique Thabut (University of Paris)H-Index: 56
#2Arnaud PauwelsH-Index: 16
Last. Philippe SogniH-Index: 31
view all 65 authors...
Background & Aims The Baveno VI consensus meeting concluded that an early transjugular intra-hepatic porto-systemic shunt (TIPS) must be considered in high-risk patients with cirrhosis, presenting with variceal bleeding (VB) (Child B + active bleeding at endoscopy or Child C10-13 patients). Whether this therapeutic approach is feasible in a real-life setting remains unclear. The aim of this study was to determine (i) the proportion of patients eligible for early-TIPS among patients with cirrhosi...
55 CitationsSource
ABSTRACTIntroduction: The usefulness of nasogastric aspiration and nasogastric lavage in patients with gastrointestinal bleeding is controversial, as evidenced by conflicting recommendations, both among and within society guidelines.Areas covered: Considering these controversies, we reviewed the evidence regarding the following questions: 1) Can nasogastric lavage stop or slow down the bleeding and improve subsequent endoscopic visualization? 2) Is nasogastric aspiration helpful for the localiza...
4 CitationsSource
#1Stephen Lee (U of A: University of Alberta)H-Index: 3
#2Lynora Saxinger (U of A: University of Alberta)H-Index: 6
Last. Puneeta Tandon (U of A: University of Alberta)H-Index: 46
view all 12 authors...
Background and aimsCurrent guidelines recommend antibiotic prophylaxis in all patients presenting with cirrhosis and acute variceal hemorrhage (AVH). We aimed to evaluate the characteristics and clinical impact of “early” infections (developing within 14 days) of AVH in a real-world setting.MethodsWe analyzed retrospective data from a cohort of 371 adult patients with cirrhosis and AVH all of whom had received antibiotic prophylaxis (74% men; mean age 56 years), admitted to tertiary care hospita...
4 CitationsSource
#1Javier Fernández (University of Barcelona)H-Index: 52
#2Frédéric Bert (University of Paris)H-Index: 24
Last. Marie-Hélène Nicolas-Chanoine (University of Paris)H-Index: 49
view all 3 authors...
Abstract Antimicrobial resistance has become a major global public health security problem that needs coordinated approaches at regional, national and international levels. Antibiotic overuse and the failure of control measures to prevent the spread of resistant bacteria in the healthcare environment have led to an alarming increase in the number of infections caused by resistant bacteria, organisms that resist many (multi-drug and extensively drug-resistant strains), if not all (pan-drug-resist...
70 CitationsSource
#1Angels EscorsellH-Index: 44
#2Oana PavelH-Index: 6
Last. Jaime BoschH-Index: 123
view all 8 authors...
Balloon tamponade is recommended only as a “bridge” to definitive therapy in patients with cirrhosis and massive or refractory esophageal variceal bleeding (EVB), but is frequently associated with rebleeding and severe complications. Preliminary, noncontrolled data suggest that a self-expandable, esophageal covered metal stent (SX-ELLA Danis; Ella-CS, Hradec Kralove, Czech Republic) may be an effective and safer alternative to balloon tamponade. We conducted a randomized, controlled trial aimed ...
109 CitationsSource
Cited By1
Abstract null Portal hypertension, defined as increased pressure in the portal vein, develops as a consequence of increased intrahepatic vascular resistance due to the dysregulation of liver sinusoidal endothelial cells (LSECs) and hepatic stellate cells (HSCs), frequently arising from chronic liver diseases. Extrahepatic hemodynamic changes contribute to the aggravation of portal hypertension. The complexity of the pathogenesis of portal hypertension and unsuccessful translation of preclinical ...