Risk factors and mortality rates of carbapenem-resistant Gram-negative bacterial infections in intensive care units

Background The prevalence of hospital-acquired infections caused by carbapenem-resistant gram-negative bacteria(CRGNB)is increasing worldwide.Several risk factors have been associated with such infections.The present study aimed to identify risk factors and determine the mortality rates associated with CRGNB infections in intensive care units.Methods This retrospective case-control study was conducted at Erciyes University Hospital(Kayseri,Turkey)between January 2017 and December 2021.Demographic and laboratory data were obtained from the Infection Control Committee data and record system.Patients who had CRGNB infection 48–72 h after hospitalization were assigned to the case group,while those who were not infected with CRGNB during hospitalization formed the control group.Risk factors,comorbidity,demographic data,and mortality rates were compared between the two groups.Results Approximately 1449 patients(8.97%)were monitored during the active follow-up period;of those,1171 patients were included in this analysis.CRGNB infection developed in 14 patients(70.00%)who had CRGNB colonization at admission;in 162(78.26%)were colonized during hospitalization,whereas 515(54.56%)were not colonized.There was no significant difference in age,sex(male/female)or comorbidities.The total length of hospital stay was statistically significantly longer(P=0.001)in the case group(median:24[interquartile range:3–378]days)than the control group(median:16[interquartile range:3–135]days).The rates of colonization at admission(25.5%;vs.10.6%,P=0.001)and mortality(64.4%vs.45.8%,P=0.001)were also significantly higher in the cases than in the control group,respectively.In the univariate analysis,prolonged hospitalization,the time from intensive care unit admission to the development of infection,presence of CRGNB colonization at admission,transfer from other hospitals,previous antibiotic use,enteral nutrition,transfusion,hemodialysis,mechanical ventilation,tracheostomy,reintubation,central venous catheter,arterial catheterization,chest tube,total parenteral nutrition,nasogastric tube use,and bronchoscopy procedures were significantly associated with CRGNB infections(P<0.05).Multivariate analysis identified the total length of stay in the hospital(odds ratio[OR]=1.02;95%confidence interval[CI]:1.01 to 1.03;P=0.001),colonization(OR=2.19;95%CI:1.53 to 3.13;P=0.001),previous antibiotic use(OR=2.36;95%CI:1.53 to 3.62;P=0.001),intubation(OR=1.59;95%CI:1.14 to 2.20;P=0.006),tracheostomy(OR=1.42;95%CI:1.01 to 1.99;P=0.047),and central venous catheter use(OR=1.62;95%CI:1.20 to 2.19;P=0.002)as the most important risk factors for CRGNB infection.Conclusions Colonization,previous use of antibiotics,and invasive interventions were recognized as the most important risk factors for infections.Future research should focus on measures for the control of these parameters.

Improving treatment plan and mental health in children with abdominal infection for broad-spectrum bacterial infections

BACKGROUND Pediatric abdominal infection is a common but serious disease that requires timely and effective treatment.In surgical treatment,accurate diagnosis and rational application of antibiotics are the keys to improving treatment effects.AIM To investigate the effect of broad-spectrum bacterial detection on postoperative antibiotic therapy.METHODS A total of 100 children with abdominal infection who received surgical treatment in our hospital from September 2020 to July 2021 were grouped.The observation group collected blood samples upon admission and sent them for broad-spectrum bacterial infection nucleic acid testing,and collected pus or exudate during the operation for bacterial culture and drug sensitivity testing;the control group only sent bacterial culture and drug sensitivity testing during the operation.RESULTS White blood cell count,C-reactive protein,procalcitonin,3 days after surgery,showed better postoperative index than the control group(P<0.05).The hospital stay in the observation group was significantly shorter than that in the control group.The hospitalization cost in the observation group was significantly lower than that in the control group,and the difference between the two groups was statistically significant(P<0.05).CONCLUSION Early detection of broad-spectrum bacterial infection nucleic acids in pediatric abdominal infections can help identify pathogens sooner and guide the appropriate use of antibiotics,improving treatment outcomes and reducing medical costs to some extent.

Retrospective study of the incidence, risk factors, treatment outcomes of bacterial infections at uncommon sites in cirrhotic patients

BACKGROUND Bacterial infections(BI)negatively affect the natural course of cirrhosis.The most frequent BI are urinary tract infections(UTI),pneumonia,and spontaneousbacterial peritonitis(SBP).AIM To assess the relevance of bacterial infections beyond the commonly recognized types in patients with cirrhosis and to investigate their relationship with other clinical variables.METHODS We retrospectively analyzed patients with cirrhosis and BI treated between 2015 and 2018 at our tertiary care center.BIs were classified as typical and atypical,and clinical as well as laboratory parameters were compared between the two groups.RESULTS In a cohort of 488 patients with cirrhosis,we identified 225 typical BI(95 UTI,73 SBP,72 pulmonary infections)and 74 atypical BIs,predominantly cholangitis and soft tissue infections(21 each),followed by intra-abdominal BIs(n=9),cholecystitis(n=6),head/throat BIs(n=6),osteoarticular BIs(n=5),and endocarditis(n=3).We did not observe differences concerning age,sex,or etiology of cirrhosis in patients with typical vs atypical BI.Atypical BIs were more common in patients with more advanced cirrhosis,as evidenced by Model of End Stage Liver Disease(15.1±7.4 vs 12.9±5.1;P=0.005)and Child-Pugh scores(8.6±2.5 vs 8.0±2;P=0.05).CONCLUSION Atypical BIs in cirrhosis patients exhibit a distinct spectrum and are associated with more advanced stages of the disease.Hence,the work-up of cirrhosis patients with suspected BI requires detailed work-up to elucidate whether typical BI can be identified.

High mortality associated with gram-negative bacterial bloodstream infection in liver transplant recipients undergoing immunosuppression reduction

BACKGROUND Immunosuppression is an important factor in the incidence of infections in transplant recipient.Few studies are available on the management of immunosuppression(IS)treatment in the liver transplant(LT)recipients complicated with infection.The aim of this study is to describe our experience in the management of IS treatment during bacterial bloodstream infection(BSI)in LT recipients and assess the effect of temporary IS withdrawal on 30 d mortality of recipients presenting with severe infection.AIM To assess the effect of temporary IS withdrawal on 30 d mortality of LT recipients presenting with severe infection.METHODS A retrospective study was conducted with patients diagnosed with BSI after LT in the Department of Liver Surgery,Renji Hospital from January 1,2016 through December 31,2017.All recipients diagnosed with BSI after LT were included.Univariate and multivariate Cox regression analysis of risk factors for 30 d mortality was conducted in the LT recipients with Gram-negative bacterial(GNB)infection.RESULTS Seventy-four episodes of BSI were identified in 70 LT recipients,including 45 episodes of Gram-positive bacterial(GPB)infections in 42 patients and 29 episodes of GNB infections in 28 patients.Overall,IS reduction(at least 50%dose reduction or cessation of one or more immunosuppressive agent)was made in 28(41.2%)cases,specifically,in 5(11.9%)cases with GPB infections and 23(82.1%)cases with GNB infections.The 180 d all-cause mortality rate was 18.5%(13/70).The mortality rate in GNB group(39.3%,11/28)was significantly higher than that in GPB group(4.8%,2/42)(P=0.001).All the deaths in GNB group were attributed to worsening infection secondary to IS withdrawal,but the deaths in GPB group were all due to graft-versus-host disease.GNB group was associated with significantly higher incidence of intra-abdominal infection,IS reduction,and complete IS withdrawal than GPB group(P<0.05).Cox regression showed that rejection(adjusted hazard ratio 7.021,P=0.001)and complete IS withdrawal(adjusted hazard ratio 12.65,P=0.019)were independent risk factors for 30 d mortality in patients with GNB infections after LT.CONCLUSION IS reduction is more frequently associated with GNB infection than GPB infection in LT recipients.Complete IS withdrawal should be cautious due to increased risk of mortality in LT recipients complicated with BSI.

Association between infections caused by multidrug-resistant gram-negative bacteria and mortality in critically ill patients

The incidence of gram-negative multidrug-resistant(MDR) bacterial pathogens is increasing in hospitals and particularly in the intensive care unit(ICU) setting. The clinical consequences of infections caused by MDR pathogens remain controversial. The purpose of this review is to summarize the available data concerning the impact of these infections on mortality in ICU patients. Twenty-four studies, conducted exclusively in ICU patients, were identified through Pub Med search over the years 2000-2015. Bloodstream infection was the only infection examined in eight studies, respiratory infections in four and variable infections in others. Comparative data on the appropriateness of empirical antibiotic treatment were provided by only seven studies. In ten studies the presence of antimicrobial resistance was not associated with increased mortality; on the contrary, in other studies a significant impact of antibiotic resistance on mortality was found, though, sometimes, mediated by inappropriate antimicrobial treatment. Therefore, a direct association between infections due to gram-negative MDR bacteria and mortality in ICU patients cannot be confirmed. Sample size, presence of multiple confounders and other methodological issues may influence the results. These data support the need for further studies to elucidate the real impact of infections caused by resistant bacteria in ICU patients.

Bacterial infections in cirrhotic patients with hepatocellular carcinoma

AIMS To establish the prevalence of bacterial infection in cir- rhotic patients with hepatocellular carcinoma(HCC). METHODS All 719 cirrhotic patients with HCC were investigat- ed retrospectively for the prevalence of bacterial infections. RESULTS The incidence of bacterial infection was 15.4% (111/719).According to Child-Pugh classification,the inci- dences of bacterial infection in class A,B and C were 2.3%,8. 0%,and 26.4 %,respectively.The bacterial infection increased with the severity of cirrhosis and severe bacterial infections usual- ly occurred in Child-Pugh class B and C patients. CONCLUSIONS The susceptibility of HCC patients to bacterial infection is mainly due to the underlying cirrhosis and not to the HCC itself.

Flexible Copper‑Doped Silica Fibers Promote Infected Conjunctival Tissue Repair Through Antibacterial and Anti‑inflammatory Effects

The conjunctiva is crucial in safeguarding the eye from harm or infection,thereby ensuring the preservation of the vision.The repair of infected conjunctival damage is necessary.The objective of this study is to develop copper-doped flexible silica nanofibers(SiO_(2)@Cu NFs)with multifunctional antibacterial and anti-inflammatory characteristics.The continuous release of copper ions from electrospun membranes is shown to be effective to promote antibacterial and bioactive functions.Nanofiber membranes also exhibit biocompatibility and promote cell growth,angiogenesis,and inflammation modulation.In vivo evaluations further reveal the therapeutic efficacy of SiO_(2)@Cu NFs to promote the structural and the functional recoveries of the conjunctiva.Taken together,SiO_(2)@Cu NFs may hold significant promise for the fabrication of alterna-tive ocular bandage to suppress bacterial infection and promote repair of ocular tissues and may potential be also used for related disciplines.

Oxygen vacancy boosting Fenton reaction in bone scaffold towards fighting bacterial infection

Bacterial infection is a major issue after artificial bone transplantation due to the absence of antibacterial function of bone scaffold,which seriously causes the transplant failure and even amputation in severe cases.In this study,oxygen vacancy(OV)defects Fe-doped Ti O2(OV-FeTiO2)nanoparticles were synthesized by nano TiO2and Fe3O4via high-energy ball milling,which was then incorporated into polycaprolactone/polyglycolic acid(PCLGA)biodegradable polymer matrix to construct composite bone scaffold with good antibacterial activities by selective laser sintering.The results indicated that OV defects were introduced into the core/shell-structured OV-FeTiO2nanoparticles through multiple welding and breaking during the high-energy ball milling,which facilitated the adsorption of hydrogen peroxide(H2O2)in the bacterial infection microenvironment at the bone transplant site.The accumulated H2O2could amplify the Fenton reaction efficiency to induce more hydroxyl radicals(·OH),thereby resulting in more bacterial deaths through·OH-mediated oxidative damage.This antibacterial strategy had more effective broad-spectrum antibacterial properties against Gram-negative Escherichia coli(E.coli)and Gram-positive Staphylococcus aureus(S.aureus).In addition,the PCLGA/OV-FeTiO2scaffold possessed mechanical properties that match those of human cancellous bone and good biocompatibility including cell attachment,proliferation and osteogenic differentiation.

Evaluating bacterial contamination and surgical site infection risks in intracorporeal anastomosis: Role of bowel preparation

We recently read the study by Kayano et al on intracorporeal anastomosis(IA)for colon cancer,which assessed bacterial contamination and medium-term onco-logical outcomes and affirmed that IA is analogous to extracorporeal anastomosis in reducing intraperitoneal bacterial risk and achieving similar oncological results.Our commentary addresses gaps,particularly concerning bowel preparation and surgical site infections(SSIs),and highlights the need for comprehensive details on the bowel preparation methods that are currently employed,including mecha-nical bowel preparation,oral antibiotics(OA),their combination,and specific OA types.We emphasize the necessity for further analyses that investigate these me-thods and their correlation with SSI rates,to enhance clinical protocol guidance and optimize surgical outcomes.Such meticulous analyses are essential for refi-ning strategies to effectively mitigate SSI risk in colorectal surgeries.

Selective intestinal decontamination for the prevention of early bacterial infections after liver transplantation

Bacterial infection in the first month after liver transplantation is a frequent complication that poses a serious risk for liver transplant recipients as contributes substantially to increased length of hospitalization and hospital costs being a leading cause of death in this period. Most of these infections are caused by gramnegative bacilli, although gram-positive infections, especially Enterococcus sp. constitute an emerging infectious problem. This high rate of early postoperative infections after liver transplant has generated interest in exploring various prophylactic approaches to surmount this problem. One of these approaches is selective intestinal decontamination(SID). SID is a prophylactic strategy that consists of the administration of antimicrobials with limited anaerobicidal activity in order to reduce the burden of aerobic gram-negative bacteria and/or yeast in the intestinal tract and so prevent infections caused by these organisms. The majority of studies carried out to date have found SID to be effective in the reduction of gram-negative infection, but the effect on overall infection is limited due to a higher number of infection episodes by pathogenic enterococci and coagulase-negative staphylococci. However, difficulties in general extrapolation of the favorable results obtained in specific studies together with the potential risk of selection of multirresistant microorganisms has conditioned controversy about the routinely application of these strategies in liver transplant recipients.

Management of bacterial and fungal infections in end stage liver disease and liver transplantation: Current options and future directions

Patients with liver cirrhosis are susceptible to infections due to various mechanisms, including abnormalities of humoral and cell-mediated immunity and occurrence of bacterial translocation from the intestine. Bacterial infections are common and represent a reason for progression to liver failure and increased mortality. Fungal infections, mainly caused by Candida spp., are often associated to delayed diagnosis and high mortality rates. High level of suspicion along with prompt diagnosis and treatment of infections are warranted. Bacterial and fungal infections negatively affect the outcomes of liver transplant candidates and recipients, causing disease progression among patients on the waiting list and increasing mortality, especially in the early posttransplant period. Abdominal, biliary tract, and bloodstream infections caused by Gram-negative bacteria [e.g., Enterobacteriaceae and Pseudomonas aeruginosa(P. aeruginosa)] and Staphylococcus spp. are commonly encountered in liver transplant recipients. Due to frequent exposure to broad-spectrum antibiotics, invasive procedures, and prolonged hospitalizations, these patients are especially at risk of developing infections caused by multidrug resistant bacteria. The increase in antimicrobial resistance hampers the choice of an adequate empiric therapy and warrants the knowledge of the local microbial epidemiology and the implementation of infection control measures. The main characteristics and the management of bacterial and fungal infections in patients with liver cirrhosis and liver transplant recipients are presented.

Diagnosis and management of bacterial infections in decompensated cirrhosis

Bacterial infections are one of the most frequent complications in cirrhosis and result in high mortality rates.Patients with cirrhosis have altered and impaired immunity,which favours bacterial translocation.Episodes of infections are more frequent in patients with decompensated cirrhosis than those with compensated liver disease.The most common and life-threatening infection in cirrhosis is spontaneous bacterial peritonitis followed by urinary tract infections,pneumonia,endocarditis and skin and soft-tissue infections.Patients with decompensated cirrhosis have increased risk of developing sepsis,multiple organ failure and death.Risk factors associated with the development of infections are severe liver failure,variceal bleeding,low ascitic protein level and prior episodes of spontaneous bacterial peritonitis (SBP).The prognosis of these patients is closely related to a prompt and accurate diagnosis.An appropriate treatment decreases the mortality rates.Preventive strategies are the mainstay of the management of these patients.Empirical antibiotics should be started immediately following the diagnosis of SBP and the first-line antibiotic treatment is third-generation cephalosporins.However,the efficacy of currently recommended empirical antibiotic therapy is very low in nosocomial infections including SBP,compared to community-acquired episodes.This may be associated with the emergence of infections caused by Enterococcus faecium and extended-spectrum β-lactamaseproducing Enterobacteriaceae,which are resistant to the first line antimicrobial agents used for treatment.The emergence of resistant bacteria,underlines the need to restrict the use of prophylactic antibiotics to patients with the greatest risk of infections.Nosocomial infections should be treated with wide spectrum antibiotics.Further studies of early diagnosis,prevention and treatment are needed to improve the outcomes in patients with decompensated cirrhosis.

Bacteriological Profile of Infections Encountered in a Pneumology Service in a Moderate-Income Country [Pneumology Department of CHU Cocody (Côte d’Ivoire)]

Introduction: Infections represent a real public health problem aggravating the morbidity and mortality of hospitalized patients. Methods: This was a retrospective study with descriptive purposes over a period of 05 years, in the Pneumology Department of the University Hospital of Cocody. Results: The average age in our population was 42 years. We observed a male predo- minance of 64.5%, with a sex ratio of 1.8. Medical history was dominated by HIV infection (23.5%), followed by tuberculosis (15.6%). Concerning lifestyle, smoking was found in 38% of cases. Symptoms progressed chronically in 80% of cases. An infectious syndrome was found in 75% of cases. Microbial culture was positive in 42% of cases. Pseudomonas aeruginosa and Klebsiella pneumoniae were encountered in 26.4% of cases each, followed by Echerichia coli in 10.4% of cases. Klebsiella pneumoniae in the first three years topped the list, but gradually. Pseudomonas aeruginosa maintained its leadership over the last three years. Pseudomonas aeruginosa isolates expressed a resistance rate of 9.8% to ceftazidime and 8.1% to imipenem;to aztreonam (36%), ticarcillin (33.3%) and levofloxacin. These strains were susceptible to fosfomycin (100%), mero- penem (96.6%) and amikacin (96%). For isolated strains of Entero- bacteria- ceae, resistance was observed about ticarcillin (83.3%) and amoxicillin clavula- nic acid (71.2%). Streptococcaceae showed resistance to tetracycline (69.2%) and erythromycin (50%). Over the years there has been an increase in re- sistance to amoxicillin-clavulanic acid ceftriaxone. The death rate was 14%. Conclusion: The bacterial profile of infections is dominated by germs respon- sible for nosocomial infection with significant mortality.

Strategies for combating bacterial biofilm infections

Formation of biofilm is a survival strategy for bacteria and fungi to adapt to their living environment, especially in the hostile environment. Under the protection of biofilm, microbial cells in biofilm become tolerant and resistant to antibiotics and the immune responses, which increases the difficulties for the clinical treatment of biofilm infections. Clinical and laboratory investigations demonstrated a perspicuous correlation between biofilm infection and medical foreign bodies or indwelling devices. Clinical observations and experimental studies indicated clearly that antibiotic treatment alone is in most cases insufficient to eradicate biofilm infections. Therefore, to effectively treat biofilm infections with currently available antibiotics and evaluate the outcomes become important and urgent for clinicians. The review summarizes the latest progress in treatment of clinical biofilm infections and scientific investigations, discusses the diagnosis and treatment of different biofilm infections and introduces the promising laboratory progress, which may contribute to prevention or cure of biofilm infections. We conclude that, an efficient treatment of biofilm infections needs a well-established multidisciplinary collaboration, which includes removal of the infected foreign bodies, selection of biofilm-active, sensitive and well-penetrating antibiotics, systemic or topical antibiotic administration in high dosage and combinations, and administration of anti-quorum sensing or biofilm dispersal agents.

Multidrug-resistant bacterial infections after liver transplantation: An ever-growing challenge

Bacterial infections are a leading cause of morbidity and mortality among solid organ transplant recipients.Over the last two decades,various multidrug-resistant(MDR)pathogens have emerged as relevant causes of infection in this population.Although this fact reflects the spread of MDR pathogens in health care facilities worldwide,several factors relating to the care of transplant donor candidates and recipients render these patients particularly prone to the acquisition of MDR bacteria and increase the likelihood of MDR infectious outbreaks in transplant units.The awareness of this high vulnerability of transplant recipients to infection leads to the more frequent use of broad-spectrum empiric antibiotic therapy,which further contributes to the selection of drug resistance.This vicious cycle is difficult to avoid and leads to a scenario of increased complexity and narrowed therapeutic options.Infection by MDR pathogens is more frequently associated with a failure to start appropriate empiric antimicrobial ther-apy.The lack of appropriate treatment may contribute to the high mortality occurring in transplant recipients with MDR infections.Furthermore,high therapeutic failure rates have been observed in patients infected with extensively-resistant pathogens,such as carbapenemresistant Enterobacteriaceae,for which optimal treatment remains undefined.In such a context,the careful implementation of preventive strategies is of utmost importance to minimize the negative impact that MDR infections may have on the outcome of liver transplant recipients.This article reviews the current literature regarding the incidence and outcome of MDR infections in liver transplant recipients,and summarizes current preventive and therapeutic recommendations.

Bacterial infections other than spontaneous bacterial peritonitis in cirrhosis

Cirrhotic patients are immunocompromised with a high risk of infection.Proinflammatory cytokines and hemodynamic circulation derangement further facilitate the development of serious consequences of infections.Other than spontaneous bacterial peritonitis,bacteremia and bacterial infections of other organ systems are frequently observed.Gram-negative enteric bacteria are the most common causative organism.Other bacterial infections,such as enterococci,Vibrio spp.,Aeromonas spp.,Clostridium spp.,Listeria monocytogenes,Plesiomonas shigelloides and Mycobacterium tuberculosis are more prevalent and more virulent.Generally,intravenous third generation cephalosporins are recommended as empirical antibiotic therapy.Increased incidences of gram-positive and drug-resistant organisms have been reported,particularly in hospitalacquired infections and in patients receiving quinolones prophylaxis.This review focuses upon epidemiology,microbiology,clinical features and treatment of infections in cirrhosis other than spontaneous bacterial peritonitis,including pathogen-specific and liver diseasespecific issues.

Risk factors and outcome of bacterial infections in cirrhosis

Viable and non-viable pathological bacterial translocation promote a self-perpetuating circle of dysfunctional immune activation and systemic inflammation facilitating infections and organ failure in advanced cirrhosis.Bacterial infections and sepsis are now recognized as a distinct stage in the natural progression of chronic liver disease as they accelerate organ failure and contribute to the high mortality observed in decompensated cirrhosis.The increasing knowledge of structural,immunological and hemodynamic pathophysiology in advanced cirrhosis has not yet translated into significantly improved outcomes of bacterial infections over the last decades.Therefore,early identification of patients at the highest risk for developing infections and infectionrelated complications is required to tailor the currently available measures of surveillance,prophylaxis and therapy to the patients in need in order to improve the detrimental outcome of bacterial infections in cirrhosis.

Clinical characteristics and 28-d outcomes of bacterial infections in patients with hepatitis B virus-related acute-on-chronic liver failure

BACKGROUND Acute-on-chronic liver failure (ACLF),which includes hepatic and multiple extrahepatic organ failure,is a severe emergency condition that has high mortality.ACLF can rapidly progress and requires an urgent assessment of condition and referral for liver transplantation.Bacterial infections (BIs) trigger ACLF and play pivotal roles in the deterioration of clinical course.AIM To investigate the clinical characteristics and 28-d outcomes of first Bis either at admission or during hospitalization in patients with hepatitis B virus (HBV)-ACLF as defined by the Chinese Group on the Study of Severe Hepatitis B(COSSH).METHODS A total of 159 patients with HBV-ACLF and 40 patients with acute decompensation of HBV-related chronic liver disease combined with first BIs were selected for a retrospective analysis between October 2014 and March 2016 The characteristics of BIs,the 28-d transplant-free survival rates,and the independent predictors of the 28-d outcomes were evaluated.RESULTS A total of 194 episodes of BIs occurred in 159 patients with HBV-ACLF.Among the episodes,13.4 To were community-acquired,46.4 To were healthcare-associated,and 40.2% belonged to nosocomial BIs.Pneumonia (40.7%),spontaneous bacterial peritonitis (SBP)(34.5%),and bloodstream infection (BSI)(13.4%) were the most prevalent.As the ACLF grade increased,the incidence of SBP showed a downward trend (P=0.021).Sixty-one strains of bacteria,including 83.6% Gramnegative bacteria and 29.5% multidrug-resistant organisms,were cultivated from 50 patients with ACLF.Escherichia coli (44.3%) and Klebsiella pneumoniae (23.0%)were the most common bacteria.As the ACLF grade increased,the 28-d transplant-free survival rates showed a downward trend (ACLF-1,55.7%;ACLF-2,29.3%;ACLF-3,5.4%;P <0.001).The independent predictors of the 28-doutcomes of patients with HBV-ACLF were COSSH-ACLF score (hazard ratio[HR]=1.371),acute kidney injury (HR=2.187),BSI (HR=2.339),prothrombin activity (HR=0.967),and invasive catheterization (HR=2.173).CONCLUSION For patients with HBV-ACLF combined with first BIs,pneumonia is the most common form,and the incidence of SBP decreases with increasing ACLF grade.COSSH-ACLF score,acute kidney injury,BSI,prothrombin activity,and invasive catheterization are the independent predictors of 28-d outcomes.

Update and actual trends on bacterial infections following liver transplantation

Recent advances in effective antimicrobial prophylactic strategies have led to a decline in the incidence of opportunistic infections in liver transplant recipients. However, morbidity and mortality due to infectious diseases remain as major problems. Bacterial infections occurring early after transplant are mainly related to the technical aspects of the procedure. By contrast, after the first postoperative days and beyond, the nature and variety of infectious complications change. Opportunistic bacterial infections are uncommon after 6 mo in patients receiving stable and reduced maintenance doses of immunosuppression with good graft function and little is documented about these cases in the literature. Transplant recipients may be more susceptible to some pathogens, such as the Nocardia species, Legionella species, Listeria monocytogenes , Mycoplasma species, Salmonella species or Rhodococcus equi. Respiratory infections due to capsulated bacteria, such as Streptococcus pneumoniae and Haemophilus intTuenza, can be life- threatening if not promptly treated in this population. These late bacterial infections may be very difficult to recognize and treat in this population. In this article, we review what has been described in the literature with regards to late bacterial infections following liver transplantation.

Toll-like receptor 4 polymorphisms and bacterial infections in patients with cirrhosis and ascites

AIM To assess the relationship between the presence of toll-like receptor 4(TLR4) polymorphisms and bacterial infections in cirrhotic patients with ascites. METHODS We prospectively included consecutive patients with cirrhosis and ascites hospitalized during a 6-year period. Patients with human immunodeficiency virus(HIV) infection or any other immunodeficiency, patients with advanced hepatocellular carcinoma(beyond Milan's criteria) or any other condition determining poor short-term prognosis, and patients with a permanent urinary catheter were excluded. The presence of D299 G and/or T399 I TLR4 polymorphisms was determined by sequencing and related to the incidence and probability of bacterial infections, other complications of cirrhosis, hepatocellular carcinoma, and mortality during follow-up. A multivariate analysis to identify predictive variables of mortality in the whole series was performed. RESULTS We included 258 patients: 28(10.8%) were carriers of D299G and/or T399I TLR4 polymorphisms(polymorphism group) and 230 patients were not(wildtype group). The probability of developing any bacterial infection at one-year follow-up was 78% in the polymorphism group and 69% in the wild-type group(P = 0.54). The one-year probability of presenting infections caused by gram-negative bacilli(51% vs 44%, P = 0.68), infections caused by gram-positive cocci(49% vs 40%, P = 0.53), and spontaneous bacterial peritonitis(29% vs 34%, respectively, P = 0.99) did not differ between the two groups. The oneyear probability of transplant-free survival was 55% in the polymorphism group and 66% in the wild-type group(P = 0.15). Multivariate analysis confirmed that age, Child-Pugh score, active alcohol intake, previous hepatic encephalopathy, hepatocellular carcinoma and serum creatinine were associated with a higher risk of death during follow-up. CONCLUSION Genetic polymorphisms D299 G and/or T399 I of TLR4 do not seem to play a relevant role in the predisposition of cirrhotic patients with ascites to bacterial infections.