Epidemiology and Effects of Bacterial Infections in Patients With Cirrhosis Worldwide

Salvatore Piano, Virendra Singh, Paolo Caraceni, Rakhi Maiwall, Carlo Alessandria, Javier Fernandez, Elza Cotrim Soares, Dong Joon Kim, Sung Eun Kim, Monica Marino, Julio Vorobioff, Rita de Cassia Ribeiro Barea, Manuela Merli, Laure Elkrief, Victor Vargas, Aleksander Krag, Shivaram Prasad Singh, Laurentius Adrianto Lesmana, Claudio Toledo, Sebastian MarcianoXavier Verhelst, Florence Wong, Nicolas Intagliata, Liane Rabinowich, Luis Colombato, Sang Gyune Kim, Alexander Gerbes, Francois Durand, Juan Pablo Roblero, Kalyan Ram Bhamidimarri, Thomas D. Boyer, Marina Maevskaya, Eduardo Fassio, Hyoung Su Kim, Jae Seok Hwang, Pere Gines, Adrian Gadano, Shiv Kumar Sarin, Paolo Angeli, Michele Bartoletti, Carlos Brodersen, Tony Bruns, Robert A. de Man, Annette Dam Fialla, Carmine Gambino, Vikas Gautam, Marcos Girala, Adria Juanola, Jeong Han Kim, Tae Hun Kim, Pramod Kumar, Barbara Lattanzi, Tae Hee Lee, Cosmas A. Rinaldi Lesmana, Richard Moreau, Preetam Nath, Gustavo Navarro, Ji Won Park, Gisela Pinero, Nikolaos T. Pyrsopoulos, Sophie Restellini, Gustavo Romero, Marco Sacco, Tiago Sevá-Pereira, Macarena Simón-Talero, Do Seon Song, Ki Tae Suk, Hans Van Vlierberghe, Sun Young Yim, Eileen Laurel Yoon, Giacomo Zaccherini

Research output: Contribution to journalArticleResearch

277 Citations (Scopus)


© 2019 AGA Institute Background & Aims: Bacterial infections are common and life-threatening in patients with cirrhosis. Little is known about the epidemiology of bacterial infections in different regions. We performed a multicenter prospective intercontinental study to assess the prevalence and outcomes of bacterial and fungal infections in patients with cirrhosis. Methods: We collected data from 1302 hospitalized patients with cirrhosis and bacterial or fungal infections at 46 centers (15 in Asia, 15 in Europe, 11 in South America, and 5 in North America) from October 2015 through September 2016. We obtained demographic, clinical, microbiology, and treatment data at time of diagnosis of infection and during hospitalization. Patients were followed until death, liver transplantation, or discharge. Results: The global prevalence of multidrug-resistant (MDR) bacteria was 34% (95% confidence interval 31%–37%). The prevalence of MDR bacteria differed significantly among geographic areas, with the greatest prevalence in Asia. Independent risk factors for infection with MDR bacteria were infection in Asia (particularly in India), use of antibiotics in the 3 months before hospitalization, prior health care exposure, and site of infection. Infections caused by MDR bacteria were associated with a lower rate of resolution of infection, a higher incidence of shock and new organ failures, and higher in-hospital mortality than those caused by non-MDR bacteria. Administration of adequate empirical antibiotic treatment was independently associated with improved in-hospital and 28-day survival. Conclusions: In a worldwide study of hospitalized patients, we found a high prevalence of infection with MDR bacteria in patients with cirrhosis. Differences in the prevalence of MDR bacterial infections in different global regions indicate the need for different empirical antibiotic strategies in different continents and countries. While we await new antibiotics, effort should be made to decrease the spread of MDR bacteria in patients with cirrhosis.
Original languageEnglish
Pages (from-to)1368-1380.e10
Number of pages23
Issue number5
Publication statusPublished - 1 Apr 2019


  • Global
  • Resistance
  • Sepsis
  • Stewardship


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