Multidrug-resistant pathogens are prevalent in cirrhosis with higher rates in lower-middle-income countriesGram-negative Bacteria and Resistance Patterns in Cirrhosis Patients

International journal of antimicrobial agents Published September 1, 2026 Study authors: Ozdemir Cansu, Paul Tuhin, Egoh Kasope, Wanford Joseph J, Dekker Denise, Shawcross Debbie L, Paintsi… PubMed ↗ DOI ↗ Editorial oversight: Dr. Amelia Tan, PhD · Internal Medicine & Chronic Disease

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Key Takeaway

Recognize high MDR prevalence in cirrhosis, especially higher ESBL, VRE, and CRE rates in lower-middle-income countries.

This systematic review and proportional meta-analysis evaluates the prevalence of multidrug-resistance (MDR) and etiological bacterial pathogens among adults with cirrhosis. The analysis included 2781 clinical infections and 381 colonisation observations to determine common infection types and resistance patterns.

Key findings indicate that spontaneous bacterial peritonitis is the predominant infection type at 89%, while urinary tract infections account for 7%. Gram-negative bacteria were identified in 60% of isolates, including Escherichia coli (29%) and Klebsiella pneumoniae (11%). Gram-positive pathogens were found in 39% of cases, with Enterococcus spp. at 14% and Staphylococcus aureus at 6%. The overall pooled MDR proportion was 23% (95% CI: 13-37).

Notably, the study highlights geographic disparities in resistance. In lower-middle-income countries, the MDR proportion was 56% (compared to 15%-41%), and ESBL prevalence was 24% (compared to 8%-10%). Furthermore, VRE and CRE rates in these regions were 23% and 32% respectively, compared to 2% and 1% in other settings. These findings underscore the necessity of integrated phenotypic and genomic surveillance to inform empiric antimicrobial therapy for patients with cirrhosis.

How this fits prior evidence

This meta-analysis confirms and extends the finding that multidrug-resistant bacterial infections are prevalent among hospitalized patients with cirrhosis. It provides specific data on the types of pathogens involved, such as Gram-negative bacteria (60% of isolates) and the high prevalence of MDR (23% overall) in this population. Additionally, it highlights significant geographic variations in resistance rates for ESBL, VRE, and CRE in lower-middle-income countries.

This review analyzed data from over 2,700 clinical infections and 381 cases of bacterial colonization in adults with cirrhosis. The study focused on non-bloodstream infections to identify the types of bacteria present and how resistant those bacteria were to common medications.

Researchers found that spontaneous bacterial peritonitis was the most common infection type, occurring in 89% of cases. Among the bacteria identified, 60% were Gram-negative, including Escherichia coli and Klebsiella pneumoniae. Gram-positive pathogens were found in 39% of cases. The study also noted that 23% of all samples showed multi-drug resistance (MDR).

The data showed significantly higher rates of specific resistant bacteria in lower-middle-income countries. These included higher rates of ESBL, VRE, and CRE. Because of these complex resistance patterns, the study suggests that doctors need better monitoring of both physical and genetic traits of bacteria to choose the best treatments for patients with liver disease.

What this means for you:

Gram-negative bacteria are common in cirrhosis infections, with higher resistance rates noted in some regions.

Common questions

What types of bacteria are most common in patients with cirrhosis?

The study found that 60% of the bacterial isolates were Gram-negative. Specifically, Escherichia coli made up 29% of the samples, while Klebsiella pneumoniae accounted for 11%. Gram-positive pathogens were found in 39% of the cases.

How common is multi-drug resistance in these infections?

The overall pooled proportion of multi-drug resistance (MDR) was 23%. However, the study noted much higher rates of specific resistant types in lower-middle-income countries, including ESBL at 24%, VRE at 23%, and CRE at 32%.

What was the most common type of infection found?

Spontaneous bacterial peritonitis was the most common type of infection identified in the study, appearing in 89% of the cases. Urinary tract infections were found in 7% of the cases.

Study Details

Study typeMeta analysis

EvidenceLevel 1

PublishedSep 2026

PMID42208776

View Original Abstract ↓

OBJECTIVES: To systematically characterise the global distribution of bacterial pathogens, antimicrobial resistance patterns, and resistance determinants in non-bloodstream infections among adults with cirrhosis. METHODS: We performed a systematic review and proportional meta-analysis of studies reporting AMR in non-bloodstream bacterial infections among patients with cirrhosis. PubMed, Embase, Scopus and Web of Science were searched up to 15 September 2025. Pooled proportion estimates of multidrug-resistance (MDR) and the etiological bacterial pathogens were calculated using random-effects models. Subgroup analyses were performed by country income, continent, and bacterial species. RESULTS: Thirty-one studies contributed data from 2781 clinical infections and 381 colonisation observations. Spontaneous bacterial peritonitis predominated (89%), followed by urinary tract infections (7%). Gram-negative bacteria accounted for 60% of isolates (Escherichia coli 29%, Klebsiella pneumoniae 11%), while Gram-positive pathogens represented 39% (Enterococcus spp. 14%, Staphylococcus aureus 6%). The overall pooled MDR proportion was 23% (95% CI: 13-37), with higher burdens in lower-middle-income countries (MDR 56% vs. 15%-41%; ESBL 24% vs. 8%-10%; VRE 23% vs. 2%; CRE 32% vs. 1%). Genotypic data identified 436 resistance genes with marked continental differences. CONCLUSION: In cirrhosis-associated non-bloodstream infections, Gram-negative bacteria predominate and are associated with high levels of MDR, particularly in lower-middle-income countries. These findings highlight the need for integrated phenotypic and genomic surveillance of resistance patterns to inform empiric antimicrobial therapy.

Multidrug-resistant pathogens are prevalent in cirrhosis with higher rates in lower-middle-income countriesGram-negative Bacteria and Resistance Patterns in Cirrhosis Patients

How this fits prior evidence

Common questions

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Multidrug-resistant pathogens are prevalent in cirrhosis with higher rates in lower-middle-income countriesGram-negative Bacteria and Resistance Patterns in Cirrhosis Patients

How this fits prior evidence

Common questions

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