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.
Bacterial species isolated from AF obtained from patients
with SBP and hospitalized in Beaujon hospital (1998-2007)
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
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)
E.coli
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)
Population structure of E. coli
- 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
Prevalence of virulence factor (VF) genes according to phylogenetic
groups in 76 E. coli isolates from patients with SBP (1998-2005)
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)
hly
0
0
18 (51)
1 (5.6)
19 (25)
cnf1
0
0
17 (49)
0
17 (22)
fyuA
8 (40)
1 (33)
35 (100)
11 (61)
55 (72)
aer
10 (50)
2 (66)
19 (54)
12 (67)
43 (56)
Toxins
Siderophores
Mean VF score of B2 versus non B2: 15.4 vs 7.3 p<10-4
Comparison of host factors in patients with B2 isolates and those
with non-B2 isolates.
Value in the indicated group*
Variable
Patients with B2
isolates (n= 35)
Patients with non-B2
isolates (n= 41)
P
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
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
4,389
4,501
NS
11
10
0.1100
Hospital-acquired SBP
11 (31)
16 (39)
NS
Positive blood cultures
9 (26)
15 (37)
0.1487
MELD score
AF neutrophils (cells/mm3)
AF protein (g/L)
* data are no (%) of patients or mean value ; NS, non significant (p ≥ 0.2) ; SBP, spontaneous bacterial peritonitis
AF, ascitic fluid, red indicates host factors independently associated with non-B2 isolates
10/76 (13%) patients with fluoroquinolone
prophylaxis
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
Multiple logistic regression of risk factors for in-hospital
mortality1
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
1: the first multivariate analysis tested the MELD score and the second multivariate
analysis 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)
Species
S. oralis
S. mitis
S. salivarius
S. gordonii
S. sanguis
S. vestibularis
S. mutans
others
SBP
(n = 39)***
Bacteremia without
SBP (n = 17)
14
10
4
3
3
3
0
2
6
1
6
3
0
0
1
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
penicillin:
71 %
amoxicillin: 87.5 %
cefotaxime: 89.3 %
erythromycin: 59 %
levofloxacin: 100 %
moxifloxacin: 100 %
Ten patients had a prior
episode of SBP and
were receiving
norflaxacin prophylaxis.
No VGS resistant to
fluoroquinolones.
Demographic and biological data in 115 episodes of SBP
caused by viridans group streptococci or E. coli
Variable
SBP caused by
p
VGS (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. coli
related to extended-spectrum
ß-lactamase (ESBL) production,
notably CTX-M enzymes
TOHO-like
CTX-M-1, 3, 15
CTX-M-2
CTX-M-3, 15
CTX-M-2, -5
CTX-M-9, -14, 18, 19, 20, 21
CTX-M-14
CTX-M-, 3, 15
CTX-M-2, - 5
CTX-M-9,-14
CTX-M-9, -13, -14
CTX-M-15
CTX-M-1,10,15
CTX-M-3
CTX-M-4, -6
CTX-M-3
CTX-M-3, 15
CTX-M-16, -17
CTX-M-9,-14
CTX-M-1,10,15,32
CTX-M-9, -16
CTX-M-8
CTX-M-3
CTX-M-2
Endémic
Sporadic
CTX-M-1
CTX-M-2
2005
CTX-M-8
CTX-M-9
Canton R. Curr. Opin. Microbial. 2006
Lewis J, AAC 2007, « CTX-M-type as the predominant ESBL isolated in a US health
care system » (dominance of CTX-M-15)
Groupe B2
Resistance to fluoroquinolones
Lower number of VF-encoding genes than expected in B2 isolates
Canada
Portugal
England
France
Switzerland
Turkey
Spain
Korea
India
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)
Beaujon Hospital (2006): incidence of fecal
ESBL-positive enterobacteriaceae
Period
7/2 – 6/3
15/6 – 15/12
Incidence / 100 screened patients
Hepatology*
ICU**
3.75
4.7
4
Hospital
2
* 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 2008
Good 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 diagnosis
including tuberculosis peritonitis in cirrhotic patients
Characteristics of cirrhotic patients in 76
episodes of spontaneous bacterial peritonitis
(SBP)
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)
Platelet (cells/mm3)
8,850 ± 5,989
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)
Total protein (g/L)
* Data are means ± SD or numbers (%) of patients
4,451 ± 4,720
10.4 ± 5.1
Distribution of phylogenetic groups and virulence factor (VF)
genes in relation to susceptibility to ciprofloxacin
Prevalence of group or VF gene, no. (%)
Ciprofloxacin-susceptible
(n= 64)
Ciprofloxacin-resistant
(n=12)
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)
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)
Trait
Phylogenetic group
VF genes
Unvariate analysis of host and bacterial factors associated with in-hospital mortality
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
31.6
23.1
0.0012
10,293
7,850
0.1163
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
MELD score
Blood neutrophils
(cells/mm3)
Platelet (cells/m3)
* 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
Sterile ascite
3
9
Bacterascites (PNM < 250 mm3)
5
* one patient with endocardites
 primary bacteremia = 16