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Bacterial Infections in Patients with Cirrhosis Admitted to the Hospital

Bacterial infections are frequently diagnosed in advanced cirrhosis and are associated with the development of organ failure (acute-on-chronic liver failure) and worse survival [1, 2]. In their work, published in this issue, Gomes et al. [3] retrospectively studied the prevalence of bacterial infections in a single-center large sample of patients with cirrhosis and bacterial infections admitted to a medical ward from 2008 to 2014 (372 out of 964 admissions in noncontinuous years). Their main findings were the following: (1) overall, the most frequent infections diagnosed were urinary tract infection (n = 121; 32.5%), respiratory tract infection (n = 109; 29.3%), and spontaneous bacterial peritonitis (n = 97; 26.1%); (2) overall, bacteria were identified in 198 (53.2%) cases, with 124 (62.6%) of those being Gram negative; (3) from 2008 to 2014, while the prevalence of community-acquired infections increased (49.0 vs. 70.7%), the prevalence of nosocomial infections decreased (51.0 vs. 29.3%); (4) from 2008 to 2014, the prevalence of multiresistant bacteria increased (9.6 vs. 14.4%) – overall, 77.8% (42/54) of those cases were nosocomial; (5) from 2008 to 2014, while the median MELD score decreased (17 vs. 14), the in-hospital mortality rate increased (7.0 vs. 25.0%). The findings of Gomes et al. [3] provide a real-life characterization of the current epidemiology of bacterial infections in patients with cirrhosis admitted to a large district hospital in the north of Portugal. Furthermore, they emphasize some key characteristics of bacterial infections in this group of patients [4]: they are frequent (38.6% of ward stays), but a positive microbiological diagnosis is often lacking (46.8%); therefore, a great deal of clinical suspicion is needed to make the working diagnosis; in a cohort of patients admitted to the ward largely from the emergency department (89.5%), Gram-negative and nonresistant bacteria are still preponderant; thus, current protocols of antimicrobial treatments may still apply effectively. Despite all of this, the findings of Gomes et al. [3] raise several questions. The first one is: why is nosocomial infection rate decreasing over time? As some relevant fac-