Advertisement

Prospective controlled trial of selective parenteral and enteral antimicrobial regimen in fulminant liver failure

Authors

  • Nancy Rolando,

    1. Institute of Liver Studies, King's College School of Medicine and Dentistry, London SE5 9RX, United Kingdom
    Search for more papers by this author
  • Alexander Gimson,

    1. Institute of Liver Studies, King's College School of Medicine and Dentistry, London SE5 9RX, United Kingdom
    Search for more papers by this author
  • Jim Wade,

    1. Department of Medical Microbiology, King's College School of Medicine and Dentistry, London SE5 9RX, United Kingdom
    Search for more papers by this author
  • John Philpott-Howard,

    1. Department of Medical Microbiology, King's College School of Medicine and Dentistry, London SE5 9RX, United Kingdom
    Search for more papers by this author
  • Mark Casewell,

    1. Department of Medical Microbiology, King's College School of Medicine and Dentistry, London SE5 9RX, United Kingdom
    Search for more papers by this author
  • Roger Williams M.D, FRCP, FRCS, FRCPE, FRACP, FACP

    Director, Corresponding author
    1. Institute of Liver Studies, King's College School of Medicine and Dentistry, London SE5 9RX, United Kingdom
    • Institute of Liver Studies, King's College School of Medicine and Dentistry, Bessemer Road, London SE5 9PJ, United Kingdom
    Search for more papers by this author

Abstract

To compare the efficacy of a selective parenteral and enteral antimicrobial regimen in patients with fulminant liver failure, we classified 104 patients on reaching grade II encephalopathy as infected or noninfected. Patients who were infected were randomly assigned to receive IV cefuroxime (group 1) or selective parenteral and enteral antimicrobial regimen (group 2). Noninfected patients were randomly selected to receive either selective parenteral and enteral antimicrobial regimen (group 3) or no initial antimicrobials until clinically indicated (group 4). The four groups were comparable regarding age, sex, cause of disease, coma grade, international normalization ratio, presence of kidney failure and indicators of poor prognosis on admission to the study. Clinical parameters such as white cell count, temperature or changes in the chest radiograph, which were used to stratify patients into those infected or not, were not good predictors of infection because early infection rates were similar in the two groups. Three patients died within 24 hr and were excluded from the analysis. We found 42 microbiologically confirmed infections: group 1, 6 of 21; group 2, 8 of 21; group 3, 9 of 28; and group 4, 19 of 31. A reduction in infection was seen between groups 3 and 4 (p < 0.05). Patients receiving the selective parenteral and enteral antimicrobial regimen (groups 2 and 3) had fewer infections than the control group (group 4) (p < 0.005). Groups receiving early antimicrobial therapy (groups 1, 2 and 3) had a lower incidence of infection compared with group 4 (p < 0.0005). Overall, 55.5% survived, with no significant difference between the four groups. Of 36 patients who fulfilled criteria for liver transplantation, 15 of 24 patients who received early antimicrobials (groups 1, 2 and 3) and 3 of 12 control patients (group 4) underwent transplantation (p < 0.05). Selective parenteral and enteral antimicrobial regimen reduces the risk of infection in patients with fulminant liver failure, but this effect is probably related to the early administration of antimicrobials. No reduction in length of stay in the unit or in the cost of antimicrobials was found. (HEPATOLOGY 1993;17:196–201.)

Ancillary