Antimicrobial resistance (AMR) occurs when bacteria, viruses, fungi and parasites no longer respond to antimicrobial agents. As a result of drug resistance, antibiotics and other antimicrobial agents become ineffective and infections become harder or impossible to treat, increasing the risk of disease spread, severe illness and death.
The WAAW 2023 campaign builds on the previous year’s theme "Preventing antimicrobial resistance together”. Antimicrobial resistance is a growing threat to human and animal health, plants and the environment. Addressing AMR is a global endeavor that requires collaboration across sectors to preserve the effectiveness of antimicrobials. To effectively reduce antimicrobial resistance, all sectors must use antimicrobials prudently and appropriately, take preventive measures to decrease the incidence of infections and follow good practices in disposal of antimicrobial contaminated waste.
This year, EF CLIF joins the World Health Organization’s color campaign to go blue for AMR to raise awareness about the importance of appropriate antimicrobial use and the threat of AMR in the context of chronic liver disease.
The continuous rise in emergence of multidrug resistant organisms (MDROs) – microbes, predominantly bacteria, resistant to one or more antimicrobial agents, including beta-lactam antibiotics – affecting patients with cirrhosis is of global concern.
Patients that present complications of cirrhosis are particularly susceptible to infection by MDROs as a result of bacterial translocation of viable bacteria from the gastrointestinal tract to other tissues and organs. Infections are one of the leading triggers of acute-on-chronic liver failure (ACLF) – a severe form of acutely decompensated cirrhosis characterized by multiorgan system failure and short-term mortality. The growing prevalence of MDROs in patients with acutely decompensated cirrhosis and ACLF is also associated with increased length of in-hospital stay, repeated hospitalizations, the need for invasive procedures, frequent prophylactic antibiotic treatment for preventing nosocomial infection, and depending on the local epidemiology, variations in empirical antimicrobial treatment including practices in narrowing the spectrum of antimicrobial action, de-escalation strategies and cessation .
Antimicrobial stewardship and effective use of empirical antibiotic treatment
Empirical antimicrobial treatment is usually given to patients with an unidentified proven or suspected infection. Severe or life threatening infections are common among critically ill patients. Most infections in the intensive care unit are bacterial or fungal in origin and require antimicrobial treatment for clinical resolution. In this context, antibiotics are started empirically on the basis of the best guidelines available to improve patient outcomes. The timing of antibiotics in patients with life threatening infections including sepsis and septic shock is recognized as one of the most important determinants of survival for this patient population.
Evidence-based antimicrobial stewardship programs need to be implemented in the management and care of patients with acutely decompensated cirrhosis and ACLF to improve the use of antimicrobial agents and reduce the antimicrobial resistance rate without negatively impact patient outcomes.
EF CLIF researchers have recently contributed to the EASL Clinical Practice Guidelines on ACLF published in Journal of Hepatology – a set of statements that include recommendations intended to optimize care for patients with ACLF. The main objective of the Clinical Practice Guidelines on ACLF is helping clinicians to recognize the syndrome, make triage decisions, identify and manage acute extrahepatic precipitants (including, but not limited to, bacterial and fungal infections), identify organ systems that require support or replacement, define potential criteria for futility of intensive care, and identify potential indications for liver transplantation .
About the Clinical Practice Guidelines on ACLF
The development of these guidelines followed a standard operating procedure set out by the European Society for the Study of the Liver (EASL) meeting the international standards for clinical practice guidelines set out by the Guidelines International Network. The process involved the formulation of clinically relevant questions using the PICO framework (i.e., patient, problem, or pupulation (P); intervention (I); comparison, control, or comparator (C); outcome (O)) that were critically assessed through a Delphi survey by a 38-member panel, including clinicians, patients, and experts in the field beyond the clinical practice guideline panel and the EASL Governing Board. A deep literature review of published body of knowledge was conducted to make proposals for statements and recommendation for each section of the guidelines. The level of evidence was graded according to the Oxford Centre for Evidence-based Medicine and the strength of recommendations was categorized as either “weak” or “strong”. If clear evidence was not available, recommendations were based on the opinions of the expert panel (level of evidence 5).
1. Patel VC, Williams R. Antimicrobial resistance in chronic liver disease. Hepatol. Int. 2020;14(1):24–34. DOI:10.1007/s12072-019-10004-1
2. European Association for the Study of the Liver. EASL Clinical Practice Guidelines on acute-on-chronic liver failure. J. Hepatol. 2023;79(2):461–491. DOI:10.1016/j.jhep.2023.04.021