Reply to: “Another clinical unmet need in liver patients: Multidrug-resistant bacteria in decompensated cirrhosis”

We thank Dr. Rui Morais for their interest in our recent publication that highlighted that antibiotic resistance constitutes a prevalent and alarming healthcare problem in patients with decompensated cirrhosis in Europe. In just 7 years, the global prevalence of multidrug-resistant (MDR) bacterial infections increased from 29% to 38% in patients admitted to the hospital with acute decompensation. This Letter to the Editor reports retrospective data from a single center in Porto, Portugal, and shows that more than half of the culture positive infections (51%) were caused by MDR bacteria, mainly ESBL-producing Enterobacteriaceae and vancomycin-susceptible enterococci. The main reason behind the higher prevalence of MDR bacterial infections in the Portuguese series is that nosocomial infections were overrepresented in this cohort (87% of all infections), a factor that increases the risk of developing an MDR infection by almost 3-fold. Moreover, our study showed a high heterogeneity in the prevalence and type of MDR bacteria among centers, even in the same geographical region or city. Authors also investigated independent risk factors for MDR infection in their series and found that long-term antibiotic prophylaxis increased the risk of infection by these difficult to treat strains by 2.25 (1.14–4.47, p = 0.02). This finding contrasts with our results but is in line with previously reported data. The low number of patients on long-term quinolone prophylaxis in our study (n = 7) probably explains this discrepancy.

Finally, and in contrast with our study, the authors did not find a significant association between antibiotic resistance and mortality. However, the retrospective nature of the Portuguese study limits its capacity to adequately address this issue, very well demonstrated in large scale studies published recently.^, 

Our study and the data reported in the letter by Morais et al., demand the urgent evaluation of new strategies aimed at preventing the spread of antibiotic resistance in the cirrhotic population, including epidemiological surveillance and antibiotic stewardship programs and rapid microbiological tests.