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World J Clin Cases. Jan 26, 2023; 11(3): 534-544
Published online Jan 26, 2023. doi: 10.12998/wjcc.v11.i3.534
Impact of multidrug resistance on the management of bacterial infections in cirrhosis
Carlos Terra, Ângelo Zambam de Mattos, Marcelo Souza Chagas, Andre Torres, Denusa Wiltgen, Barbara Muniz Souza, Renata Mello Perez
Carlos Terra, Marcelo Souza Chagas, Andre Torres, Barbara Muniz Souza, Gastroenterology-Liver Unit, State University of Rio de Janeiro, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
Carlos Terra, Liver Unit, Casa de Saúde São José-Rede Santa Catarina, Rio de Janeiro 22271-080, Rio de Janeiro, Brazil
Carlos Terra, Ângelo Zambam de Mattos, Marcelo Souza Chagas, Andre Torres, Denusa Wiltgen, Barbara Muniz Souza, Renata Mello Perez, Alliance of Brazilian Centers for Cirrhosis Car, The ABC Group, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil
Carlos Terra, Liver Unit, Federal Hospital of Lagoa, Rio de Janeiro 22470-050, Rio de Janeiro, Brazil
Ângelo Zambam de Mattos, Graduate Program in Medicine: Hepatology, Federal University of Health Sciences of Porto Alegre, Porto Alegre 90020-090, Rio Grande do Sul, Brazil
Ângelo Zambam de Mattos, Gastroenterology and Hepatology Unit, Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre 90020-090, Rio Grande do Sul, Brazil
Marcelo Souza Chagas, Internal Medicine, Federal Hospital of Lagoa, Rio de Janeiro 22470-050, Rio de Janeiro, Brazil
Denusa Wiltgen, Department of Internal Medicine, Federal University of Health Sciences of Porto Alegre, Porto Alegre 90020-090, Brazil
Renata Mello Perez, Hepatology Division, Federal University of Rio de Janeiro, Rio de Janeiro 21941-617, Rio de Janeiro, Brazil
Renata Mello Perez, IDOR, D’Or Institute for Research and Education, Rio de Janeiro 22281-100, Rio de Janeiro, Brazil
Author contributions: Terra C, de Mattos ÂZ, Chagas MS, Torres A, Wiltgen D, Souza BM, and Perez RM performed the research, analyzed the data, and wrote the manuscript; all authors have read and approve the final manuscript.
Conflict-of-interest statement: All authors report no relevant conflicts of interest for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Carlos Terra, MD, PhD, Associate Professor, Doctor, Gastroenterology-Liver Unit, State University of Rio de Janeiro, Boulevard 28 Setembro, 77-3rd floor-Vila Isabel, Rio de Janeiro 20551-030, Rio de Janeiro, Brazil. carlosterrario@hotmail.com
Received: November 10, 2022
Peer-review started: November 10, 2022
First decision: November 26, 2022
Revised: December 22, 2022
Accepted: January 5, 2023
Article in press: January 5, 2023
Published online: January 26, 2023
Abstract

Patients with cirrhosis have an increased risk of infection and differently from other complications, that over the years are improving in their outcomes, infections in cirrhotic patients are still a major cause of hospitalization and death (up to 50% in-hospital mortality). Infections by multidrug-resistant organisms (MDRO) have become a major challenge in the management of cirrhotic patients with significant prognostic and cost-related impact. About one third of cirrhotic patients with bacterial infections is infected with MDR bacteria and their prevalence has increased in recent years. MDR infections have a worse prognosis compared to infections by non-resistant bacteria because they are associated with lower rate of infection resolution. An adequate management of cirrhotic patients with infections caused by MDR bacteria depends on the knowledge of some epidemiological aspects, such as the type of infection (spontaneous bacterial peritonitis, pneumonia, urinary tract infection and spontaneous bacteremia), bacteriological profile of antibiotic resistance at each health care unit and site of infection acquisition (community acquired, healthcare associated or nosocomial). Furthermore, regional variations in the prevalence of MDR infections determine that the choice of empirical antibiotic therapy must be adapted to the local microbiological epidemiology. Antibiotic treatment is the most effective measure to treat infections caused by MDRO. Therefore, optimizing antibiotic prescribing is critical to effectively treat these infections. Identification of risk factors for multidrug resistance is essential to define the best antibiotic treatment strategy in each case and the choice of an effective empirical antibiotic therapy and its early administration is cardinal to reduce mortality. On the other hand, the supply of new agents to treat these infections is very limited. Thus, specific protocols that include preventive measures must be implemented in order to limit the negative impact of this severe complication in cirrhotic patients.

Keywords: Cirrhosis, Infection, Multidrug-resistance, Bacterial, Antibiotics, Microbiota

Core Tip: Infections by multidrug-resistant organisms (MDRO) have become a major challenge in the management of cirrhotic patients with significant prognostic and cost-related impact. This review presents the main epidemiological data, clinical impact, risk factors, and the best management of cirrhotic patients infected with MDR bacteria.