title: Long-term use of antibiotics and proton pump inhibitors predict development of infections in patients with cirrhosis.
abstract: OBJECTIVE
  Bacterial infections, particularly repeated infections, are significant causes of morbidity and mortality among patients with cirrhosis. We investigated and characterized risk factors for repeat infections in these patients.
  
  
  METHODS
  In a prospective study, we collected data from 188 patients hospitalized with cirrhosis and infections and enrolled in the North American Consortium for the Study of End-Stage Liver Disease (12 centers). Patients were followed up for 6 months after hospital discharge and data were analyzed on type of infections and factors associated with subsequent infections.
  
  
  RESULTS
  Six months after hospital discharge, 14% of subjects had received liver transplants, 27% died, and 59% were alive without liver transplantation. After discharge, 45% had subsequent infections, but only 26% of the subsequent infections occurred at the same site. Compared with patients not re-infected, patients with repeat infections were older and a higher proportion used proton pump inhibitors (PPIs) (P = .006), rifaximin (P < .001), or prophylactic therapy for spontaneous bacterial peritonitis (SBP) (P < .001). Logistic regression showed that SBP prophylaxis (odds ratio [OR], 3.44; 95% confidence interval [CI], 1.56-7.63), PPI use (OR, 2.94; 95% CI, 1.39-6.20), SBP at hospital admission (OR, 0.37; 95% CI, 0.15-0.91), and age (OR, 1.06; 95% CI, 1.02-1.11) were independent predictors of subsequent infections.
  
  
  CONCLUSIONS
  Patients hospitalized with cirrhosis and infections are at high risk for subsequent infections, mostly at different sites, within 6 months of index infection resolution. Those at highest risk include previously infected older patients receiving PPIs and/or SBP prophylaxis, although these associations do not prove that these factors cause the infections. New strategies are needed to prevent infections in patients with cirrhosis.
authors.affiliation: Medicine, Baylor University Medical Center, Dallas, Texas. Electronic address: Jacquelo@BaylorHealth.edu.
authors.forename: Jacqueline G
authors.initials: JG
authors.lastname: O'Leary
authors.affiliation: Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: K Rajender
authors.initials: KR
authors.lastname: Reddy
authors.affiliation: Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Florence
authors.initials: F
authors.lastname: Wong
authors.affiliation: Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota.
authors.forename: Patrick S
authors.initials: PS
authors.lastname: Kamath
authors.affiliation: Medicine, University of California, San Diego, San Diego, California.
authors.forename: Heather M
authors.initials: HM
authors.lastname: Patton
authors.affiliation: Medicine, University of Colorado, Denver, Colorado.
authors.forename: Scott W
authors.initials: SW
authors.lastname: Biggins
authors.affiliation: Medicine, University of Texas Health Science Center, Houston, Texas.
authors.forename: Michael B
authors.initials: MB
authors.lastname: Fallon
authors.affiliation: Medicine, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Guadalupe
authors.initials: G
authors.lastname: Garcia-Tsao
authors.affiliation: Medicine, Emory University, Atlanta, Georgia.
authors.forename: Ram M
authors.initials: RM
authors.lastname: Subramanian
authors.affiliation: Medicine, Beth Israel Deaconess, Boston, Massachusetts.
authors.forename: Raza
authors.initials: R
authors.lastname: Malik
authors.affiliation: Biostatistics, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia.
authors.forename: Leroy R
authors.initials: LR
authors.lastname: Thacker
authors.affiliation: Medicine, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia.
authors.forename: Jasmohan S
authors.initials: JS
authors.lastname: Bajaj
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001424:Bacterial Infections / Q000453:epidemiology*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D008875:Middle Aged; D009656:North America; D011446:Prospective Studies; D054328:Proton Pump Inhibitors / Q000627:therapeutic use*; D012307:Risk Factors
chemical_list: D000900:Anti-Bacterial Agents; D054328:Proton Pump Inhibitors
keywords: Antibiotic; Complication; Decompensation; NACSELD