title: Risk of Bacterial Infection in Patients With Cirrhosis and Acute Variceal Hemorrhage, Based on Child-Pugh Class, and Effects of Antibiotics.
abstract: OBJECTIVE
  Antibiotics frequently are overused and are associated with serious adverse events in patients with cirrhosis. However, these drugs are recommended for all patients presenting with acute variceal hemorrhage (AVH). We investigated whether patients should be stratified for antibiotic prophylaxis based on Child-Pugh scores, to estimate risks of bacterial infection, rebleeding, and mortality, and whether antibiotics have equal effects on patients of all Child-Pugh classes. We performed a sensitivity analysis using model for end-stage liver disease (MELD) scores.
  
  
  METHODS
  In a retrospective study, we analyzed data from 381 adult patients with cirrhosis and AVH (70% men; mean age, 56 y), admitted from 2000 through 2009 to 2 tertiary care hospitals in Edmonton, Alberta, Canada. We excluded patients with bacterial infection on the day of AVH. The association between antibiotic prophylaxis and outcomes was adjusted by liver disease severity and by a propensity score.
  
  
  RESULTS
  The patients included in the study had mean MELD scores of 16, and 54% received antibiotic prophylaxis. Overall, antibiotic therapy was associated with lower risks of infection (adjusted odds ratio, 0.37; 95% confidence interval, 0.91-0.74) and mortality (adjusted odds ratio, 0.63; 95% confidence interval, 0.31-1.29). Among patients categorized as Child-Pugh class A given antibiotics, only 2% developed infections and the mortality rate was 0.4%. Among patients categorized as Child-Pugh class B given antibiotics, 6% developed infections, compared with 14% of patients who did not receive antibiotics; antibiotics did not affect mortality. Administration of antibiotics to patients categorized as Child-Pugh class C reduced infections and mortality by approximately 50%, compared with patients who did not receive antibiotics. MELD scores were not as useful as Child-Pugh class in identifying patients at risk for infection.
  
  
  CONCLUSIONS
  Based on a retrospective analysis of patients with cirrhosis and AVH, those categorized as Child-Pugh class A had lower rates of bacterial infection and lower mortality rates in the absence of antibiotic prophylaxis than patients categorized as classes B or C. The recommendation for routine antibiotic prophylaxis for this subgroup requires further evaluation.
authors.affiliation: Cirrhosis Care Clinic, Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada. Electronic address: ptandon@ualberta.ca.
authors.forename: Puneeta
authors.initials: P
authors.lastname: Tandon
authors.affiliation: Cirrhosis Care Clinic, Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Juan G
authors.initials: JG
authors.lastname: Abraldes
authors.affiliation: Cirrhosis Care Clinic, Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Adam
authors.initials: A
authors.lastname: Keough
authors.affiliation: Cirrhosis Care Clinic, Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Ravin
authors.initials: R
authors.lastname: Bastiampillai
authors.affiliation: Cirrhosis Care Clinic, Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Saumya
authors.initials: S
authors.lastname: Jayakumar
authors.affiliation: Cirrhosis Care Clinic, Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Michelle
authors.initials: M
authors.lastname: Carbonneau
authors.affiliation: Cirrhosis Care Clinic, Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Eric
authors.initials: E
authors.lastname: Wong
authors.affiliation: Cirrhosis Care Clinic, Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Dina
authors.initials: D
authors.lastname: Kao
authors.affiliation: Cirrhosis Care Clinic, Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Vince G
authors.initials: VG
authors.lastname: Bain
authors.affiliation: Cirrhosis Care Clinic, Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
authors.forename: Mang
authors.initials: M
authors.lastname: Ma
mesh_terms: D000328:Adult; D000368:Aged; D000416:Alberta; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D019072:Antibiotic Prophylaxis / Q000379:methods*; D001424:Bacterial Infections / Q000453:epidemiology*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000150:complications*; D006801:Humans; D015994:Incidence; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D062606:Tertiary Care Centers; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents
keywords: Advanced Liver Disease; Antibiotic Resistance; Bleeding; Stratification