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United European Gastroenterol J. 2017 Dec;5(8):1090-1099. doi: 10.1177/2050640617704564. Epub 2017 Apr 04.

Bacterial infections in acute variceal hemorrhage despite antibiotics-a multicenter study of predictors and clinical impact.

United European gastroenterology journal

Stephen Lee, Lynora Saxinger, Mang Ma, Verónica Prado, Joaquin Fernández, Deepali Kumar, Juan Gonzalez-Abraldes, Adam Keough, Ravin Bastiampillai, Michelle Carbonneau, Javier Fernandez, Puneeta Tandon


  1. Cirrhosis Care Clinic-Gastroenterology, University of Alberta, Edmonton, Alberta, Canada.
  2. Infectious Diseases, University of Alberta, Edmonton, Alberta, Canada.
  3. Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain.
  4. Infectious Diseases University of Toronto, Toronto, Ontario, Canada.

PMID: 29238587 PMCID: PMC5721982 DOI: 10.1177/2050640617704564


BACKGROUND AND AIMS: Current guidelines recommend antibiotic prophylaxis in all patients presenting with cirrhosis and acute variceal hemorrhage (AVH). We aimed to evaluate the characteristics and clinical impact of "early" infections (developing within 14 days) of AVH in a real-world setting.

METHODS: We analyzed retrospective data from a cohort of 371 adult patients with cirrhosis and AVH all of whom had received antibiotic prophylaxis (74% men; mean age 56 years), admitted to tertiary care hospitals in Edmonton, Alberta, Canada, and Barcelona, Spain. Sensitivity analyses were presented for culture-positive (confirmed) infections.

RESULTS: The mean MELD was 16. Fifty-two percent of patients received quinolones, 45% third-generation cephalosporins and 3% other antibiotics. Fourteen percent (51/371) developed an infection within 14 days of AVH. Seventy-five percent of infections were culture positive and occurred at a mean of six days from AVH. When all infections were considered, respiratory infections were the most common (53%) followed by urinary tract infections (17%) and bacteremia (16%). Resistance patterns differed between countries. Outpatient antibiotic prophylaxis (OR 5.4) and intubation (OR 2.6) were independent predictors of bacterial infection. Bacterial infection (OR 2.6) and the MELD (OR 1.2) were independent predictors of six-week mortality.

CONCLUSIONS: Early bacterial infections develop in 14% of cirrhotic patients with AVH despite antibiotic prophylaxis, and have a negative impact on six-week mortality. Intubation and outpatient antibiotic prophylaxis are associated with increased risk of early bacterial infections. Patients at risk should be followed closely with prompt infection workup and local antibiogram-based expansion of antibiotic therapy in case of clinical decline.

Keywords: Cirrhosis; antibiotic prophylaxis; antibiotic resistance; microbiology; variceal bleed


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