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Bacterial infections in cirrhosis

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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Bacterial infections in cirrhosis

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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 SBP Changing 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/clavulanate Type 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 cirrhosis In-hospital mortality

    30. Predictors of survival Multivariable 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

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