Language

English

Publication Date

8-1-2026

Journal

Alimentary Pharmacology & Therapeutics

DOI

10.1111/apt.70716

PMID

42129064

PMCID

PMC13420993

PubMedCentral® Posted Date

5-13-2026

PubMedCentral® Full Text Version

Post-print

Abstract

Background and aims: The rising burden of multidrug-resistant (MDRO) and carbapenem-resistant organisms (CRO) among patients with cirrhosis and spontaneous bacterial peritonitis (SBP) is compromising the effectiveness of standard empiric therapy. This multicentre study evaluated resistance patterns, independent predictors of MDRO and CRO infection, and clinical outcomes to inform risk-based empiric therapy and antimicrobial stewardship in ascitic infections.

Methods: We analysed clinical characteristics and outcomes of hospitalized patients with cirrhosis and culture-positive ascitic fluid infections from 13 centres across India. SBP was defined as ascitic neutrophil count (ANC) ≥ 250/mm3; culture-positive cases with ANC < 250/mm3 were classified as non-neutrocytic bacterascites (NNBA). Predictors of MDRO, CRO and mortality were assessed through regression models.

Results: Among 319 patients (median age 49 years; 79.9% male; 65.8% with acute-on-chronic liver failure), 74.6% of isolates were gram-negative. MDRO and CRO were identified in 53.6% and 24.1% of infections, respectively. Nosocomial/healthcare-associated acquisition, circulatory failure, elevated leukocyte count and SBP prophylaxis were independently associated with MDRO infection, while the nosocomial setting, leukocyte count and circulatory failure predicted CRO infection. MDRO infection was associated with poorer survival. Respiratory failure, liver failure, systemic inflammation, presence of MDRO and higher ACLF severity independently predicted mortality. Nearly one-third of culture-positive infections had ANC < 250/mm3 yet showed similar mortality to SBP. Based on clinical setting and risk profile, an empiric treatment framework was proposed.

Conclusions: There is a high burden of MDRO and CRO in ascitic infections among hospitalized patients with cirrhosis, with clinically relevant impact on outcomes. Empiric antibiotic selection should be guided by acquisition setting, illness severity and resistance risk factors, with stewardship oversight. Similar outcomes between NNBA and SBP suggest that microbiological evidence, rather than neutrophil count alone, should guide decisions.

Keywords

Adult, Aged, Female, Humans, Male, Middle Aged, Anti-Bacterial Agents, Bacterial Infections, Carbapenems, Drug Resistance, Multiple, Bacterial, India, Liver Cirrhosis, Peritonitis, Risk Factors, antimicrobial resistance, carbapenem‐resistant organisms, cirrhosis, empiric antibiotic therapy, multidrug‐resistant organisms, spontaneous bacterial peritonitis

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