Bacterial Infection in Liver Cirrhosis: the Microbiologist Point of View

Prof. Marie-Hélène NICOLAS-CHANOINE

Bacterial infections

life-threatening complications in cirrhotic patients and common

30 to 50 % of hospitalized cirrhotic patients are concerned by bacterial infections

Spontaneous Bacterial Peritonitis (SBP) (± bacteremia)

Urinary Tract Infection (UTI) (± bacteremia)

Pulmonary infection

Others (peritoneal

tuberculosis)

25 % of death directly due to bacterial infection

Host risk factors for SBP

• Surviving to a previous SBP episode

• Low ascitic fluid protein levels (<10g/L)

• Gastrointestinal hemorrhage

Physiopathology of SBP

SBP is caused by intestinal micro-organisms that translocate through the mucosal barrier to the mesenteric lymph nodes , enter the

bloodstream and reach the ascitic fluid.

Parameter Number (%)

Community Nosocomial Total

Episode number 128 69 197

Isolate number 130 74 204

Plurimicrobial 2 5 7 (3.5)

Enterobacteriacae 67 43 110

E.coli 61 (47) 27 (36) 88 (43)

Klebsiella spp 2 6 8

Others 4 10 14

Streptococci 52 (40) 15 (20) 67 (32)

Viridans group 27 11 38

S. bovis 9 2 11

Pneumococci 7 2 9

B group 8 0 8

S. aureus 2 5 7

Enterococcus spp 1 5 6 (3)

Others 7 3 10

Candida 2 3 5 (2.5)

Bacterial species isolated from AF obtained from patients

with SBP and hospitalized in Beaujon hospital (1998-2007)

Are bacterial factors involved in morbidity or/and mortality in cirrhotic patients with SBP?

“Genetic background of Escherichia coli isolates from patients with spontaneous bacterial peritonitis: relationship with host factors and prognosis”.

F. Bert et al, Clin. Microbiol. Infect. (in press)

- 4 phylogenetic groups: A, B1, B2 and D

- extraintestinal pathogens: more often group B2 isolates

- virulence factors (VF)-encoding genes

- group B2 isolates have more VF genes than non B2 group isolates

Population structure of E. coli

VF gene Prevalence of VF gene, No. (%) of isolates

Group A(n=20)

Group B1(n=3)

Group B2(n=35)

Group D(n=18)

Total(n=76)

Adhesins

papC 7 (35) 0 26 (74) 6 (33) 39 (51)

papG allele II 0 0 15 (43) 6 (33) 21 (28)

papG allele III 0 0 11 (31) 0 11 (14)

sfa/foc 0 0 18 (51) 0 18 (24)

Toxins

hly 0 0 18 (51) 1 (5.6) 19 (25)

cnf1 0 0 17 (49) 0 17 (22)

Siderophores

fyuA 8 (40) 1 (33) 35 (100) 11 (61) 55 (72)

aer 10 (50)

2 (66) 19 (54) 12 (67) 43 (56)

Prevalence of virulence factor (VF) genes according to phylogeneticgroups in 76 E. coli isolates from patients with SBP (1998-2005)

Mean VF score of B2 versus non B2: 15.4 vs 7.3 p<10-4

Value in the indicated group*

Variable Patients with B2isolates (n= 35)

Patients with non-B2isolates (n= 41)

PP

Age (year) 55 55 NS

Male gender 26 (75) 34 (83) NS

Alcoholism 22 (65) 25 (64) NS

Viral hepatitis 8 (24) 11 (28) NS

Hepatocellular carcinoma 7 (20) 4 (10) NS

Previous SBP episode 2 (6) 12 (30) 0.0153

Norfloxacin prophylaxis 1 (3) 9 (22) 0.0172

MELD score 26 29 0.1953

Blood neutrophils (cells/mm3) 10,752 7,931 NS

Platelet (cells/m3) 136,828 100,049 0.0823

Prothrombin ratio (%) 40 33 0.0558

Serum bilirubin (μmol/L) 200 178 NS

Serum creatinine (μmol/L) 142 182 NS

Serum sodium (μmol/L) 131 132 NS

AF neutrophils (cells/mm3) 4,389 4,501 NS

AF protein (g/L) 11 10 0.1100

Hospital-acquired SBP 11 (31) 16 (39) NS

Positive blood cultures 9 (26) 15 (37) 0.1487

Comparison of host factors in patients with B2 isolates and thosewith non-B2 isolates.

* data are no (%) of patients or mean value ; NS, non significant (p ≥ 0.2) ; SBP, spontaneous bacterial peritonitisAF, ascitic fluid, red indicates host factors independently associated with non-B2 isolates

10/76 (13%) patients with fluoroquinoloneprophylaxis

Prevalence of fluoroquinolone resistance in the 76 SBP E. coli = 16%

Fluorouinolone resistance significantly higher in patients with norfloxacin prophylaxis than in those without :70% vs 7.6%, p <10-4

Fluoroquinolone resistance significantly higher in non B2 isolates than in B2 isolates: 30% vs 0% , p <0.001

Overall, we found that the prevalence of non B2 isolates (fewer VF and more often resistant) increased with the severity of liver disease

Variable OR CI 95 % P

MELD score 1.832 1.29 – 2.59 0.0007

Hospital-acquired SBP

4.13 1.20 – 14.21 0.0247

Prothrombin ratio 1.513 1.02 – 14.05 0.0412

Serum creatinine level

1.774 1.13 – 2.78 0.0127

Hospital-acquired SBP

4.04 1.16 – 14.05 0.0281

Multiple logistic regression of risk factors for in-hospital mortality1

1: the first multivariate analysis tested the MELD score and the second multivariateanalysis tested the components of the score, 2: value for an increase of 5, 3: value for a decrease of 10 %, 4: value for an increase of 50 μmol/L

Host factors, namely the severity of renal and hepatic dysfunctions outweigh bacterial factors in predicting SBP in-hospital mortality

Viridans Streptococci

Viridans group streptococci (VGS) in 56 episodes*of SBP and/or bacteremia in 51 patients** (1998-2006)

SpeciesSBP

(n = 39)***Bacteremia without

SBP (n = 17)

S. oralis 14 6

S. mitis 10 1

S. salivarius 4 6

S. gordonii 3 3

S. sanguis 3 0

S. vestibularis 3 0

S. mutans 0 1

others 2 0* 60,7 % acquired in the community,** 5 patients with 2 consecutive episodes*** 4 episodes with bacteremia

Liver Transplantation (in press)

Antibiotic susceptibility of the 56 VGS

Ten patients had a prior episode of SBP and were receiving norflaxacin prophylaxis.

No VGS resistant to fluoroquinolones.

penicillin: 71 %amoxicillin: 87.5 %cefotaxime: 89.3 %erythromycin: 59 %levofloxacin: 100 %moxifloxacin: 100 %

Demographic and biological data in 115 episodes of SBP caused by viridans group streptococci or E. coli

VariableSBP caused by

pVGS (n = 39) E. coli (n = 76)

Age (year) 59.3 54.7 NS

Male gender 30 (76.9 %) 60 (78.9 %) NS

Alcoholism 18 (46.2 %) 46 (63 %) NS

Viral hepatitis 17 (43.6 %) 19 (36 %) NS

Carcinoma 7 (17.8 %) 11 (14.5 %) NS

MELD score 19.5 27.9 <0.01

Norfloxacin prophylaxis 9 (23.1 %) 10 (13.2 %) NS

Blood PMN (cells/mm3) 7,672 8,850 NS

AF PMN (cells/mm3) 1,426 4,451 <0.001

AF protein (g/L) 9.2 10.4 NS

Nosocomial origin 13 (33.3 %) 24 (31.6 %) NS

Positive blood cultures 4 (10.5 %) 29 (35.5 %) <0.01

15-day mortality 9 (23.1 %) 27 (38 %)* NS NS, non significant; PMN, polymorphonuclear leucocytes; AF, ascitic fluid.* Data available for 71 patients.

Multi drug-resistance in E. colirelated to extended-spectrum ß-lactamase (ESBL) production, notably CTX-M enzymes

Endémic CTX-M-1 CTX-M-8 CTX-M-9Sporadic CTX-M-2

2005

CTX-M-2, - 5

CTX-M-16, -17

CTX-M-8

CTX-M-9, -16

CTX-M-1, 3, 15

CTX-M-9, -14, 18, 19, 20, 21

CTX-M-2, -5

CTX-M-, 3, 15

CTX-M-2

TOHO-like

CTX-M-2

CTX-M-3, 15

CTX-M-14

CTX-M-3, 15

CTX-M-9, -13, -14

CTX-M-3

CTX-M-3

CTX-M-9,-14

CTX-M-1,10,15

CTX-M-4, -6

CTX-M-3

CTX-M-15

CTX-M-9,-14

CTX-M-1,10,15,32

Lewis J, AAC 2007, « CTX-M-type as the predominant ESBL isolated in a US health care system » (dominance of CTX-M-15)

Canton R. Curr. Opin. Microbial. 2006

Groupe B2Resistance to fluoroquinolonesLower number of VF-encoding genes than expected in B2 isolates

Canada

France

Spain

England

Turkey

India

Portugal

Switzerland

Korea

ESBL-producing E.coli and cirrhotic patients ?

Still rare as agent responsible for SBP / bacteremia

- 2 patients, June and Sept 2007 at Beaujon hospital - Korean J Hepatol sept 2007: survey on 12 years, emergence of ESBL-producing E. coli

but carried in the digestive tract (rectal swabs)

Period Incidence / 100 screened patients

Hepatology* ICU** Hospital

7/2 – 6/3 3.75 4.7

15/6 – 15/12 4 2

Beaujon Hospital (2006): incidence of fecal ESBL-positive enterobacteriaceae

* patients screened at admission,** patients screened at admission, then once a week

8 patients with ESBL-producing E. coli, 5 CTX-M-15 and 2 isolates belonging to clone ST131

In 2008Good and bad news about clinical and microbiological data with regard to SBP

Good news: norfloxacin prophylaxis not only decreases the risk of second SBP but also delays hepato-renal syndrome and improves survival in cirrhosis. Fernandez J et al, Gastroenterology. 2007 Sep;133(3):818-24.

Bad news. E. coli is become the enterobacterial species the most concerned by ESBL and fluoroquinolone resistance is extremely frequent in those E. coli producing CTX-M enzyme

Frederic Bert: infection in cirrhotic patients and patients with liver transplant

Véronique Leflon Guibout: molecular mechanisms of resistance and molecular epidemiology

Latifa Noussair: Mycobacterium tuberculosis infection diagnosisincluding tuberculosis peritonitis in cirrhotic patients

Characteristic Value*

Epidemiological features

Age (yr) 54.7 ± 10.6

Male gender 60 (78.9)

Alcoholism 46 (63)

Viral Hepatitis 19 (36)

Carcinoma 11 (14.5)

Previous SBP episode 14 (18.4)

Norfloxacin prophylaxis 10 (13.2)

Meld score 27.9 ± 9.7

Blood variables

PMN (cells/mm3) 8,850 ± 5,989

Platelet (cells/mm3) 117,000 ± 85,618

Prothrombin ratio (%) 35.9 ± 15.6

Bilirubin (µmol/L) 188 ± 138

Creatinine (µmol/L) 163 ± 140

Sodium (mmol/L) 131 ± 5.6

Ascitic fluid variables

PMN (cells/mm3) 4,451 ± 4,720

Total protein (g/L) 10.4 ± 5.1

Characteristics of cirrhotic patients in 76episodes of spontaneous bacterial peritonitis(SBP)

* Data are means ± SD or numbers (%) of patients

Prevalence of group or VF gene, no. (%)

TraitCiprofloxacin-susceptible

(n= 64)Ciprofloxacin-resistant

(n=12)

Phylogenetic group

A 13 (20.3) 7 (58.3)

B1 2 (3.1) 1 (8.3)

B2 35 (54.7) 0

D 14 (21.9) 4 (33.3)

VF genes

papC 34 (53.1) 5 (41.7)

papGII 21 (32.8) 0

papGIII 11 (17.2) 0

sfa/foc 18 (28.1) 0

hly 19 ( 29.7) 0

cnf1 17 (26.6) 0

fyuA 49 (76.6) 6 (50)

aer 36 (56.2) 7 (58.3)

Distribution of phylogenetic groups and virulence factor (VF)genes in relation to susceptibility to ciprofloxacin

Value in the indicated group*

Variable Patients who died (n= 38) Patients who survived (n= 33) P

Age (year) 51.7 53 NS

Male gender 31 (81.6) 25 (75.7) NS

Alcoholism 21 (58.3) 22 (68.7) NS

Viral hepatitis 10 (27.8) 8 (25) NS

Hepatocellular carcinoma 6 (15.8) 5 (15.1) NS

Previous SBP episode 5 (13.2) 8 (24.2) NS

Norfloxacin prophylaxis 3 (7.9) 6 (18.2) NS

MELD score 31.6 23.1 0.0012

Blood neutrophils (cells/mm3) 10,293 7,850 0.1163

Platelet (cells/m3) 117,552 114,180 NS

Prothrombin ratio (%) 31.1 42.2 0.0048

Serum bilirubin (μmol/L) 227.2 153.3 0.0357

Serum creatinine (μmol/L) 201.7 112.6 0.093

Serum sodium (μmol/L) 130.9 131.9 NS

AF neutrophils (cells/mm3) 4,992 4,181 NS

AF protein (g/L) 10.4 9.7 NS

B2 group 16 (48.1) 17 (51.5) NS

VF score 2.9 2.9 NS

Amoxicillin resistance 21 (55.3) 14 (42.4) NS

Amoxi-clavulanate resistance 5 (13.2) 5 (15.1) NS

Cefatoxime resistance 1 (2.6) 1 (3) NS

Ciprofloxacin resistance 5 (13.2) 6 (18.2) NS

Cotrimoxazole resistance 14 (36.8) 7 (21.2) 0.1542

Hospital-acquired SBP 16 (42.1) 7 (21.2) 0.0065

Positive blood cultures 16 (42.1) 8 (24.2) 0.1161

Appropriate empiric antibiotics 33 (94.3) 30 (96.7) NS

Albumin therapy 9 (23.7) 11 (33.3) NS

Unvariate analysis of host and bacterial factors associated with in-hospital mortality

* data are no (%) of patients or mean value ; NS, non significant (p ≥ 0.2) ; SBP, spontaneous bacterial peritonitis ; AF, ascite fluid ; VF, virulence factor

Bacteremia without SBP (n = 17)*Ascite Number

without 3

Sterile ascite 9

Bacterascites (PNM < 250 mm3) 5* one patient with endocardites

primary bacteremia = 16