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Infections and cirrhosis. More frequent complication in patients with cirrhosis (30 to 47% in hospitalized patients) (1) Mortality related factor: 30% vs 5 - 12% (2) The most frequent types of infection: SBP (7 - 31%), urinary (12 - 29%) pulmonary infections (6 - 21%) and bacteremia (10 - 12%)Th
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1. Bacterial infections in cirrhosis Dr Jean-Didier Grangé
Hôpital Tenon, Paris, France
AP-HP - Université Paris VI
2. Infections and cirrhosis More frequent complication in patients with cirrhosis (30 to 47% in hospitalized patients) (1)
Mortality related factor: 30% vs 5 - 12% (2)
The most frequent types of infection: SBP (7 - 31%), urinary (12 - 29%) pulmonary infections (6 - 21%) and bacteremia (10 - 12%)
The most severe (mortality): pulmonary (30 à 41%) and SBP (20 à 30 %)
4. Type of bacteria isolated in SBPChanging epidemiology ?
7. Prognosis of SBP
8. Curative treatment of SBP
9. Cefotaxime - plus - albumin Results Cefotaxime : 2g/6 h IV
Albumin (n = 63)
1.5 g/kg within 6 hours of enrollment
1 g/kg on day 3
10. Cefotaxime - plus - albumin Mortality
11. Decision criteria
12. Summary –Treatment of SBP SBP : PMN > 250/ mm3
cefotaxime or amoxicillin/clavulanic acid
Prevention of renal insufficiency? Avoid aminoglycosides, NSAIDs, large volume paracentesis? Baseline BUN elevation ? albumin
Assess response to treatment (48 hours)
Uncomplicated SBP : oral therapy with quinolones or amoxicillin-clavulanic acid
One year survival : 30 to 40 %– Secondary prophylaxis– Evaluation for liver transplantation
13. Cirrhosis and pulmonary infections Frequent: 6 to 21% in prospective studies
No RCT in patients with cirrhosis
Mortality : 30 to 40 %
Fine Score
14.
15. Community-Acquired Pneumonia Treatment in patients with cirrhosis
16. Treatment of infections (n=96)Cefotaxime vs amoxicilline/clavulanate
17. Moxifloxacin vs amoxicilline/clavulanateType of infections (4 countries, 28 centers)
18. Treatment of infections (n=143)
19. SBP resolution (n = 35)
20. Pneumonia resolution (n = 21)
21. Prophylaxis Patients with ascites who are recovering from a prior episode of SBP
Those with an ascitic albumin concentration of les than 10g/L
Those with gastrointestinal bleeding
22. Prevent recurrence of SBP (n = 80)
23. Antibiotic prophylaxis in hospitalized patients ascites protein < 15 g/L (n = 63)
24. Patients without prior SBP ascites protein < 15g/L (n=107)
25. Long-term prophylaxis in patients with ascites - Meta-analysis 4 RCT, 1 meta-analysis
26. Selection of highly resistant Gram-negative pathogens and risk of emergence of enterococcus and methicillin-resistant Staphylococcus aureus. Campillo B et al. Epidemiol Infect 2001;127:443-50
Factors of development of quinolone-resistant negative Gram bacilli :
Length of antibiotic prophylaxis
Prevalence rate of quinolone resistance in care unit, hospital or country
Immunosuppression (steroid therapy, HIV, cancer)
Cereto F et al. Eur J Gastroenterol Hepatol 2002;14:81-3
Risks of antibiotic prophylaxis
28. Antibiotic prophylaxis and early rebleeding
29. Variceal bleeding in patients with cirrhosisIn-hospital mortality
30. Predictors of survivalMultivariable analysis Lower Child-Pugh Score
Absence of hypovolemic shock
Endoscopic therapy (? pharmacological therapy)
Antibiotic prophylaxis
Younger age
31. Short-term prophylaxis Effective in the prevention of infections, significant improvement in survival
Short-term prophylaxis should be considered standard of care in cirrhotic patients admitted with GI hemorrhage
Norfloxacin : 400 mg BID or ofloxacin for 7 days
Hospitalized patients with ascites protein < 10 g/L:- Norfloxacin 400 mg/d during hospitalization stay
32. Long-term prophylaxis Effective in the prevention of infections, risk of bacterial resistance
Patients recovering from an episode of SBP : norfloxacin 400 mg QD until disappearance of ascites, transplant or death
Patients without prior SBP and ascites protein < 10g/L. The indication depends of individual infection risk, therapeutic plan and local bacterial ecology
Patients without prior SBP and ascites protein > 10g/L.
? antibiotic prophylaxis is no recommended
34. Norfloxacine et prokinétiques Prospectif
Simple aveugle
Contrôlée, randomisée
35. Norfloxacine et prokinétiques