Bacterial infections in cirrhosis: epidemiological changes with invasive procedures and norfloxacin prophylaxis

Hepatology. 2002 Jan;35(1):140-8. doi: 10.1053/jhep.2002.30082.


The extensive use of invasive procedures and of long-term norfloxacin prophylaxis in the management of cirrhotic patients may have influenced the epidemiology of bacterial infections in cirrhosis. We conducted a prospective evaluation of all bacterial infections diagnosed in patients with cirrhosis in a Liver Unit between April 1998 and April 2000. A total of 405 patients presented 572 bacterial infections in 507 admissions. Spontaneous bacterial peritonitis was the most frequent infection (138 cases). Gram-positive cocci were responsible for 53% of total bacterial infections in the study, being the main bacteria isolated in nosocomial infections (59%). Patients requiring treatment in an intensive care unit and those submitted to invasive procedures presented a higher rate of infections caused by gram-positive cocci (77% vs. 48%, P <.001 and 58% vs. 40%, P <.02, respectively). Fifty percent of culture-positive spontaneous bacterial peritonitis in patients on long-term norfloxacin administration (n = 93) and 16% in patients not receiving this therapy (n = 414) were caused by quinolone-resistant gram-negative bacilli, P =.01. The rate of culture-positive spontaneous bacterial peritonitis caused by trimethoprim-sulfamethoxazole-resistant gram-negative bacilli was also very high in patients on long-term norfloxacin administration (44% vs. 18%, P =.09). In conclusion, infections caused by gram-positive cocci have markedly increased in cirrhosis. This phenomenon may be related to the current high degree of instrumentation of cirrhotic patients. Quinolone-resistant spontaneous bacterial peritonitis constitutes an emergent problem in patients on long-term norfloxacin prophylaxis, with trimethoprim-sulfamethoxazole not being a valid alternative.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Aged
  • Anti-Infective Agents / therapeutic use*
  • Bacterial Infections / epidemiology*
  • Bacterial Infections / microbiology
  • Bacterial Infections / prevention & control*
  • Critical Care
  • Drug Resistance, Microbial
  • Escherichia coli / isolation & purification
  • Female
  • Gram-Negative Bacteria
  • Gram-Positive Cocci
  • Hepatitis C
  • Humans
  • Kidney / physiopathology
  • Liver / physiopathology
  • Liver Cirrhosis / microbiology*
  • Liver Cirrhosis / mortality
  • Liver Cirrhosis / virology
  • Liver Cirrhosis, Alcoholic / microbiology
  • Male
  • Middle Aged
  • Norfloxacin / therapeutic use*
  • Peritonitis / microbiology
  • Prospective Studies
  • Sulfamethoxazole / therapeutic use
  • Trimethoprim / therapeutic use


  • Anti-Infective Agents
  • Trimethoprim
  • Sulfamethoxazole
  • Norfloxacin