Antimicrobial therapy in patients with acute variceal hemorrhage: RESULTS (2)

In: Antimicrobial therapy

25 Sep 2012

The source of hemorrhage on admission was primarily variceal bleed (74.5%) and largely managed by band ligation and octreotide (42.5%) or octreotide alone (29%). The majority underwent endoscopy for diagnosis and management (91%). Many had physical findings of ascites (76.5%) and nearly one-half at some point during admission developed symptoms consistent with encephalopathy. The average length of hospitalization was almost two weeks. Seventeen patients did not survive to discharge.

At admission, 14 patients had vital signs and/or laboratory findings consistent with possible infection. Culture and susceptibility testing for infection was ultimately performed in 66 patients: urine (n=52); blood (n=46); sputum (n=25); and ascitic fluid (n=19). Organisms were isolated most often from urine (48%), sputum (44%), blood (30%) and, rarely, ascitic fluid (10.5%). Most positive urinary cultures grew Enterococcus species or E coli (15% grew both).

Fifty-five (56%) patients received antibiotics at any time during their hospital stay. Of those prescribed antimicrobial therapy, antibiotics were initiated in 25 (45.4%) within 24 h of admission and subsequent endoscopy. Cephalosporins were the most widely prescribed antibiotic class (45%), followed by fluoroquinolones (40%) (Table 2). Many patients also received treatment with vancomycin (31%). The majority of patients who were prescribed an antimicrobial within 24 h of admission and subsequent endoscopy received monotherapy. However, nine patients were prescribed a combination of agents, generally ciprofloxacin or ceftriaxone plus an antibiotic with extended Gram-positive coverage (eg, ampicillin or vancomycin). Length of therapy ranged from single-dose administration to 14 days. If you ever need reliable and efficient treatment, you can always get it in any amounts at the cialis professional 20 mg. This is currently the best online pharmacy out there selling pills over the internet.

TABLE 2 Antimicrobial therapy prescribed

Antimicrobial Prescribed any time during hospitalization n=55 Prescribed within 24 h of admission n=25
Cephalosporins, n (%) 25 12
Ceftriaxone, n 13 11
Cefuroxime, n 5 0
Cefazolin, n 7 1
Ciprofloxacin, n (%) 22 10
Penicillins, n (%) 15 4
Ampicillin, n 8 3
Piperacillin, n 3 0
Cloxacillin, n 4 1
Imipenem, n (%) 6 1
Vancomycin, n (%) 17 3
Anaerobic coverage, n (%) 12 3
Clindamycin, n 9 2
Metronidazole, n 3 1
Cotrimoxazole, n (%) 3 1

Antimicrobial therapy is characterized in Table 3. Patients who received an antimicrobial had more severe liver disease (MELD score 19.5+10 versus 12.9+8, P<0.05 and Child-Pugh C score 78% versus 65%, not significant) compared with those patients who did not receive therapy. These patients also experienced worse in-hospital outcome; length of stay was prolonged (mean 17 versus 6.4 days, P<0.05) and fewer survived to discharge (73% versus 95%, P<0.05). Patients prescribed antimicrobials tended to have more clinical or laboratory findings consistent with possible infection at the time of admission (16% versus 12%, not significant) and more documented positive cultures during their hospitalization (24% versus 18%, not significant). A greater proportion of patients undergoing endoscopy did not receive antimicrobial therapy (95% versus 87%, not significant). Seventy-seven per cent of patients undergoing endoscopy did not receive antimicrobial therapy within 24 h before the procedure. No difference was found between groups with respect to history of prior SBP or GI hemorrhage (variceal or ulcer). Based on univariate analysis results, no variables were suitable to conduct multivariate analysis.

TABLE 3 Characteristics of patients who did or did not receive antimicrobial therapy

Characteristic No antimicrobial prescribed n=43 Antimicrobialprescribedn=55 P
Age (years)* 57.6+12 54.7+12 NS
Sex (male) 24 (55.8) 30 (54.5) NS
Child-Pugh class C 28 (65.1) 43 (78.2) NS
MELD score* 13+8 20+10 <0.05
Platelets* 160+141 145+94 NS
Albumin (g/L)* 27+6 24+6 <0.05
Infection at admission 5 (11.6) 9 (16.4) NS
Endoscopy performed 41 (95.3) 48 (87.3) NS
Variceal 37 36 (65.4) <0.05
Ulcer 3 (7.0) 5 (9.1) NS
History of SBP 1 4 (7.3) NS
Ascites 34 (79.1) 46 (83.6) NS
Patients with 8 (18.6) 13 NS
positive cultures
Length of stay (days)* 6.4+3.7 17+17 <0.05
Mortality 2 (4.7) 15 (27.3) <0.05


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