Bacterial infections in cirrhosis: Epidemiological changes with invasive procedures and norfloxacin prophylaxis

Abstract

The extensive use of invasive procedures and of long‐term norfloxacin prophylaxis in the management of cirrhotic patients may have influenced the epidemiology of bacterial infections in cirrhosis. We conducted a prospective evaluation of all bacterial infections diagnosed in patients with cirrhosis in a Liver Unit between April 1998 and April 2000. A total of 405 patients presented 572 bacterial infections in 507 admissions. Spontaneous bacterial peritonitis was the most frequent infection (138 cases). Gram‐positive cocci were responsible for 53% of total bacterial infections in the study, being the main bacteria isolated in nosocomial infections (59%). Patients requiring treatment in an intensive care unit and those submitted to invasive procedures presented a higher rate of infections caused by gram‐positive cocci (77% vs. 48%, P < .001 and 58% vs. 40%, P < .02, respectively). Fifty percent of culture‐positive spontaneous bacterial peritonitis in patients on long‐term norfloxacin administration (n = 93) and 16% in patients not receiving this therapy (n = 414) were caused by quinolone‐resistant gram‐negative bacilli, P = .01. The rate of culture‐positive spontaneous bacterial peritonitis caused by trimethoprim‐sulfamethoxazole–resistant gram‐negative bacilli was also very high in patients on long‐term norfloxacin administration (44% vs. 18%, P = .09). In conclusion, infections caused by gram‐positive cocci have markedly increased in cirrhosis. This phenomenon may be related to the current high degree of instrumentation of cirrhotic patients. Quinolone‐resistant spontaneous bacterial peritonitis constitutes an emergent problem in patients on long‐term norfloxacin prophylaxis, with trimethoprim‐sulfamethoxazole not being a valid alternative.