Primary prophylaxis for spontaneous bacterial peritonitis is linked to antibiotic resistance in the Veterans Health
Bryan D Badal1, Scott Silvey2, Lyuba Dragilev3
1Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Central Virginia Veterans Health Care System, Richmond, Virginia, USA.
Abstract:
Spontaneous bacterial peritonitis (SBP) is a major cause of mortality. Although SBP primary prophylaxis (SBPPr) with fluoroquinolones and trimethoprim-sulfamethoxazole (TMP-SMX) is often used, resistance could reduce its benefit.
Aim:
Analyze peritoneal fluid resistance patterns in patients with a first SBP episode with/without SBPPr using the Veterans Health Administration corporate data warehouse and to evaluate national antibiograms. Corporate data warehouse data were extracted using validated International Classification of Disease-9/10 codes, culture, resistance data, and outcomes of 7553 patients who developed their first inpatient SBP between 2009 and 2019 and compared between those with/without SBPPr. Escherichia coli ( E. coli ) and Klebsiella pneumoniae ( K. pneumoniae ) sensitivity to ciprofloxacin and TMP-SMX was calculated using 2021 Veterans Health Administration antibiogram data from all states. The most common isolates were E. coli , K. pneumoniae , and Staphylococcus species. Veterans taking ciprofloxacin SBBPr had higher fluoroquinolone resistance (34% vs 14% no SBPPr, p <0.0001); those taking TMP-SMX had higher TMP-SMX resistance (40% vs 14%, p <0.0001). SBPPr patients showed higher culture positivity, greater length of stay, higher second SBP, and higher probability of liver transplant rates versus no SBPPr. Multivariable models showed SBBPr to be the only variable associated with gram-negative resistance, and SBPPr was associated with a trend toward longer length of stay. E. coli ciprofloxacin sensitivity rates were 50%-87% and 43%-92% for TMP-SMX. K. pneumoniae ciprofloxacin sensitivity was 76%-100% and 72%-100% for TMP-SMX.
Conclusion:
Among patients who developed their first SBP episode, there was a higher prevalence of antibiotic resistance in those on SBPPr, with a high rate of fluoroquinolone resistance across the Veterans Health Administration sites.
Insights
Antibiotic resistance is higher in patients receiving spontaneous bacterial peritonitis prophylaxis (SBPPr). This increased resistance, particularly to fluoroquinolones, was observed in veterans undergoing SBPPr compared to those not on prophylaxis.
Area of Science:
- Infectious Diseases
- Hepatology
- Pharmacology
Background:
- Spontaneous bacterial peritonitis (SBP) is a severe complication of liver disease, often associated with high mortality.
- Primary prophylaxis (SBPPr) using fluoroquinolones or trimethoprim-sulfamethoxazole (TMP-SMX) is common but may lead to antibiotic resistance.
- Understanding resistance patterns is crucial for effective SBP management.
Purpose of the Study:
- To analyze peritoneal fluid resistance patterns in patients with their first SBP episode.
- To compare resistance in patients with and without prior SBPPr.
- To evaluate national antibiogram data for common SBP pathogens.
Main Methods:
- Retrospective analysis of 7553 patients with first SBP episode (2009-2019) from the Veterans Health Administration corporate data warehouse.
- Comparison of antibiotic resistance, culture positivity, and clinical outcomes between patients with and without SBPPr.
- Calculation of pathogen sensitivity rates using national Veterans Health Administration antibiogram data.
Main Results:
- Patients on SBPPr exhibited significantly higher resistance to fluoroquinolones (34% vs. 14%) and TMP-SMX (40% vs. 14%) compared to those without SBPPr.
- SBPPr was associated with increased culture positivity, longer hospital stays, higher rates of a second SBP, and increased liver transplant probability.
- Multivariable analysis identified SBPPr as the sole predictor of gram-negative resistance.
Conclusions:
- A higher prevalence of antibiotic resistance, especially fluoroquinolone resistance, exists in patients receiving SBPPr.
- These findings highlight potential challenges in SBP management due to prophylaxis-induced resistance.
- Further research into alternative prophylaxis strategies or resistance monitoring is warranted.
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