Multidrug-resistant colonization in decompensated cirrhosis outside the ICU predicts infection and poor outcomes

Infections caused by multidrug- (MDROs) or extensively drug- (XDROs) resistant organisms are an increasing global concern in cirrhosis. While MDRO colonization is a recognized risk factor for infection in critical care settings, evidence in ward-based patients with decompensated cirrhosis is limited. This study aimed to determine the prevalence, dynamics, and clinical impact of MDRO colonization outside the intensive care unit (ICU) and to identify predictors of colonization and infection.

We conducted a single-center prospective study (2017-2020) enrolling 408 patients with decompensated cirrhosis consecutively admitted to the ward (n = 272) or ICU (n = 136). Rectal and nasal swabs were obtained at admission and weekly for up to 12 months. Colonization dynamics, resistance profiles, infection rates, and outcomes were analyzed in ward patients, with the ICU cohort serving as a comparator.

Baseline rectal MDRO colonization was common in both the ward and ICU (23% vs. 17%; p = 0.38) and increased over time, reaching similar rates at 1 year (39% vs. 43%; p = 0.13). XDROs emerged during follow-up in both settings. In ward patients, baseline (52% vs. 19%; p <0.0001) or follow-up (55% vs. 11%; p <0.0001) colonization was associated with MDRO infection by the colonizing strain and with higher mortality (60% vs. 22%; p <0.0001). Baseline (hazard ratio [HR] 9.6; p <0.0001) and follow-up colonization (HR 4.4; p <0.0001) independently predicted infection, and colonization at either time point predicted mortality (HR 2.07; p <0.0001). Recent acute-on-chronic liver failure predicted colonization (HR 2.5; p <0.0001) and infection (HR 2.8; p = 0.0003).

MDRO colonization is frequent and clinically significant outside the ICU in patients with cirrhosis, predicting both infection and mortality. Extending targeted surveillance and antibiotic stewardship beyond critical care may help reduce infection-related morbidity and mortality.

This study demonstrates that rectal colonization with multidrug-resistant organisms is both common and clinically significant in patients with decompensated cirrhosis outside the intensive care unit. These findings are highly relevant for hepatologists, infectious disease clinicians, and epidemiologists, as colonized ward patients faced a substantially increased risk of developing infections from their colonizing strain and experienced worse outcomes, particularly those with recent acute-on-chronic liver failure. Practically, incorporating colonization status into empirical antibiotic decision-making and evaluating targeted multidrug-resistant organism surveillance strategies beyond the intensive care unit could enhance early management and improve risk stratification. While further work is needed to assess feasibility and cost-effectiveness, our results provide a strong evidence base to inform the development of surveillance-driven approaches in routine cirrhosis care.