complicanze infettive iatrogene - aisf · profilassi antibiotica in chirurgia surgical site...
TRANSCRIPT
INFECTIONS IN END STAGE LIVER DISEASES AND LIVER
TRANSPLANTATION
Umberto Cillo, Antonio Ottobrelli, Nicola Petrosillo, Marco Senzolo, Gabriele Missale
COMPLICANZE INFETTIVE IATROGENE
COMPLICANZE INFETTIVE IATROGENE
• CHIRURGIA
• MANOVRE INVASIVE PERCUTANEE
• ERCP
• NUTRIZIONE PARENTERALE
Durata di degenza, costi e rischio di mortalità della
chirurgia non-resettiva epatica nel paziente cirrotico
Cirrhosis complicated
by PH
Cirrhosis
Normal
Csikesz NG, et al. J Am Coll Surg 2009;208:96Millwala F, et al. WJG 2007; 13:4056
PROFILASSI ANTIBIOTICA IN CHIRURGIA
Surgical Site Infections (SSIs)PNLG Antibioticoprofilassi perioperatoria nell'adulto - 2008
FATTORI DI RISCHIO PER SSIs
Pessaux P, et al. Arch Surg 2003; 138:314
Pessaux P, et al. Arch Surg 2003; 138:314
Fattori di rischio per morbidità da infezioni extra SSI
Pessaux P, et al. Arch Surg 2003; 138:314
Fattori di rischio per morbidità da infezioni extra SSI
analisi multivariata
Infective risk assessment for surgical diagnostic and therapeutic
procedures, is there an evidence for antibiotic prophylaxis ?
• Based on the high prevalence of infections and the related
mortality rate in cirrhotic patients undergoing abdominal (as
well extra-abdominal) surgery, keen attention needs to be
taken in the clinical care of these patients. However, at this
time there are no studies available in the medical literature
addressing the specific issue of antibiotic prophylaxis in these
patients.
• No specific recommendations are therefore available and
further scientific efforts in this setting are urgently required in
the near future.
Antibiotic prophylaxis for patients undergoing elective
endoscopic retrograde cholangiopancreatography (1)
Brand M, et al. Cochrane Database of Systematic reviews , issue 11, 2010
Antibiotic prophylaxis for patients undergoing elective
endoscopic retrograde cholangiopancreatography (2)
Brand M, et al. Cochrane Database of Systematic reviews , issue 11, 2010
Infective risk assessment for ERCP in ESLD and OLT patient.
Which prophylaxis has to be adopted
• Antibiotic prophylaxis for patients undergoing elective endoscopic retrograde cholangiopancreatography prevents cholangitis (RR 0.54, 95% CI 0.33-0.91), septicemia (RR 0.35, 95%, CI 0.11—1.11), bacteremia (RR 0.50, 95% CI 0.33-0.78) and pancreatitis (RR 0.54, 95% CI 0.29-1.00) but without evidence of overall mortality reduction (RR 1.33, 95 CI 0.32-5.44). (I A)
• Of note, antibiotic prophylaxis benefit in preventing cholangitis was not demonstrated in patients in whom the ERCP resolved the biliary obstruction at the first procedure (RR 0.98, 95%; CI 0.35 to 2.69) (1). (I B).
• Prophylactic use of Cefotaxime, Piperacillin, Cefonicid, Cefuroxime, Minocyclinedemonstrated the same efficacy ( I A)
• In OLT patients with posttransplant biliary strictures, antibiotic prophylaxis is alwaysreccomended and continuation of antibiotics after the procedure may be beneficial (III B)
At this time there are no studies available in the medical literature addressing infective risk and the specific issue of antibiotic prophylaxis in patients with end ESLD
Banerjee S, et al. Gastrointest Endosc 2008;67:791
Brand M, et al. Cochrane Database of Systematic reviews , issue 11, 2010
Infective risk assessment for invasive diagnostic and
therapeutic percutaneous procedures in ESLD. Which
prophylaxis has to be adopted
• Central venous access
• Hepatic venous pressure gradient measurement
• Transgiugular liver biopsy
• Toracenthesis
• Transjugular intrahepatic porto-systemic shunt
(TIPS)
• Percutaneous tretment of liver tumors (PEI, RF)
• Transarterial chemoembolization (TACE)
Catheter related blood stream infections
(CR-BSIs)
Incidence of catheter related bloodstream infections
(CRBSIs) ranges between 3% to 4% in Europe with 1.12-
4.2 CRBSIs per 1000 catheter days, 8400-14,400 CRBSIs
episodes per year and 1000-1584 associated deaths per
year in a 4 countries epidemilogical study (II)
Tacconelli E, et al. J Hospital Infect 2009; 72:97
Central venous catheters treated with anti-infective
agents in preventing bloodstream infections
Hockenhull JC, et al. Health Technology Assessment 2008; Vol. 12
Gram negative bacteria are an increasing cause of CR-BSIs with
an incidence of 40%, but cirrhosis is associated with a lower risk
of Gram negative catheter related bacteraemia
Marcos M, et al. Antimicrob Chemoter 2011; 66:2119
Catheter related blood stream
infections (CR-BSIs)
• Patients who have more susceptibility to infections are more prone to develop severe CR-BSIs (II), however no specific epidemiological data are present in cohorts of patients with end stage liver disease.
• A significant advantage in preventing CRBSI of anti-infective central venous catheter has been demonstrated (I), but the indication to its use in cirrhotic patients needs further evidence.
• Recommendations: no prohylaxis (C)
Endotipsitis-persistent infection of transjugular intrahepatic
portosystemic shunt: risk of infection and aetiologic agents
Mizrahi M, et al. Liver Int 2010;30:175
•Bacteriemia incidence 35 cases/99 patients (35%)•Sustained bacteriemia incidence 5/99 patients (5%)
•Sustained bacteriemia developed a median of 100 days after TIPS placement (range, 6–732 days)
De Simone JA, et al. Clinical Infectious Diseases 2000; 30:384
•84 patients, 105 TIPS interventions: Infection rate 17%
Deibert P, et al. Dis Dis Sci 1998; 43:1708
•High risk patients: Child C, variceal rebleedingInfection rate 53%
Powels A, et al. Hepatology 1996; 24:802
Endotipsitis-persistent infection of transjugular intrahepatic
portosystemic shunt: antibiotic prophylaxis
Deibert P, et al. Dis Dis Sci 1998; 43:1708
Treatment Ce ftriaxone 1 gr ev Ceftriaxone 2 gr ev p Tips re lated infec tion 1/40 1/42 ns
Gulberg V, et al. Hepato-Gastroenterology 1999; 46:1126
Endotipsitis-persistent infection of transjugular
intrahepatic portosystemic shunt
• The use of prophylactic antibiotics during the initial TIPS
procedure is controversial, and despite the lack of evidence,
prophylaxis is the common practice
• Recommenations: Consideration should be given to remove
the central venous catheter after TIPS insertion if not
necessary (B). 1 gr ceftriaxone ev prior the procedure (A). 1.5-
3gr Ampicillin/Sulbactam inravenously (B)
Percutaneous treatment of liver tumors
(PEI, RF, TACE)
• Main infective complication is liver abscess, that is a rare event for
PEI and RF ablation (0.2-1.1%), with higher incidence reported for
trans-arterial chemoembolization (0.6-2.6%) [Reed RA, at al. J Vasc Interv Radiol.
1994; 5:367]
Bouza C, et al. BMC Gastroenterol 2009; 9:31Curley SA, et al. Ann Surg 2004; 239:450
The biliary abnormality prone to ascending biliary infection is the most
important predisposing factor to the development of liver abscess
after TACE and RF
De Baere T, et al. Am J Roentgenol 2003;181:695
Abscess occurred significantly (p < 0.00001) more frequently in
patients bearing a bilioenteric anastomosis (3/3) than in other patients
(4/223)
TACE
Song SY, et al. J Vasc Interv Radiol 2001;12:313
RF
Percutaneous treatment of liver tumors,
antibiotic prophylaxis
• TACE, TAERecommendation: in high risk patients Levofloxacin 500mg/d and metronidazole500mg td before procedure until 2 weeks after discharge along with bowel preparation with neomycin and erythromycin can be considered (B). Alternatively intravenous tazobactam/piperacillin for 36 hours after procedure (B)
• PEI and RFA
Recommendation: no prophylaxis (C).
Levofloxacin 500mg/d and metronidazole 500mg td before procedure until 2 weeks after discharge along with bowel preparation with neomycin and erythromycin can be considered in high risk patients (B)
Geschwind JF et al. J Vasc Interv Radiol 2002;13:1163
Patel S, et al. J Vasc Interv Radiol 2006;17:1931
Clinical management of patients with ESLD, which are the risks of
iatrogenic nosocomial infections related to parenteral nutrition
Yoneyama K, et al. J Gastroenterol 2002; 37:1028 Dupeyron C, et al. Infect Control Hosp Epidemiol 2001;22:427
•Intravenous hyperalimentation (IVH) infection is one of the causes of hospital
acquired infections in ESLD patient with an increased risk for Stphylococcus aureus
infections
% % % %
MSSA 111/589 18.8 %MRSA 96/589 16.3 %
Intravenous hyperalimentation (IVH) and
risk of CR-BIs
Recommendations:
• Healthcare personnel who care for patients with ESLD should be trained on the indications for intravascular catheter use, proper procedures for the insertion and maintenance of intravascular catheters, and appropriate infection control measures to prevent intravascular catheter-related infections (I A)
• Intravascular catheter that are no longer essential should be promptly removed (I A)
• Before insertion or during use of an intravascular catheter systemic antimicrobial prophylaxis should not been administered to prevent catheter colonization or catheter-related bloodstream infections (III C)
O’Grady NP, et al. Am J Infect Control 2011;39(4 Suppl 1):S1
OSSERVAZIONI CONCLUSIVE
•Chirurgia:
-nonostante vi sia una elevata frequenza di infezioni nelpaziente cirrotico e un significativo impatto sulla mortalità, non esistono studi di profilassi antibiotica in questi pazienti
•Procedure diagnostiche ed interventistiche percutanee:
-il rischio infettivo per procedure come: TACE e RF deriva dastudi che hanno incluso anche pazienti non cirrotici
-gli studi comparativi di profilassi antibiotica per TACE neipazienti ad elevato rischio (anastomosi bilio-enteriche) sonostudi retrospettivi condotti in pazienti cirrotici e non cirrotici(metastasi ipervascolari)