Bowel Colonization With Carbapenem‐Resistant Bacteria Is Associated With Short‐Term Outcomes in Patients With Acute‐On‐Chronic Liver Failure

BACKGROUND: Bowel colonization with antimicrobial-resistant bacteria has been associated with worse clinical outcomes in patients with cirrhosis; however, it has not been studied in patients with acute-on-chronic liver failure (ACLF). We evaluated whether fecal isolation of carbapenem-resistant gram-negative bacteria (CR-GNB) among patients with ACLF affects short-term outcomes. METHODS: Patients of APASL-ACLF (n = 339) were screened between June 2020 and December 2021, and 150 were included. Stool cultures were carried out at baseline and every 5 days thereafter until discharge or death. All surviving patients were followed until 60 days after discharge. RESULTS: Mean age was 44.8 (8.8) years, with 86% males and alcohol as etiology in 66%. CR-GNB organisms were isolated from stool in 42% of hospitalized ACLF patients, with E. coli and Klebsiella pneumoniae as the most common species. Patients with CR-GNB fecal carriage were associated with higher CTP, MELD, and DF scores but not with recent antibiotics, proton pump inhibitors, or lactulose use. Extraintestinal infections developed in 59.3% overall, most commonly UTI, pneumonia, and SBP. Infectious complications developed in 57.3% and 19.7% with and without CR-GNB in the stool (RR: 5.5; p < 0.001). Peripheral cultures were positive in 60.7% with infections, with species concordant with the fecal isolates found in 90.7%. Isolation of CR-GNB from stool and high bilirubin were independently associated with both in-hospital mortality and 60-day mortality (p = 0.05). CONCLUSIONS: Hospitalized ACLF patients with CR-GNB in the stool have a significantly higher risk of extraintestinal infections, in-hospital mortality, and short-term mortality up to 60 days. TRIAL NUMBER: [NCT04383106].