Burden, risk factors, and outcomes of multidrug-resistant bacterial colonisation at multiple sites in patients with cirrhosis

• Published in: JHEP reports Vol. 5; no. 8; p. 100788
• Main Authors: Verma, Nipun, Divakar Reddy, P. Venkata, Vig, Shashi, Angrup, Archana, Biswal, Manisha, Valsan, Arun, Garg, Pratibha, Kaur, Parminder, Rathi, Sahaj, De, Arka, Premkumar, Madhumita, Taneja, Sunil, Ray, Pallab, Duseja, Ajay, Singh, Virendra
• Format: Journal Article
• Language: English
• Published: Netherlands Elsevier B.V 01.08.2023; Elsevier
• Subjects: Antimicrobial resistance; Cirrhosis; MDR; Mortality; One health; SES; ACLF; NAFLD; BSIs; SSTIs; VRE; HR; AARC; FU; One health; EASL; ESBL; CLIF; MDR; 3GCRes; BAFLD; PDR; AIH; SBP; AST; CR-Acineto; DILI; AD; OR; Mortality; AMR; XDR; BL + BLI; MDRO; Cirrhosis; SOFA; APASL; AVH; MELD; UGI; CRE; ALD; Antimicrobial resistance; HE; CTP; MR-staph; SOFC
• ISSN: 2589-5559; 2589-5559
• DOI: 10.1016/j.jhepr.2023.100788

The reported burden of multidrug-resistant organism (MDRO) infections is highest in patients with cirrhosis from India. We evaluated whether colonisation at multiple barriers predisposes to such infections and poor outcomes in patients with cirrhosis. We prospectively performed swab cultures, antimicrobial susceptibility testing (AST), and genotype testing for MDROs from various sites (rectum, nose, composite-skin, and central-line) in patients with cirrhosis (2020–2021) on admission and follow-up at a tertiary institute. We analysed clinical data, risk factors for MDROs, and patient outcomes. Of 125 patients aged 49 years, 85.6% males, 60.8% with acute-on-chronic liver failure, 99 (79.2%) were identified as ‘colonisers’. MDRO-colonisation at rectum, nose, skin, or central line was observed in 72.7% (88/121), 30.0% (36/120), 14.9% (18/121), and 3.3% (4/121) patients, respectively. Patients were colonised with the following types of bacteria: extended-spectrum beta-lactamase (71/125), carbapenem-resistant Enterobacterales (67/125), MDR-Enterococcus (48/125), MDR-Acinetobacter (21/125), or methicillin-resistant Staphylococcus aureus (4/125). Multiple precipitants of acute-decompensation (odds ratio [OR]: 3.4, p = 0.042), norfloxacin prophylaxis (OR: 3.9, p = 0.008), and MDRO infection at admission (OR: 8.9, p = 0.041) were the independent predictors of colonisation. Colonisation increased the risk of infection by MDROs at admission (OR: 8.5, p = 0.017) and follow up (OR: 7.5, p <0.001). Although any-site colonisers were at greater risk of cerebral failure and poorer Child–Pugh scores, the nasal and skin colonisers were at higher risk of cerebral and circulatory failures than non-colonisers (p <0.05).Patients with more than one site colonisation (prevalence: 30%) developed multi-organ failure (p <0.05), MDRO infection (OR: 7.9, p <0.001), and poorer 30-day survival (hazard ratio: 2.0, p = 0.005). A strikingly high burden of MDRO colonisation among patients with cirrhosis in India necessitates urgent control measures. Multiple-site colonisation increases the risk of MDR-infections, multi-organ failure, and mortality in patients with cirrhosis. Infections by bacteria resistant to multiple antibiotics are an emerging cause of death in cirrhosis. We showed that ∼70–80% of critically ill hospitalised patients with cirrhosis carry such bacteria with the highest rate in the rectum, nose, skin, and central line port. Carbapenem-resistant and vancomycin-resistant bacteria were amongst the most common colonising bacteria. The presence of these bacteria at multiple sites increased the risk of multidrug-resistant infections, multiple organ failures, and death in patients with cirrhosis. [Display omitted] •Multidrug-resistant organism (MDRO) colonisation at multiple sites at admission and Day 7 was assessed in patients with cirrhosis.•A total of 80% of patients were colonised with MDROs (20% with pan-drug-resistant bacteria).•The rectum was the most common site of colonisation, followed by nose, skin, and central line.•Multiple precipitants of acute decompensation, norfloxacin prophylaxis, and infection by multiple drug-resistant bacteria independently predisposed to colonisation by MDROs.•MDRO colonisation, especially at multiple sites, increased the risk of infections by multiple drug-resistant bacteria, multi-organ failures, and mortality in patients with cirrhosis.