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.
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Prof. Marie-Hélène NICOLAS-CHANOINE
Bacterial infections Point of View
life-threatening complications in cirrhotic patients and common
25 % of death directly due to bacterial infection by bacterial infections
Spontaneous Bacterial Peritonitis (SBP) (± bacteremia)
Urinary Tract Infection (UTI) (± bacteremia)
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 by bacterial infections
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 in cirrhotic patients with SBP?E. coli
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
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
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
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 dysfunctions outweigh bacterial factors in predicting SBP in-hospital mortality Streptococci
Viridans group streptococci (VGS) in 56 episodes*of dysfunctions outweigh bacterial factors in predicting SBP in-hospital mortality
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 dysfunctions outweigh bacterial factors in predicting SBP in-hospital mortality
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.
TOHO-like caused by viridans group streptococci or
CTX-M-1, 3, 15
CTX-M-9, -14, 18, 19, 20, 21
CTX-M-, 3, 15
CTX-M-9, -13, -14
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 caused by viridans group streptococci or
Resistance to fluoroquinolones
Lower number of VF-encoding genes than expected in B2 isolates
Canada caused by viridans group streptococci or
ESBL-producing caused by viridans group streptococci or E.coli and cirrhotic patients ?
but carried in the digestive tract (rectal swabs)
Beaujon caused by viridans group streptococci or Hospital (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 caused by viridans group streptococci or
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 caused by viridans group streptococci or
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 caused by viridans group streptococci or
episodes of spontaneous bacterialperitonitis
* Data are means ± SD or numbers (%) of patients
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)* with in-hospital mortality
* one patient with endocardites
primary bacteremia = 16