A prospective multicentre study of the epidemiology and outcomes of bloodstream infection in cirrhotic patients

M. Bartoletti, M. Giannella, R. Lewis, P. Caraceni, S. Tedeschi, M. Paul, C. Schramm, T. Bruns, M. Merli, N. Cobos-Trigueros, E. Seminari, P. Retamar, P. Muñoz, M. Tumbarello, P. Burra, M. Torrani Cerenzia, B. Barsic, E. Calbo, A.E. Maraolo, N. PetrosilloM.A. Galan-Ladero, G. D'Offizi, N. Bar Sinai, J. Rodríguez-Baño, G. Verucchi, M. Bernardi, P. Viale, C. Campoli, G. Siccardi, S. Ambretti, A. Stallmach, M. Venditti, C. Lucidi, S. Ludovisi, M. De Cueto, M.D. Navarro, E. Lopez Cortes, E. Bouza, M. Valerio, A. Eworo, R. Losito, M. Senzolo, E. Nadal, A. Ottobrelli, M. Varguvic, C. Badia, G. Borgia, I. Gentile, E. Boumis, A. Rianda

Research output: Contribution to journalArticle

Abstract

Objectives: To describe the current epidemiology of bloodstream infection (BSI) in patients with cirrhosis; and to analyse predictors of 30-day mortality and risk factors for antibiotic resistance. Methods: Cirrhotic patients developing a BSI episode were prospectively included at 19 centres in five countries from September 2014 to December 2015. The discrimination of mortality risk scores for 30-day mortality were compared by area under the receiver operator risk and Cox regression models. Risk factors for multidrug-resistant organisms (MDRO) were assessed with a logistic regression model. Results: We enrolled 312 patients. Gram-negative bacteria, Gram-positive bacteria and Candida spp. were the cause of BSI episodes in 53%, 47% and 7% of cases, respectively. The 30-day mortality rate was 25% and was best predicted by the Sequential Organ Failure Assessment (SOFA) and Chronic Liver Failure–SOFA (CLIF-SOFA) score. In a Cox regression model, delayed (>24 hours) antibiotic treatment (hazard ratio (HR) 7.58; 95% confidence interval (CI) 3.29–18.67; p <0.001), inadequate empirical therapy (HR 3.14; 95% CI 1.93–5.12; p <0.001) and CLIF-SOFA score (HR 1.35; 95% CI 1.28–1.43; p <0.001) were independently associated with 30-day mortality. Independent risk factors for MDRO (31% of BSIs) were previous antimicrobial exposure (odds ratio (OR) 2.91; 95% CI 1.73–4.88; p <0.001) and previous invasive procedures (OR 2.51; 95% CI 1.48–4.24; p 0.001), whereas spontaneous bacterial peritonitis as BSI source was associated with a lower odds of MDRO (OR 0.30; 95% CI 0.12–0.73; p 0.008). Conclusions: MDRO account for nearly one-third of BSI in cirrhotic patients, often resulting in delayed or inadequate empirical antimicrobial therapy and increased mortality rates. Our data suggest that improved prevention and treatment strategies for MDRO are urgently needed in the liver cirrhosis patients. © 2017 European Society of Clinical Microbiology and Infectious Diseases
Original languageEnglish
Pages (from-to)546.e1-546.e8
JournalClinical Microbiology and Infection
Volume24
Issue number5
DOIs
Publication statusPublished - 2018

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Multicenter Studies
Epidemiology
Prospective Studies
Confidence Intervals
Mortality
Infection
Odds Ratio
Proportional Hazards Models
Logistic Models
End Stage Liver Disease
Gram-Positive Bacteria
Therapeutics
Microbial Drug Resistance
Peritonitis
Gram-Negative Bacteria
Candida
Liver Cirrhosis
Fibrosis
Anti-Bacterial Agents
Liver

Keywords

  • antiinfective agent, adult
  • all cause mortality
  • antibiotic therapy
  • Article
  • bacterial peritonitis
  • bloodstream infection
  • Candida
  • carbapenem-resistant Enterobacteriaceae
  • chronic liver failure
  • cohort analysis
  • Enterococcus faecium
  • extended spectrum beta lactamase producing Enterobacteriaceae
  • female
  • human
  • invasive procedure
  • liver cirrhosis
  • major clinical study
  • male
  • methicillin susceptible Staphylococcus aureus
  • middle aged
  • multidrug resistance
  • nonhuman
  • pathogenesis
  • priority journal
  • prospective study
  • risk factor
  • Sequential Organ Failure Assessment Score
  • Streptococcus pneumoniae
  • therapy delay
  • aged
  • antibiotic resistance
  • clinical trial
  • comorbidity
  • complication
  • disease management
  • health survey
  • mortality
  • multicenter study
  • outcome assessment
  • prognosis
  • sepsis, Aged
  • Comorbidity
  • Disease Management
  • Drug Resistance, Microbial
  • Female
  • Humans
  • Liver Cirrhosis
  • Male
  • Middle Aged
  • Mortality
  • Patient Outcome Assessment
  • Population Surveillance
  • Prognosis
  • Prospective Studies
  • Risk Factors
  • Sepsis

Cite this

Bartoletti, M., Giannella, M., Lewis, R., Caraceni, P., Tedeschi, S., Paul, M., ... Rianda, A. (2018). A prospective multicentre study of the epidemiology and outcomes of bloodstream infection in cirrhotic patients. Clinical Microbiology and Infection, 24(5), 546.e1-546.e8. https://doi.org/10.1016/j.cmi.2017.08.001

A prospective multicentre study of the epidemiology and outcomes of bloodstream infection in cirrhotic patients. / Bartoletti, M.; Giannella, M.; Lewis, R.; Caraceni, P.; Tedeschi, S.; Paul, M.; Schramm, C.; Bruns, T.; Merli, M.; Cobos-Trigueros, N.; Seminari, E.; Retamar, P.; Muñoz, P.; Tumbarello, M.; Burra, P.; Torrani Cerenzia, M.; Barsic, B.; Calbo, E.; Maraolo, A.E.; Petrosillo, N.; Galan-Ladero, M.A.; D'Offizi, G.; Bar Sinai, N.; Rodríguez-Baño, J.; Verucchi, G.; Bernardi, M.; Viale, P.; Campoli, C.; Siccardi, G.; Ambretti, S.; Stallmach, A.; Venditti, M.; Lucidi, C.; Ludovisi, S.; De Cueto, M.; Navarro, M.D.; Lopez Cortes, E.; Bouza, E.; Valerio, M.; Eworo, A.; Losito, R.; Senzolo, M.; Nadal, E.; Ottobrelli, A.; Varguvic, M.; Badia, C.; Borgia, G.; Gentile, I.; Boumis, E.; Rianda, A.

In: Clinical Microbiology and Infection, Vol. 24, No. 5, 2018, p. 546.e1-546.e8.

Research output: Contribution to journalArticle

Bartoletti, M, Giannella, M, Lewis, R, Caraceni, P, Tedeschi, S, Paul, M, Schramm, C, Bruns, T, Merli, M, Cobos-Trigueros, N, Seminari, E, Retamar, P, Muñoz, P, Tumbarello, M, Burra, P, Torrani Cerenzia, M, Barsic, B, Calbo, E, Maraolo, AE, Petrosillo, N, Galan-Ladero, MA, D'Offizi, G, Bar Sinai, N, Rodríguez-Baño, J, Verucchi, G, Bernardi, M, Viale, P, Campoli, C, Siccardi, G, Ambretti, S, Stallmach, A, Venditti, M, Lucidi, C, Ludovisi, S, De Cueto, M, Navarro, MD, Lopez Cortes, E, Bouza, E, Valerio, M, Eworo, A, Losito, R, Senzolo, M, Nadal, E, Ottobrelli, A, Varguvic, M, Badia, C, Borgia, G, Gentile, I, Boumis, E & Rianda, A 2018, 'A prospective multicentre study of the epidemiology and outcomes of bloodstream infection in cirrhotic patients', Clinical Microbiology and Infection, vol. 24, no. 5, pp. 546.e1-546.e8. https://doi.org/10.1016/j.cmi.2017.08.001
Bartoletti, M. ; Giannella, M. ; Lewis, R. ; Caraceni, P. ; Tedeschi, S. ; Paul, M. ; Schramm, C. ; Bruns, T. ; Merli, M. ; Cobos-Trigueros, N. ; Seminari, E. ; Retamar, P. ; Muñoz, P. ; Tumbarello, M. ; Burra, P. ; Torrani Cerenzia, M. ; Barsic, B. ; Calbo, E. ; Maraolo, A.E. ; Petrosillo, N. ; Galan-Ladero, M.A. ; D'Offizi, G. ; Bar Sinai, N. ; Rodríguez-Baño, J. ; Verucchi, G. ; Bernardi, M. ; Viale, P. ; Campoli, C. ; Siccardi, G. ; Ambretti, S. ; Stallmach, A. ; Venditti, M. ; Lucidi, C. ; Ludovisi, S. ; De Cueto, M. ; Navarro, M.D. ; Lopez Cortes, E. ; Bouza, E. ; Valerio, M. ; Eworo, A. ; Losito, R. ; Senzolo, M. ; Nadal, E. ; Ottobrelli, A. ; Varguvic, M. ; Badia, C. ; Borgia, G. ; Gentile, I. ; Boumis, E. ; Rianda, A. / A prospective multicentre study of the epidemiology and outcomes of bloodstream infection in cirrhotic patients. In: Clinical Microbiology and Infection. 2018 ; Vol. 24, No. 5. pp. 546.e1-546.e8.
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title = "A prospective multicentre study of the epidemiology and outcomes of bloodstream infection in cirrhotic patients",
abstract = "Objectives: To describe the current epidemiology of bloodstream infection (BSI) in patients with cirrhosis; and to analyse predictors of 30-day mortality and risk factors for antibiotic resistance. Methods: Cirrhotic patients developing a BSI episode were prospectively included at 19 centres in five countries from September 2014 to December 2015. The discrimination of mortality risk scores for 30-day mortality were compared by area under the receiver operator risk and Cox regression models. Risk factors for multidrug-resistant organisms (MDRO) were assessed with a logistic regression model. Results: We enrolled 312 patients. Gram-negative bacteria, Gram-positive bacteria and Candida spp. were the cause of BSI episodes in 53{\%}, 47{\%} and 7{\%} of cases, respectively. The 30-day mortality rate was 25{\%} and was best predicted by the Sequential Organ Failure Assessment (SOFA) and Chronic Liver Failure–SOFA (CLIF-SOFA) score. In a Cox regression model, delayed (>24 hours) antibiotic treatment (hazard ratio (HR) 7.58; 95{\%} confidence interval (CI) 3.29–18.67; p <0.001), inadequate empirical therapy (HR 3.14; 95{\%} CI 1.93–5.12; p <0.001) and CLIF-SOFA score (HR 1.35; 95{\%} CI 1.28–1.43; p <0.001) were independently associated with 30-day mortality. Independent risk factors for MDRO (31{\%} of BSIs) were previous antimicrobial exposure (odds ratio (OR) 2.91; 95{\%} CI 1.73–4.88; p <0.001) and previous invasive procedures (OR 2.51; 95{\%} CI 1.48–4.24; p 0.001), whereas spontaneous bacterial peritonitis as BSI source was associated with a lower odds of MDRO (OR 0.30; 95{\%} CI 0.12–0.73; p 0.008). Conclusions: MDRO account for nearly one-third of BSI in cirrhotic patients, often resulting in delayed or inadequate empirical antimicrobial therapy and increased mortality rates. Our data suggest that improved prevention and treatment strategies for MDRO are urgently needed in the liver cirrhosis patients. {\circledC} 2017 European Society of Clinical Microbiology and Infectious Diseases",
keywords = "antiinfective agent, adult, all cause mortality, antibiotic therapy, Article, bacterial peritonitis, bloodstream infection, Candida, carbapenem-resistant Enterobacteriaceae, chronic liver failure, cohort analysis, Enterococcus faecium, extended spectrum beta lactamase producing Enterobacteriaceae, female, human, invasive procedure, liver cirrhosis, major clinical study, male, methicillin susceptible Staphylococcus aureus, middle aged, multidrug resistance, nonhuman, pathogenesis, priority journal, prospective study, risk factor, Sequential Organ Failure Assessment Score, Streptococcus pneumoniae, therapy delay, aged, antibiotic resistance, clinical trial, comorbidity, complication, disease management, health survey, mortality, multicenter study, outcome assessment, prognosis, sepsis, Aged, Comorbidity, Disease Management, Drug Resistance, Microbial, Female, Humans, Liver Cirrhosis, Male, Middle Aged, Mortality, Patient Outcome Assessment, Population Surveillance, Prognosis, Prospective Studies, Risk Factors, Sepsis",
author = "M. Bartoletti and M. Giannella and R. Lewis and P. Caraceni and S. Tedeschi and M. Paul and C. Schramm and T. Bruns and M. Merli and N. Cobos-Trigueros and E. Seminari and P. Retamar and P. Mu{\~n}oz and M. Tumbarello and P. Burra and {Torrani Cerenzia}, M. and B. Barsic and E. Calbo and A.E. Maraolo and N. Petrosillo and M.A. Galan-Ladero and G. D'Offizi and {Bar Sinai}, N. and J. Rodr{\'i}guez-Ba{\~n}o and G. Verucchi and M. Bernardi and P. Viale and C. Campoli and G. Siccardi and S. Ambretti and A. Stallmach and M. Venditti and C. Lucidi and S. Ludovisi and {De Cueto}, M. and M.D. Navarro and {Lopez Cortes}, E. and E. Bouza and M. Valerio and A. Eworo and R. Losito and M. Senzolo and E. Nadal and A. Ottobrelli and M. Varguvic and C. Badia and G. Borgia and I. Gentile and E. Boumis and A. Rianda",
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doi = "10.1016/j.cmi.2017.08.001",
language = "English",
volume = "24",
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TY - JOUR

T1 - A prospective multicentre study of the epidemiology and outcomes of bloodstream infection in cirrhotic patients

AU - Bartoletti, M.

AU - Giannella, M.

AU - Lewis, R.

AU - Caraceni, P.

AU - Tedeschi, S.

AU - Paul, M.

AU - Schramm, C.

AU - Bruns, T.

AU - Merli, M.

AU - Cobos-Trigueros, N.

AU - Seminari, E.

AU - Retamar, P.

AU - Muñoz, P.

AU - Tumbarello, M.

AU - Burra, P.

AU - Torrani Cerenzia, M.

AU - Barsic, B.

AU - Calbo, E.

AU - Maraolo, A.E.

AU - Petrosillo, N.

AU - Galan-Ladero, M.A.

AU - D'Offizi, G.

AU - Bar Sinai, N.

AU - Rodríguez-Baño, J.

AU - Verucchi, G.

AU - Bernardi, M.

AU - Viale, P.

AU - Campoli, C.

AU - Siccardi, G.

AU - Ambretti, S.

AU - Stallmach, A.

AU - Venditti, M.

AU - Lucidi, C.

AU - Ludovisi, S.

AU - De Cueto, M.

AU - Navarro, M.D.

AU - Lopez Cortes, E.

AU - Bouza, E.

AU - Valerio, M.

AU - Eworo, A.

AU - Losito, R.

AU - Senzolo, M.

AU - Nadal, E.

AU - Ottobrelli, A.

AU - Varguvic, M.

AU - Badia, C.

AU - Borgia, G.

AU - Gentile, I.

AU - Boumis, E.

AU - Rianda, A.

N1 - cited By 16

PY - 2018

Y1 - 2018

N2 - Objectives: To describe the current epidemiology of bloodstream infection (BSI) in patients with cirrhosis; and to analyse predictors of 30-day mortality and risk factors for antibiotic resistance. Methods: Cirrhotic patients developing a BSI episode were prospectively included at 19 centres in five countries from September 2014 to December 2015. The discrimination of mortality risk scores for 30-day mortality were compared by area under the receiver operator risk and Cox regression models. Risk factors for multidrug-resistant organisms (MDRO) were assessed with a logistic regression model. Results: We enrolled 312 patients. Gram-negative bacteria, Gram-positive bacteria and Candida spp. were the cause of BSI episodes in 53%, 47% and 7% of cases, respectively. The 30-day mortality rate was 25% and was best predicted by the Sequential Organ Failure Assessment (SOFA) and Chronic Liver Failure–SOFA (CLIF-SOFA) score. In a Cox regression model, delayed (>24 hours) antibiotic treatment (hazard ratio (HR) 7.58; 95% confidence interval (CI) 3.29–18.67; p <0.001), inadequate empirical therapy (HR 3.14; 95% CI 1.93–5.12; p <0.001) and CLIF-SOFA score (HR 1.35; 95% CI 1.28–1.43; p <0.001) were independently associated with 30-day mortality. Independent risk factors for MDRO (31% of BSIs) were previous antimicrobial exposure (odds ratio (OR) 2.91; 95% CI 1.73–4.88; p <0.001) and previous invasive procedures (OR 2.51; 95% CI 1.48–4.24; p 0.001), whereas spontaneous bacterial peritonitis as BSI source was associated with a lower odds of MDRO (OR 0.30; 95% CI 0.12–0.73; p 0.008). Conclusions: MDRO account for nearly one-third of BSI in cirrhotic patients, often resulting in delayed or inadequate empirical antimicrobial therapy and increased mortality rates. Our data suggest that improved prevention and treatment strategies for MDRO are urgently needed in the liver cirrhosis patients. © 2017 European Society of Clinical Microbiology and Infectious Diseases

AB - Objectives: To describe the current epidemiology of bloodstream infection (BSI) in patients with cirrhosis; and to analyse predictors of 30-day mortality and risk factors for antibiotic resistance. Methods: Cirrhotic patients developing a BSI episode were prospectively included at 19 centres in five countries from September 2014 to December 2015. The discrimination of mortality risk scores for 30-day mortality were compared by area under the receiver operator risk and Cox regression models. Risk factors for multidrug-resistant organisms (MDRO) were assessed with a logistic regression model. Results: We enrolled 312 patients. Gram-negative bacteria, Gram-positive bacteria and Candida spp. were the cause of BSI episodes in 53%, 47% and 7% of cases, respectively. The 30-day mortality rate was 25% and was best predicted by the Sequential Organ Failure Assessment (SOFA) and Chronic Liver Failure–SOFA (CLIF-SOFA) score. In a Cox regression model, delayed (>24 hours) antibiotic treatment (hazard ratio (HR) 7.58; 95% confidence interval (CI) 3.29–18.67; p <0.001), inadequate empirical therapy (HR 3.14; 95% CI 1.93–5.12; p <0.001) and CLIF-SOFA score (HR 1.35; 95% CI 1.28–1.43; p <0.001) were independently associated with 30-day mortality. Independent risk factors for MDRO (31% of BSIs) were previous antimicrobial exposure (odds ratio (OR) 2.91; 95% CI 1.73–4.88; p <0.001) and previous invasive procedures (OR 2.51; 95% CI 1.48–4.24; p 0.001), whereas spontaneous bacterial peritonitis as BSI source was associated with a lower odds of MDRO (OR 0.30; 95% CI 0.12–0.73; p 0.008). Conclusions: MDRO account for nearly one-third of BSI in cirrhotic patients, often resulting in delayed or inadequate empirical antimicrobial therapy and increased mortality rates. Our data suggest that improved prevention and treatment strategies for MDRO are urgently needed in the liver cirrhosis patients. © 2017 European Society of Clinical Microbiology and Infectious Diseases

KW - antiinfective agent, adult

KW - all cause mortality

KW - antibiotic therapy

KW - Article

KW - bacterial peritonitis

KW - bloodstream infection

KW - Candida

KW - carbapenem-resistant Enterobacteriaceae

KW - chronic liver failure

KW - cohort analysis

KW - Enterococcus faecium

KW - extended spectrum beta lactamase producing Enterobacteriaceae

KW - female

KW - human

KW - invasive procedure

KW - liver cirrhosis

KW - major clinical study

KW - male

KW - methicillin susceptible Staphylococcus aureus

KW - middle aged

KW - multidrug resistance

KW - nonhuman

KW - pathogenesis

KW - priority journal

KW - prospective study

KW - risk factor

KW - Sequential Organ Failure Assessment Score

KW - Streptococcus pneumoniae

KW - therapy delay

KW - aged

KW - antibiotic resistance

KW - clinical trial

KW - comorbidity

KW - complication

KW - disease management

KW - health survey

KW - mortality

KW - multicenter study

KW - outcome assessment

KW - prognosis

KW - sepsis, Aged

KW - Comorbidity

KW - Disease Management

KW - Drug Resistance, Microbial

KW - Female

KW - Humans

KW - Liver Cirrhosis

KW - Male

KW - Middle Aged

KW - Mortality

KW - Patient Outcome Assessment

KW - Population Surveillance

KW - Prognosis

KW - Prospective Studies

KW - Risk Factors

KW - Sepsis

U2 - 10.1016/j.cmi.2017.08.001

DO - 10.1016/j.cmi.2017.08.001

M3 - Article

VL - 24

SP - 546.e1-546.e8

JO - Clinical Microbiology and Infection

JF - Clinical Microbiology and Infection

SN - 1198-743X

IS - 5

ER -