Prevalence and Resistance Rates of Infections with Enterococci in Patients with Cirrhosis

Background and Aims:

Enterococcal infections comprise a considerable threat to cirrhotic patients, since enterococci are often insusceptible (i.e. cephalosporins, carbapenems) or becoming increasingly resistant (e.g. to aminopenicillins) to recommended antibiotics.

Methods:

Microbiologic reports of samples collected from consecutive patients with cirrhosis treated at a tertiary liver centre were systematically screened for bacterial infections. Blood stream infections (BSI), urinary tract infections (UTI), respiratory tract infections (RTI), and ascites cultures/spontaneous bacterial peritonitis (SBP) including the respective antibiograms were retrospectively evaluated.

Results:

We evaluated 1963 positive cultures (UTI: n = 422, BSI: n = 673, SBP: n = 467; RTI: n = 401) from 7,077 samples of patients with cirrhosis. Enterococci were found in 17.2% of positive cultures (UTI: 25.4%, BSI: 13.4%, SBP: 21.2%, RTI: 6.2%) and AR was tested in 85.3%. Resistances to ≥1 antibiotic classes (AC) were found in 37.9%; 10.9% of cultivated enterococci were resistant to at least 2 AC. While no resistance to aminopenicillins was found in outpatient enterococcal infections, aminopenicillin-resistant strands from nosocomial infections were tested in 36.7% (n = 91/248; UTI: n = 29/76, 38.2%; BSI: n = 19/53, 26.8%; SBP: n = 29/81, 35.8%; RTI: n = 14/20, 70.0%). Vancomycin-resistant enterococci (VRE) were found in 12.1% (UTI: 7.9%; BSI: 15.5%; SBP: 16.0%; RTI: 0.0%). We did not observe any resistance of isolated enterococci species to linezolid.

Conclusions:

Enterococci are common pathogens in SBP, respiratory and urinary tract infections in patients with cirrhosis. Thus, we cannot recommend the use of cephalosporins or quinolones for empiric treatment of suspected infections in patients with cirrhosis. Multiclass-resistance and VRE were found in about 10% of cases, respectively. For cirrhotic outpatients or uncomplicated infections we recommend aminopenicillins as empiric antibiotic treatment, while for nosocomial infections a combination of penems and Gram-positive agents should be used. Our data underline the importance of assessing the local microbial epidemiology and resistance profiles in patients with cirrhosis.

Tab. 1:

Resistant rates of enterococcal infections in cirrhosis

	All positive cultures	Enterococci
Included cultures	1963	248
Resistant to >= 1 antibiotic classes	21.8%	37.9%
Resistant to >= 2 antibiotic classes	6.5%	10.9%