Burden, risk factors, and outcomes of multidrug-resistant bacterial colonisation at multiple sites in patients with cirrhosis

The reported burden of multidrug-resistant organism (MDRO) infections is highest in patients with cirrhosis from India. We evaluated whether colonisation at multiple barriers predisposes to such infections and poor outcomes in patients with cirrhosis.We prospectively performed swab cultures, antimicrobial susceptibility testing (AST), and genotype testing for MDROs from various sites (rectum, nose, composite-skin, and central-line) in patients with cirrhosis (2020-2021) on admission and follow-up at a tertiary institute. We analysed clinical data, risk factors for MDROs, and patient outcomes.Of 125 patients aged 49 years, 85.6% males, 60.8% with acute-on-chronic liver failure, 99 (79.2%) were identified as 'colonisers'. MDRO-colonisation at rectum, nose, skin, or central line was observed in 72.7% (88/121), 30.0% (36/120), 14.9% (18/121), and 3.3% (4/121) patients, respectively. Patients were colonised with the following types of bacteria: extended-spectrum beta-lactamase (71/125), carbapenem-resistant Enterobacterales (67/125), MDR-Enterococcus (48/125), MDR-Acinetobacter (21/125), or methicillin-resistant Staphylococcus aureus (4/125). Multiple precipitants of acute-decompensation (odds ratio [OR]: 3.4, p = 0.042), norfloxacin prophylaxis (OR: 3.9, p = 0.008), and MDRO infection at admission (OR: 8.9, p = 0.041) were the independent predictors of colonisation. Colonisation increased the risk of infection by MDROs at admission (OR: 8.5, p = 0.017) and follow up (OR: 7.5, p <0.001). Although any-site colonisers were at greater risk of cerebral failure and poorer Child-Pugh scores, the nasal and skin colonisers were at higher risk of cerebral and circulatory failures than non-colonisers (p <0.05).Patients with more than one site colonisation (prevalence: 30%) developed multi-organ failure (p <0.05), MDRO infection (OR: 7.9, p <0.001), and poorer 30-day survival (hazard ratio: 2.0, p = 0.005).A strikingly high burden of MDRO colonisation among patients with cirrhosis in India necessitates urgent control measures. Multiple-site colonisation increases the risk of MDR-infections, multi-organ failure, and mortality in patients with cirrhosis.Infections by bacteria resistant to multiple antibiotics are an emerging cause of death in cirrhosis. We showed that ∼70-80% of critically ill hospitalised patients with cirrhosis carry such bacteria with the highest rate in the rectum, nose, skin, and central line port. Carbapenem-resistant and vancomycin-resistant bacteria were amongst the most common colonising bacteria. The presence of these bacteria at multiple sites increased the risk of multidrug-resistant infections, multiple organ failures, and death in patients with cirrhosis.