Carbapenem-resistant Acinetobacter baumannii (CRAB) are rare in France and are usually reported in intensive care units (ICU). In 2021/2022, an unexpected increase in the incidence of CRAB isolates co-producing OXA-23 and NDM carbapenemases (OXA-23/NDM-CRAB) in several hospitals in the north of Paris prompted a common retrospective investigation. These strains were extremely resistant to both first- and second-line antibiotics, resulting in difficult-to-treat infections. We collected all cases of OXA-23/NDM-CRABs infection/colonisation between January 2020 and December 2022 in five northern Paris hospitals. Demographic and clinical data were collected for each patient. Isolates were sequenced using Illumina and representative isolates were sequenced using Nanopore. An OXA-23/NDM-CRAB was detected in 42 patients (mean age 61 years, M/F: 1.3), 58

OBJECTIVES:The optimal treatment duration for pyogenic liver abscess (PLA) is still a matter of debate, with no comparative study to date. This study aimed to compare short and long treatment duration in hospitalized adult patients with PLA. METHODS:We retrospectively included patients with PLA from 2010 to 2022. Exposure was defined as a short (≤30 days) or long (>30 days) antibiotic regimen. We applied the target trial framework with cloning, censoring, and weighting. The primary outcome was the difference in relapse-free survival 90 days after antibiotic initiation. We defined a noninferiority margin of 10%. RESULTS:Of 429 patients with PLA, 259 had a short and 170 a long-observed treatment duration. A total of 118 events were observed. The weighted risk difference (RD) in relapse-free survival between long and short treatment arm was -0.4% (95% CI: -5.9 to 4.9%), meeting the noninferiority margin. In undrained patients, the RD was -5.0% (95% CI: -15 to 5.7%), while among drained patients, the RD was 4.6% (95% CI: -4.4 to 13.5 %) in favour of short duration, achieving statistical significance for noninferiority for drained patients only. For overall survival, the weighted RD was -1.1% (95% CI: -5.9 to 3.4%), and for relapse, -0.2% (95% CI: -7.0 to 6.3%). CONCLUSIONS:In our study, an antibiotic course of ≤30 days did meet the noninferiority threshold of 10% at 90 days compared with longer durations for relapse-free survival. Noninferiority was also met in the subgroup of drained patients but not in undrained patients.

Accurate microbiological documentation seems central for managing severe pneumonia. While the FilmArray® Pneumonia + panel (FA-PP) offers rapid pathogen identification, its effectiveness during antibiotic treatment and in predicting clinical outcomes remains unclear. We conducted a prospective observational study across four ICUs from April 2022 to June 2024, including patients with ventilator-associated pneumonia (VAP) or ventilated hospital-acquired pneumonia (vHAP). Bacterial loads were monitored on days 0, 1, 3, 7 and 10 and 3 days after stopping antibiotics, using endotracheal aspirates (ETAs) analyzed by FA-PP and standard cultures. The main objective was to assess the correlation between quantitative changes in FA-PP results and clinical success. Quantitative changes over time were analyzed using mixed ordinal logistic regression. Of the 93 patients enrolled, 60.2

Abstract Background Alongside the recent worldwide expansion of hypervirulent Klebsiella pneumoniae (KP) infections, the available literature regarding cases of community acquired pneumonias (KP-CAP) remains scarce but reports a strikingly high and early mortality. We performed a retrospective multicenter study (7 ICU in France) between 2015 and 2019, comparing prognosis and severity of KP-CAP versus Streptococcus pneumoniae - CAP (SP-CAP). Methods For each KP-CAP, three SP-CAP admitted in ICUs within the same center and within the same 6-month window were selected. When available, KP strains were studied, and bacterial virulence was genetically assessed for virulence factors. The primary outcome was in-hospital mortality. Associations between clinical outcomes and type of infection were tested using univariate and multivariate logistic regressions, adjusted for pairing variables. Results Twenty-seven KP-CAP and 81 SP-CAP were included. Respective in-hospital mortality rates were 59% (n = 16) and 17% (n = 14, p < 0.001), despite adequate antibiotic therapy. KP-CAP median time from admission to death was 26.9 h [IQR 5.75–44 h] and were significantly associated with higher rates of multiple organ failures (93% vs. 42%, p < 0.001), disseminated intravascular coagulation (12% vs. 1.3%, p = 0.046), septic shock (median lactate on ICU admission 4.60 vs. 2.90 mmol/L, p = 0.030) and kidney failure (KDIGO-3: 87% vs. 44%, p < 0.001). Interestingly, alcoholism was the only identified predisposing factor of KP-CAP. Severity on ICU admission (2-fold higher for KP-CAP) was the only factor associated with mortality in a multivariate analysis. Conclusion We described a strong association between KP-CAP infection and higher and earlier mortality when compared to SP-CAP. Moreover, alcoholism was the sole predisposing factor associated with KP-CAP infection. These findings should raise awareness of clinicians involved in the management of severe CAP about this microbiological etiology. Future prospective studies are needed to confirm these results and to design strategies to improve the prognosis of such infections.

IntroductionAcute necrotizing pancreatitis (ANP) mortality increases when pancreatic necrosis is infected (IPN). Current treatment of IPN relies on prolonged antibiotic therapies associated with a step-up strategy of drainage. The objective of this study was to analyze IPN treatment outcomes in two referral centers in France.MethodsData of consecutive patients with documented IPN hospitalized in two expert centers in France between 2014 and 2019 were retrospectively reviewed. The composite primary outcome was the proportion of unsuccessful management outcome, defined as new emergency drainage to treat sepsis with organ failure, an unplanned new antibiotic course, an unplanned prolongation of antibiotic course and/or death by septic shock, within three months following the diagnosis of ANP.ResultsAll in all, 187 patients (138 males; 74.0%), with documented IPN were included. The most frequently identified microorganism was Escherichia coli (26.2%). Ninety-eight patients (52.4%) were admitted to an intensive care unit or resuscitation ward within the first two days of ANP care. Overall, 126 patients (67.4%) endured an unsuccessful outcome: new emergency drainage to treat acute sepsis (62.0%), unplanned new antibiotic course (47.1%), unplanned prolongation of antibiotic course (44.9%) and/or death by septic shock complicating IPN (8.0%).ConclusionThe unfavorable evolution in two thirds of patients shows that determination of optimal drainage timing and choice of antibiotic therapy remain major challenges in 2024.

Background: Bacterial peritonitis (BP) in patients with gastrointestinal (GI) cancer has been poorly described, and its prevalence is unknown. Objectives: This study aimed to evaluate in patients with both GI cancer and ascites the prevalence of BP, associated features, mechanisms, prognosis, and the diagnostic performance of neutrophil count in ascites. Design: A retrospective, multicenter, observational study. Methods: All patients with GI cancer and ascites who underwent at least one paracentesis sample analyzed for bacteriology over a 1-year period were included. BP was defined by a positive ascites culture combined with clinical and/or biological signs compatible with infection. Secondary BP was defined as BP related to a direct intra-abdominal infectious source. Results: Five hundred fifty-seven ascites from 208 patients included were analyzed. Twenty-eight patients had at least one episode of BP and the annual prevalence rate of BP was 14%. Among the 28 patients with BP, 19 (65%) patients had proven secondary BP and 17 (59%) patients had multi-microbial BP, mainly due to Enterobacterales . A neutrophil count greater than 110/mm 3 in ascites had negative and positive predictive values of 96% and 39%, respectively, for the diagnosis of BP. The median survival of patients with BP was 10 days (interquartile range 6–40) after the diagnosis. Conclusion: BP is not rare in patients with GI cancer and is associated with a poor short-term prognosis. When a patient with GI cancer is diagnosed with BP, a secondary cause should be sought. Further studies are needed to better define the best management of these patients.

Background: Shotgun metagenomics (SMg) sequencing has gained a considerable interest, as it enables the detection of any microorganisms through a single analysis. Due to the limitations of standard microbiological approaches, the microbial documentation of liver abscesses (LA), which is crucial for their medical management, can be difficult. Here we aimed to compare the performance of SMg with standard approaches for the microbiological documentation of LA.Methods: In this retrospective study conducted at two centers, we compared the results of standard microbiology with metagenomics analysis of consecutive LA samples. For samples tested positive for Klebsiella pneumoniae, we compared the analysis of virulence and resistance genes using metagenomics data to whole-genome sequencing of corresponding isolates obtained in culture.Results: Out of the 62 samples included, standard approaches and SMg yielded documentation in 80.6% and 96.8%, respectively. In 37.1% (23/62) of cases, both methods showed identical results, whereas in 43.5% (27/62) of cases, the samples were positive by both methods, but SMg found additional species in 88.9% (24/27), mostly anaerobes. When the standard approaches were negative, the SMg was able to detect microorganisms in 80.0% of cases (8/10). Overall, SMg identified significantly more microorganisms than culture (414 vs.105; p<0.05). K. pneumoniae genome analysis was able to detect resistance and virulence genes with a level of sensitivity depending on the depth of sequencing.Discussion: Overall, we showed that SMg had better performance in detecting and identifying microorganisms from LA samples and could help characterizing strain's resistome and virulome. Although still costly and requiring specific skills and expensive equipment, MGs methods are set to expand in the future.(c) 2023 The British Infection Association. Published by Elsevier Ltd. All rights reserved.

Caulobacter species are aerobic Gram-negative bacilli initially isolated from aquatic environments and are an uncommon cause of human infection. We report a case of bloodstream infection and postoperative meningitis caused by Caulobacter spp. that occurred in a 53-year old woman two weeks after surgery for a breast carcinoma cerebral metastasis. Polymerase chain reaction (PCR) amplification and sequencing of the 16 S ribosomal DNA identified Caulobacter spp. in three blood cultures and two cerebrospinal fluid (CSF) cultures. Based on our susceptibility results, the patient was successfully treated by a 2-week course of iv imipenem followed by a 4-week course of oral trimethoprim-sulfamethoxazole.

Amoebic liver abscess (ALA) is the fourth cause of mortality by parasitic infection. This study aimed to assess clinical, radiological and therapeutic characteristics of patients admitted for amoebic liver abscess compared to pyogenic abscess in a French digestive tertiary care-centre.The charts of patients hospitalized for a liver abscess between 2010 and 2020 were retrospectively assessed then separated in two groups: amoebic liver abscess and pyogenic liver abscess from portal underlying cause. Clinical and radiological data were collected for univariate comparison.Twenty-one patients were hospitalized during the time of the study for ALA, and 21 patients for pyogenic liver abscess with a portal mechanism. All patients hospitalized for ALA lived in and/or had travelled recently in an endemic area. In comparison with patients hospitalized for pyogenic abscess, patients admitted for ALA were younger (44years old vs. 63years old, P<0.001), had less comorbidities (5% vs. 43% of patients with at least one comorbidity, P<0.01), a longer median duration of symptoms (10days vs. 3days, P=0.015), abdominal pain (86% vs. 52%, P=0.019), and a slighter leucocytosis (9600G/L vs. 15,500G/L, P=0.041) were more frequent. On the abdominal tomodensitometry, density of ALA was higher (34 vs. 25 UH, P<0.01), associated with a focal intra-hepatic biliary dilatation and less often multiloculated.While rare in western countries, amoebic liver abscess care should not be underestimated. The presence of a solitary liver abscess of intermediate density on computed tomography, occurring on a patient returning from an endemic zone should lead the physician to a possible diagnosis of ALA.

Out of the context of haematological patients, Candida sp. is rarely retrieved from pyogenic liver abscesses (PLA).

Introduction: Amoebic liver abscess (ALA) is the fourth cause of mortality by parasitic infection. This study aimed to assess clinical, radiological and therapeutic characteristics of patients admitted for amoebic liver abscess compared to pyogenic abscess in a French digestive tertiary care-centre. Material and method: The charts of patients hospitalized for a liver abscess between 2010 and 2020 were retrospectively assessed then separated in two groups: amoebic liver abscess and pyogenic liver abscess from portal underlying cause. Clinical and radiological data were collected for univariate comparison. Results: Twenty-one patients were hospitalized during the time of the study for ALA, and 21 patients for pyogenic liver abscess with a portal mechanism. All patients hospitalized for ALA lived in and/or had travelled recently in an endemic area. In comparison with patients hospitalized for pyogenic abscess, patients admitted for ALA were younger (44years old vs. 63years old, P<0.001), had less comorbidities (5% vs. 43% of patients with at least one comorbidity, P<0.01), a longer median duration of symptoms (10days vs. 3days, P=0.015), abdominal pain (86% vs. 52%, P=0.019), and a slighter leucocytosis (9600G/L vs. 15,500G/L, P=0.041) were more frequent. On the abdominal tomodensitometry, density of ALA was higher (34 vs. 25 UH, P<0.01), associated with a focal intra-hepatic biliary dilatation and less often multiloculated. Conclusion: While rare in western countries, amoebic liver abscess care should not be underestimated. The presence of a solitary liver abscess of intermediate density on computed tomography, occurring on a patient returning from an endemic zone should lead the physician to a possible diagnosis of ALA. (c) 2023 Societe Nationale Francaise de Medecine Interne (SNFMI). Published by Elsevier Masson SAS. Allrights reserved.

Enterococci are the most frequent gram-positive bacteria recovered from pyogenic liver abscesses (PLA). This study aims to analyze the impact of the presence of Enterococcus spp. on PLA outcome. We retrospectively analyzed the characteristics and outcome of all PLA cases in which Enterococcus spp. was isolated between January 2010 and September 2019 in a French university hospital and compared them to PLA without Enterococcus spp. Enterococci were recovered from 68 of the 359 (19%) PLA cases. Among the 78 isolates, Enterococcus faecalis (n = 37, 47.7%) and Enterococcus faecium (n = 32, 41%) were the most frequent. Enterococcal PLA were more often of biliary origin (79.4% versus 54.6%, p < 0.001) or post-surgical (35.3% versus 18.6%, p = 0.004). Multivariate analysis showed an independent association between the isolation of Enterococcus spp. and 3-month mortality (HR 2.51, p = 0.011), primary failure (HR 2.15, p = 0.006), but not with relapses (HR 0.86, p = 0.739). In the subgroup of enterococcal PLA, portal vein thrombosis was the only factor significantly associated with 3-month mortality (univariate HR 3.45, p = 0.023) or primary treatment failure (multivariate, HR 4.02, p = 0.006). Enterococcus spp. identification in a PLA is associated with a higher mortality and primary treatment failure.

Pyogenic liver abscess (PLA) is a severe disease, which unfavourable evolution remains frequent. Our objective was to assess predictive factors of unfavourable outcome in patients with PLA. We conducted a retrospective study in a French tertiary care centre. All patients admitted for PLA between 2010 and 2018 were included. Unfavourable course was defined as the occurrence of a primary treatment failure (PTF), recurrence of PLA after an initial cure, or death within 3 months after diagnosis. Hazard ratios (95% CI) were calculated with multivariable Cox proportional hazard models. 302 patients were included among which 91 (30.1%) patients had an unfavourable outcome because of PTF, recurrence or death in 55 (18.2%), 28 (9.2%) and 32 (10.6%) patients, respectively. Hepatic metastases (HR 2.08; 95% CI 1.04–4.15), a nosocomial infection (2.25; 1.14–4.42), portal thrombosis (2.12; 1.14–3.93), and the isolation of Enterococcus spp. (2.18; 1.22– 3.90) were independently associated with PTF. Ischemic cholangitis (6.30; 2.70–14.70) and the isolation of Streptococcus spp. (3.72; 1.36–10.16) were associated with the risk of recurrence. Charlson comorbidity index (HR 1.30 per one point; 95% CI 1.15–1.46; p < 0.001), portal thrombosis (3.53; 1.65–7.56) and the presence of multi-drug-resistant organisms (3.81; 1.73–8.40) were associated with mortality within 3 months following PLA diagnosis. PLA drainage was the only factor associated with a lower mortality (0.14; 0.06–0.34). Identification of specific risk factors may help to improve the management of PLA and to elaborate targeted recommendations according to patient’s and disease’s characteristics.

ObjectivesTo analyze and compare the characteristics and outcomes of spontaneous meningitis (SM) versus postsurgical/traumatic meningitis (PSTM) due to Klebsiella pneumoniae.MethodsA retrospective multicentric cohort study of all K. pneumoniae meningitis cases managed between January 2007 and May 2018 was carried out in seven university hospitals in the Paris area. The microbiological characteristics of 16 available K. pneumoniae isolates were further analyzed, and the genomes of seven of those isolated from SM were sequenced.ResultsAmong 35 cases, 10 were SM and 25 were PSTM. SM cases more severe than PSTM cases, with higher septic shock (p = 0.004) and in-hospital mortality rates (p = 0.004). In contrast, relapse occurred in five patients from the PSTM group versus no patients from the SM group. All K. pneumoniae strains recovered from SM but none of those recovered from PSTM displayed hypervirulent phenotypic (positive string test) and genotypic (genes corresponding to capsular serotypes K1 or K2; virulence genes rmpA and iutA) characteristics (p < 0.0001). PSTM tended to be more frequently polymicrobial (p = 0.08) and caused by an extended-spectrum β-lactamase producing strain (p = 0.08) than SM.ConclusionsSM and PSTM are two entities differing both from a clinical and a microbiological standpoint. SM appears to be a more serious infection, induced by hypervirulent K. pneumoniae strains.

Background. Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-E) carriage is frequent among liver transplant (LT) recipients, thereby fostering a large empirical carbapenem prescription. However, ESBL-E infections occur in only 10%-25% of critically ill patients with rectal colonization. Our aim was to identify risk factors for post-LT ESBL-E infection in colonized patients. The effect of perioperative antimicrobial prophylaxis (AP) was also analyzed in patients with prophylaxis lasting Methods. Retrospective study from a prospective database including patients with a positive ESBL-E rectal screening transplanted between 2010 and 2016. Results. Among the 749 patients transplanted, 100 (13.3%) were colonized with an ESBL-E strain. Thirty-nine (39%) patients developed an infection related to the same ESBL-E (10 pulmonary, 11 surgical site, 13 urinary, 5 bloodstream) within 11 postoperative days in median. Klebsiella pneumoniae carriage, model for end-stage liver disease >= 25, preoperative spontaneous bacterial peritonitis prophylaxis, and antimicrobial exposure during the previous month were independent predictors of ESBL-E infection. We propose a colonization to infection risk score built on these variables. The prevalence of infection for colonization to infection score of 0, 1, 2, and >= 3 were 7.4%, 26.3%, 61.9%, and 91.3%, respectively. Of note, the incidence of post-LT ESBL-E infection was lower in case of perioperative AP targeting colonizing ESBL-E (P = 0.04). Conclusions. Thirty-nine percentage of ESBL-E carriers develop a related infection after LT. We identified predictors for ESBL-E infection in carriers that may help in rationalizing carbapenem prescription. Perioperative AP targeting colonizing ESBL-E may be associated with a reduced risk of post-LT ESBL-E infections.

Objective To identify predictive factors of unfavourable outcome among patients hospitalized for COVID-19. Methods We conducted a monocentric retrospective cohort study of COVID-19 patients hospitalized in Paris area. An unfavourable outcome was defined as the need for artificial ventilation and/or death. Characteristics at admission were analysed to identify factors predictive of unfavourable outcome using multivariable Cox proportional hazard models. Based on the results, a nomogram to predict 14-day probability of poor outcome was proposed. Results Between March 15th and April 14th, 2020, 279 COVID-19 patients were hospitalized after a median of 7 days after the first symptoms. Among them, 88 (31.5%) patients had an unfavourable outcome: 48 were admitted to the ICU for artificial ventilation, and 40 patients died without being admitted to ICU. Multivariable analyses retained age, overweight, polypnoea, fever, high C-reactive protein, elevated us troponin-I, and lymphopenia as risk factors of an unfavourable outcome. A nomogram was established with sufficient discriminatory power (C-index 0.75), and proper consistence between the prediction and the observation. Conclusion We identified seven easily available prognostic factors and proposed a simple nomogram for early detection of patients at risk of aggravation, in order to optimize clinical care and initiate specific therapies.KEY MESSAGES Since novel coronavirus disease 2019 pandemic, a minority of patients develops severe respiratory distress syndrome, leading to death despite intensive care. Tools to identify patients at risk in European populations are lacking. In our series, age, respiratory rate, overweight, temperature, C-reactive protein, troponin and lymphocyte counts were risk factors of an unfavourable outcome in hospitalized adult patients. We propose an easy-to-use nomogram to predict unfavourable outcome for hospitalized adult patients to optimize clinical care and initiate specific therapies.

IntroductionThe dramatic increase of the incidence of infections caused by extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) has led to an increase of 50% of carbapenem consumption all around Europe in only 5 years. This favours the spread of carbapenem-resistant Gram-negative bacilli (GNB), causing life-threatening infections. In order to limit use of carbapenems for infections actually due to ESBL-PE, health authorities promote the use of rapid diagnostic tests of bacterial resistance. The objective of this work conducted in the intensive care unit (ICU) is to determine whether an early de-escalation of empirical carbapenems guided by the result of the βLACTA test is not inferior to the reference strategy of de-escalating carbapenems after the antibiogram result has been rendered.Methods and analysisThis multicentre randomised controlled open-label non-inferiority clinical trial will include patients suffering from respiratory and/or urinary and/or bloodstream infections documented with GNB on direct examination and empirically treated with carbapenems. Empirical carbapenems will be adapted before the second dose depending on the results of the βLACTA test performed directly on the microbiological sample (intervention group) or after 48–72 hours depending on the definite antibiogram (control group). The primary outcome will combine 90-day mortality and percentage of infection recurrence during the ICU stay. The secondary outcomes will include the number of carbapenems defined daily doses and carbapenem-free days after inclusion, the proportion of new infections during ICU stay, new colonisation of patients’ digestive tractus with multidrug-resistant GNB, ICU and hospital length of stay and cost-effectiveness ratio.Ethics and disseminationThis protocol has been approved by the ethics committee of Paris-Ile-de-France IV, and will be carried out according to the principles of the Declaration of Helsinki and the Good Clinical Practice guidelines. The results of this study will be disseminated through presentation at scientific conferences and publication in peer-reviewed journals.Trial registration numberNCT03147807.

Objectives. - To evaluate a new tool for the early diagnosis of tuberculosis. Methods. - A total of 374 smear-negative clinical specimens from patients with suspected tuberculosis were evaluated using a new procedure consisting of a preliminary step of culture in broth bottles followed by the detection of Mycobacterium tuberculosis complex (Mtb) and rifampicin resistance by the Xpert MTB/RIF assay (XMTB-RIF). Results. - A total of 30 Mtb strains were isolated, all susceptible to rifampicin. When broth cultures were subjected to XMTB-RIF analysis after 15 days of incubation, sensitivity, specificity, PPV, and NPV were each 100% when compared with liquid culture. Conclusion. - The XMTB-RIF assay used in 15-day broth cultures may provide a final culture result for smear-negative specimens. This process, combined with clinical signs, may contribute to rapidly diagnosing tuberculosis and also to the early reevaluation of empirical antituberculosis treatment. (C) 2018 Published by Elsevier Masson SAS.

OBJECTIVES:So far, two types of mechanism are known to be involved in carbapenem non-susceptibility of Escherichia coli clinical isolates: reduced outer membrane permeability associated with production of ESBLs and/or overproduction of class C β-lactamases; and production of carbapenemases. Non-susceptibility to only imipenem observed in two clinical isolates suggested a new mechanism, described in the present study.METHODS:The ST was determined for the two isolates of E. coli (strains LSNy and VSBj), and their chromosomal region encoding the penicillin-binding domain of PBP2 was amplified, sequenced and then used for recombination experiments in E. coli K12 C600. Antibiotic MICs were determined using the Etest method.RESULTS:Strains LSNy and VSBj, which displayed ST23 and ST345, respectively, showed amino acid substitutions in their PBP2 penicillin-binding domain. Substitution Ala388Ser located in motif 2 (SXD) was common to the two strains. Two additional substitutions (Ala488Thr and Leu573Val) located outside the two other motifs were identified in strain LSNy, whereas another one (Thr331Pro) located in motif 1 was identified in strain VSBj. Recombination experiments to reproduce non-susceptibility to imipenem in E. coli K12 C600 were not successful when only the common substitution was transferred, whereas recombination with DNA fragments including either the three substitutions (strain LSNy) or the two substitutions (strain VSBj) were successful.CONCLUSIONS:Substitution of amino acids in the penicillin-binding domain of PBP2 is a new mechanism by which E. coli clinical isolates specifically resist imipenem.

Antimicrobial resistance has become a major global public health security problem that needs coordinated approaches at regional, national and international levels. Antibiotic overuse and the failure of control measures to prevent the spread of resistant bacteria in the healthcare environment have led to an alarming increase in the number of infections caused by resistant bacteria, organisms that resist many (multi-drug and extensively drug-resistant strains), if not all (pan-drug-resistant bacteria) currently available antibiotics. While Gram-positive cocci resistance (methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci) shows a heterogeneous geographical distribution, extended-spectrum β-lactamase-producing Enterobacteriaceae and carbapenem-resistant Enterobacteriaceae have become pandemic worldwide and endemic in some parts of the world, respectively. Moreover, currently available therapeutic options for resistant bacteria are very limited, with very few new agents in development. Antimicrobial resistance is especially relevant in decompensated cirrhosis. Firstly, cirrhotic patients are highly susceptible to develop infections caused by resistant bacteria as risk factors of multiresistance concentrate in this population (mainly repeated hospitalizations and antibiotic exposure). Secondly, inappropriate empirical antibiotic schedules easily translate into increased morbidity (acute kidney injury, acute-on-chronic liver failure, septic shock) and hospital mortality in advanced cirrhosis. Therefore, hepatologists must face nowadays a complex clinical scenario that requires new empirical antibiotic strategies that may further spread resistance. Global, regional and local preventive measures should therefore be implemented to combat antimicrobial resistance in cirrhosis including the restriction of antibiotic prophylaxis to high-risk populations, investigation on non-antibiotic prophylaxis, stewardship programs on adequate antibiotic prescription and on increasing awareness of the problem among health professionals, and well-defined early de-escalation policies based on rapid microbiological diagnostic tests. Other infection control practices such as hand hygiene and barrier precautions are also important. Clinical impact and cost-effectiveness of epidemiological surveillance programs (periodic rectal and nasal swabs) should also be explored.