Bacterial infection in liver cirrhosis the microbiologist point of view
1 / 32

Bacterial Infection in Liver Cirrhosis: the Microbiologist Point of View - PowerPoint PPT Presentation

  • Uploaded on
  • Presentation posted in: General

Bacterial Infection in Liver Cirrhosis: the Microbiologist Point of View. Prof. Marie-Hélène NICOLAS-CHANOINE. Bacterial infections. life-threatening complications in cirrhotic patients and common. 30 to 50 % of hospitalized cirrhotic patients are concerned by bacterial infections.

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.

Download Presentation

Bacterial Infection in Liver Cirrhosis: the Microbiologist Point of View

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript

Bacterial Infection in Liver Cirrhosis: the Microbiologist Point of View


Bacterial infections

life-threatening complications in cirrhotic patients and common

30 to 50 % of hospitalized cirrhotic patients are concerned by bacterial infections

25 % of death directly due to bacterial infection

Spontaneous Bacterial Peritonitis (SBP) (± bacteremia)

Urinary Tract Infection (UTI) (± bacteremia)

Pulmonary infection


(peritoneal tuberculosis)

Host risk factors for SBP

  • Surviving to a previous SBP episode

  • Low ascitic fluid protein levels (<10g/L)

  • Gastrointestinal hemorrhage

Physiopathology of SBP

SBP is caused by intestinal micro-organisms that translocate through the mucosal barrier to the mesenteric lymph nodes , enter the

bloodstream and reach the ascitic fluid.

Bacterial species isolated from AF obtained from patients

with SBP and hospitalized in Beaujon hospital (1998-2007)

Are bacterial factors involved in morbidity or/and mortality in cirrhotic patients with SBP?

“Genetic background of Escherichia coli isolates from patients with spontaneous bacterial peritonitis: relationship with host factors and prognosis”.

F. Bert et al, Clin. Microbiol. Infect. (in press)

Population structure of E. coli

  • - 4 phylogenetic groups: A, B1, B2 and D

  • - extraintestinal pathogens: more often group B2

  • isolates

  • - virulence factors (VF)-encodinggenes

  • - group B2 isolates have more VF genes than

  • non B2 group isolates

Prevalence of virulence factor (VF) genes according to phylogenetic

groups in 76 E. coli isolates from patients with SBP (1998-2005)

Mean VF score of B2 versus non B2: 15.4 vs 7.3 p<10-4

Comparison of host factors in patients with B2 isolates and those

with non-B2 isolates.

* data are no (%) of patients or mean value ; NS, non significant (p ≥ 0.2) ; SBP, spontaneous bacterial peritonitis

AF, ascitic fluid,red indicates host factors independently associated with non-B2 isolates

10/76 (13%) patients with fluoroquinolone


Prevalence of fluoroquinolone resistance in the

76 SBP E. coli = 16%

Fluorouinolone resistance significantly higher

in patients with norfloxacin prophylaxis than

in those without :70% vs 7.6%, p <10-4

Fluoroquinolone resistance significantly higher

in non B2 isolates than in B2 isolates:

30% vs 0% , p <0.001

Overall, we found that the prevalence of non B2 isolates (fewer VF and more often resistant) increased with the severity of liver disease

Multiple logistic regression of risk factors for in-hospital mortality1

1: the first multivariate analysis tested the MELD score and the second multivariate

analysis tested the componentsof the score, 2: value for an increase of 5, 3: value for a decrease of 10 %,4: value for an increase of 50 μmol/L

Host factors, namely the severity of renal and hepatic dysfunctions outweigh bacterial factors in predicting SBP in-hospital mortality

Viridans Streptococci

Viridans group streptococci (VGS) in 56 episodes*of

SBP and/or bacteremia in 51 patients** (1998-2006)

* 60,7 % acquired in the community,** 5 patients with 2 consecutive episodes

*** 4 episodes with bacteremia

Liver Transplantation (in press)

Antibiotic susceptibility

of the 56 VGS

Ten patients had a prior episode of SBP and were receiving norflaxacin prophylaxis.

No VGS resistant to fluoroquinolones.

penicillin: 71 %

amoxicillin: 87.5 %

cefotaxime: 89.3 %

erythromycin: 59 %

levofloxacin: 100 %

moxifloxacin: 100 %

Demographic and biological data in 115 episodes of SBP caused by viridans group streptococci or E. coli

NS, non significant; PMN, polymorphonuclear leucocytes; AF, ascitic fluid.* Data available for 71 patients.

Multi drug-resistance in E. colirelated to extended-spectrum ß-lactamase (ESBL) production, notably CTX-M enzymes


CTX-M-1, 3, 15


CTX-M-2, -5

CTX-M-3, 15

CTX-M-9, -14, 18, 19, 20, 21


CTX-M-, 3, 15

CTX-M-9, -13, -14


CTX-M-4, -6


CTX-M-3, 15

CTX-M-16, -17




CTX-M-9, -16








CTX-M-2, -5






Canton R. Curr. Opin. Microbial. 2006

Lewis J, AAC 2007, « CTX-M-type as the predominant ESBL isolated in a US health care system » (dominance of CTX-M-15)

Groupe B2

Resistance to fluoroquinolones

Lower number of VF-encoding genes than expected in B2 isolates










ESBL-producing E.coli and cirrhotic patients ?

  • Still rare as agent responsible for SBP / bacteremia

  • - 2 patients, June and Sept 2007 at Beaujon hospital

  • Korean J Hepatol sept 2007: survey on 12 years, emergence of ESBL-producing E. coli

but carried in the digestive tract (rectal swabs)

BeaujonHospital (2006): incidence of fecal ESBL-positive enterobacteriaceae

* patients screened at admission,** patients screened at admission, then once a week

8 patients with ESBL-producing E. coli, 5 CTX-M-15 and 2 isolates

belonging to clone ST131

In 2008

Good and bad news about clinical and microbiological data with regard to SBP

Good news: norfloxacin prophylaxis not only decreases the risk of second SBP but also delays hepato-renal syndrome and improves survival in cirrhosis. Fernandez J et al, Gastroenterology. 2007 Sep;133(3):818-24.

Bad news. E. coli is become the enterobacterial species the most concerned by ESBL and fluoroquinolone resistance is extremely frequent in those E. coli producing CTX-M enzyme

Frederic Bert: infection in cirrhotic patients and patients

with liver transplant

Véronique Leflon Guibout: molecular mechanisms of resistance

and molecular epidemiology

Latifa Noussair: Mycobacterium tuberculosis infection diagnosis

including tuberculosis peritonitis in cirrhotic patients

Characteristics of cirrhotic patients in 76

episodes of spontaneous bacterialperitonitis


* Data are means ± SD or numbers (%) of patients

Distribution of phylogenetic groups and virulence factor (VF)

genes in relation to susceptibility to ciprofloxacin

Unvariate analysis of host and bacterial factors associated with in-hospital mortality

* data are no (%) of patients or mean value ; NS, non significant (p ≥ 0.2) ; SBP, spontaneous bacterial peritonitis ; AF, ascite fluid ; VF, virulence factor

Bacteremia without SBP (n = 17)*

* one patient with endocardites

 primary bacteremia = 16

  • Login