The challenges of multi-drug-resistance in hepatology Javier Fernández, Frédéric Bert, Marie-Hélène Nicolas-Chanoine  Journal of Hepatology  Volume 65, Issue 5, Pages 1043-1054 (November 2016) DOI: 10.1016/j.jhep.2016.08.006 Copyright © 2016 Terms and Conditions

Fig. 1 Resistance to quinolones of isolated organisms in culture-positive infections occurring in cirrhotic patients by geographical areas [7,10–13,55]. The rate of strains resistant to quinolones varies markedly among countries and studies, ranging from 19% to more than 60%. Journal of Hepatology 2016 65, 1043-1054DOI: (10.1016/j.jhep.2016.08.006) Copyright © 2016 Terms and Conditions

Fig. 2 Resistance to third-generation cephalosporins (TGC) of isolated organisms in culture-positive infections occurring in cirrhotic patients by geographical areas [7,10–13,55]. The rate of strains resistant to TGC differs markedly among countries, ranging from 18% to almost 50%. Journal of Hepatology 2016 65, 1043-1054DOI: (10.1016/j.jhep.2016.08.006) Copyright © 2016 Terms and Conditions

Fig. 3 Empirical antibiotic schedules suggested in critically ill cirrhotic patients and proposed de-escalation rules. Empirical treatment is decided according to the severity of infection, the presence of risk factors for MDROs and the local epidemiology. Broader spectrum antibiotics are used in the most severe infections covering all possible pathogens. Antibiotic schedules are re-evaluated after completing 48–72h of therapy. De-escalation is decided at this moment considering microbiological isolation and clinical evolution. ∗Previous colonization, antibiotic treatment ⩾5days in the last 3months, hospitalization ⩾5days in the last 3months, and nursing-home/long-term care facility. In these patients, nasal and rectal swabs should be performed to look for MDR colonization. ∗∗High-risk infection: pneumonia, secondary peritonitis (high bacterial load) or with high-risk of severe complications (meningitis). UTI, cellulitis, catheter infection and suspected infection are considered infections of moderate or low-risk. ∗∗∗Serum C-reactive protein (CRP) levels correlate with bacterial load and liver function; ⩾25, 15 and 10mg/dl in Child-Pugh A, B and C patients, respectively. $plus azithromycin in community-acquired pneumonia. #Change glycopeptides by daptomycin in infections with high-risk of bacteremia (catheter, endocarditis) or by linezolid in pneumonia, cellulitis or meningitis. ##Consider adding one or more of these antibiotics depending on the local epidemiology, recent antibiotic treatments (6weeks) and source of infection. ###Short-term treatments are recommended in the majority of patients, except for infections caused by S. aureus, intracellular strains, fungal infection, abscesses, parapneumonic empyema, biofilm formation or infections with predefined duration of treatment. CRP, serum C-reactive protein; ESBLE, extended-spectrum β-lactamase-producing Enterobacteriaceae; MRSA, methicillin-resistant Staphylococcus aureus; VSE, vancomycin-susceptible enterococci; VRE, vancomycin-resistant enterococci. Journal of Hepatology 2016 65, 1043-1054DOI: (10.1016/j.jhep.2016.08.006) Copyright © 2016 Terms and Conditions

Fig. 4 Strategies suggested to prevent the spread of MDROs in cirrhosis. Prevention strategies should include the restriction of antibiotic prophylaxis to high-risk populations, stewardship programs on antibiotic prescription tailored according to the severity of the infection and to data on MDROs colonization (epidemiological surveillance), well-defined early de-escalation policies based on rapid microbiological tests and other infection control practices. VAP, ventilator-associated pneumonia. Journal of Hepatology 2016 65, 1043-1054DOI: (10.1016/j.jhep.2016.08.006) Copyright © 2016 Terms and Conditions