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)

25 % of death
Urinary Tract Infection (UTI)
directly due to
(± bacteremia)
bacterial
infection
Pulmonary
infection

Others
(peritoneal
tuberculosis)
 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
E.coli 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)
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 Group B1 Group B2 Group D Total
(n=20) (n=3) (n=35) (n=18) (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)
Toxins
hly 0 0 18 (51) 1 (5.6) 19 (25)
cnf1 0 0 17 (49) 0 17 (22)
Siderophores
fyuA 8 (40) 1 (33) 35 (100) 11 (61) 55 (72)
10
aer 2 (66) 19 (54) 12 (67) 43 (56)
(50)

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 Patients with non-B2 P
isolates (n= 35) isolates (n= 41)
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
MELD score 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
AF neutrophils (cells/mm3) 4,389 4,501 NS
AF protein (g/L) 11 10 0.1100
Hospital-acquired SBP 11 (31) 16 (39) NS
Positive blood cultures 9 (26) 15 (37) 0.1487
* 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 4.13 1.20 – 14.21 0.0247

SBP
Prothrombin ratio 1.513 1.02 – 14.05 0.0412

Serum creatinine 1.774 1.13 – 2.78 0.0127

level
Hospital-acquired 4.04 1.16 – 14.05 0.0281
SBP
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)
SBP Bacteremia without
Species
(n = 39)*** SBP (n = 17)
S. oralis 14 6
S. mitis 10 1
S. salivarius 4 6
S. gordonii 3 3
S. sanguis 3 0
S. vestibularis 3 0
S. mutans 0 1
others 2 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 % Ten patients had a prior

amoxicillin: 87.5 % episode of SBP and
cefotaxime: 89.3 % were receiving
erythromycin: 59 % norflaxacin prophylaxis.
levofloxacin: 100 %
moxifloxacin: 100 % No VGS resistant to
fluoroquinolones.
Demographic and biological data in 115 episodes of SBP
caused by viridans group streptococci or E. coli
SBP caused by
Variable 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-2, -5
CTX-M-3, 15
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, 15 CTX-M-3
CTX-M-16, -17
CTX-M-9,-14

CTX-M-1,10,15,32
CTX-M-9, -16

CTX-M-3 CTX-M-8

CTX-M-2 2005

Endémic Sporadic CTX-M-1 CTX-M-2 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 Incidence / 100 screened patients

Hepatology* ICU** Hospital

7/2 – 6/3 3.75 4.7

15/6 – 15/12 4 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) 8,850 ± 5,989
Platelet (cells/mm3) 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) 4,451 ± 4,720
Total protein (g/L) 10.4 ± 5.1
* Data are means ± SD or numbers (%) of patients
Distribution of phylogenetic groups and virulence factor (VF)
genes in relation to susceptibility to ciprofloxacin
Prevalence of group or VF gene, no. (%)
Ciprofloxacin-susceptible Ciprofloxacin-resistant
Trait
(n= 64) (n=12)
Phylogenetic group
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)
VF genes

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)
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

MELD score 31.6 23.1 0.0012

Blood neutrophils (cells/mm 3) 10,293 7,850 0.1163

Platelet (cells/m )
3
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/mm ) 3
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

* 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 3
Sterile ascite 9
Bacterascites (PNM < 250 mm3) 5
* one patient with endocardites

 primary bacteremia = 16