Multiresistant bacterial infections in liver cirrhosis: Clinical impact and new empirical antibiotic treatment policies

Table 1 Prevalence of different multiresistant bacteria across countries

Type of multiresistant bacteria	Prevalence rate
ESBL	South Korea, 4%-29%[13,14,19,20,24]
	Italy, 8%-20%[17,21]
	Spain and United States, 6%-9%[7,15,26]
	France, Denmark and Germany, < 5%[22,23,25]
MRSA	Italy, 7%[17,21]
	United States, 5%[26]
	Spain, 3%-4%[7,15]
	France, 2%[23]
	Denmark, Germany, 0%[22,25]
Pseudomonas aeruginosa	Spain, South Korea, 2%-3%[7,13-15,19,20,24]
	Germany, 1%[22]
	Denmark, France, 0%[23,25]
VSE	Denmark, 12%[25]
	Germany, 10%[22]
	France, 5%[23]
	Spain, 1%-7%[7,15]
VRE	United States, 9%[26]
	Spain, France, Denmark, Germany, 0%[7,15,22,23,25]

ESBL: Extended-spectrum β-lactamase-producing Enterobacteriaceae (bacteria with chromosomal β-lactamases are also included); MRSA: Methicillin-resistant Staphylococcus aureus; VSE: Vancomycin-susceptible Enterococcus; VRE: Vancomycin-resistant Enterococcus.

Table 2 Suggested empirical antibiotic therapy of bacterial infections in cirrhosis

Type of infection	Community-acquired infections	Nosocomial and HCA1 infections	Local epidemiological pattern
SBP, SBE and SB	Third generation cephalosporin	Piperacilin/tazobactam	Low prevalence of MR bacteria
	Or amoxicillin/clavulanic acid	Or carbapenem	ESBL-E
		Plus glycopeptides (or linezolid)	MRSA and VSE (when VRE)
Urinary tract infections	Third generation cephalosporin	Without sepsis:	VSE
	Or amoxicillin/clavulanic acid	Nitrofurantoin or fosfomycin
		With sepsis:	Low prevalence of MR bacteria
		Piperacilin/tazobactam
		Or carbapenem	ESBL-E
		Or plus glycopeptides (or linezolid)	MRSA and VSE (when VRE)
Pneumonia	Amoxicillin/clavulanic acid	Piperacilin/tazobactam	Low prevalence of MR bacteria
	Or ceftriaxone + macrolide	Meropenem or ceftazidime + ciprofloxacin	ESBL-E and P. aeruginosa
	Or levofloxacin	Plus vancomycin (or linezolid)	MRSA and VSE (when VRE)
	Or moxifloxacin
Skin and soft tissue infections	Amoxicillin/clavulanic acid	Meropenem or ceftazidime + oxacillin	ESBL-E and P. aeruginosa
	Or third generation cephalosporin plus oxacillin	Plus glycopeptides (or linezolid or daptomycin)	MRSA and VSE (when VRE)

¹HCA infections with at least two of the following risk factors for MR bacteria: long-term norfloxacin prophylaxis, recent infection by MR bacteria in the last 6 mo, recent use of β-lactams in the last 3 mo. SBP: Spontaneous bacterial peritonitis; SBE: Spontaneous bacterial empyema; SB: Spontaneous bacteremia; HCA: Health-care associated; ESBL-E: Extended-spectrum β-lactamase producing Enterobacteriaceae; MRSA: Methicillin-resistant Staphylococcus aureus; VSE: Vancomycin-susceptible Enterococcus; VRE: Vancomycin resistant Enterococcus.