Liver and Bile

Hepatology. 2024;79(5):1019–32

Maiwall R, Piano S, Singh V, Caraceni P, Alessandria C, Fernandez J, Cotrim Soares E, Kim DJ, Kim SE, Marino M, Vorobioff J, de Cassia Ribeiro Barea R, Merli M, Elkrief L, Vargas V, Krag A, Singh SP, Lesmana LA, Toledo C, Marciano S, Verhelst X, Wong F, Intagliata N, Rabinowich L, Colombato L, Kim SG, Gerbes A, Durand F, Roblero JP, Bhamidimarri KR, Maevskaya M, Fassio E, Kim HS, Hwang JS, Gines P, Bruns T, Gadano A, Angeli P, Sarin SK; International Club of Ascites Global Study Group

Determinants of clinical response to empirical antibiotic treatment in patients with cirrhosis and bacterial and fungal infections – Results from the ICA “Global Study” (EABCIR-Global Study)

Background: The administration of an appropriate empirical antibiotic treatment is essential in cirrhosis and severe bacterial infections. The authors aimed to investigate the predictors of clinical response of empirical antibiotic treatment in a prospective cohort of patients with cirrhosis and bacterial and fungal infections included in the International Club of Ascites (ICA) “Global Study.”
Methods: Patients hospitalized with cirrhosis and bacterial/fungal infection were prospectively enrolled at 46 centers. Clinical response to antibiotic treatment was defined according to changes in markers of infection/inflammation, vital signs, improvement of organ failure, and results of cultures.
Results: From October 2015 to September 2016, 1302 patients were included at 46 centers. A clinical response was achieved in only 61% of cases. Independent predictors of lack of clinical response to empirical treatment were C-reactive protein (odds ratio [OR] = 1.16; 95% confidence interval [CI]: 1.02–1.31), blood leukocyte count (OR = 1.39; 95% CI: 1.09–1.77), serum albumin (OR = 0.70; 95% CI: 0.55–0.88), nosocomial infections (OR = 1.96; 95% CI: 1.20–2.38), pneumonia (OR = 1.75; 95% CI: 1.22–2.53), and ineffective treatment according to antibiotic susceptibility test (OR = 5.32; 95% CI: 3.47–8.57). Patients with a lack of clinical response to first-line antibiotic treatment had a significantly lower resolution rate of infections (55% vs. 96%; p < 0.001), a higher incidence of second infections (29% vs. 15%; p < 0.001), shock (35% vs. 7%; p < 0.001) and new organ failures (52% vs. 19%; p < 0.001) than responders. Clinical response to empirical treatment was an independent predictor of 28-day survival (subdistribution = 0.20; 95% CI: 0.14–0.27).

Conclusions: Four out of 10 patients with cirrhosis do not respond to the first-line antibiotic therapy, leading to lower resolution of infections and higher mortality. Broader-spectrum antibiotics and strategies targeting systemic inflammation may improve prognosis in patients with a high degree of inflammation, low serum albumin levels, and severe liver impairment

DOI: 10.1097/hep.0000000000000653