Multidrug-resistant colonization in decompensated cirrhosis outside the ICU predicts infection and poor outcomes

Background & aims Infections by multidrug- (MDROs) or extensively drug- (XDROs) resistant organisms are a growing global concern in cirrhosis. MDRO colonization is a recognised risk factor for infection in critical care settings, but evidence in ward-based patients with decompensated cirrhosis is scarce. This study aims to determine the prevalence, dynamics, and clinical impact of MDRO colonization in decompensated cirrhosis outside the ICU, and to identify predictors of colonization and infection. Methods Single-centre prospective study (2017–2020) enrolling 408 patients with decompensated cirrhosis consecutively admitted to the ward (n=272) or ICU (n=136). Rectal/nasal swabs were obtained at admission and weekly for up to 12 months. Colonization dynamics, resistance profiles, infection rates, and outcomes were analysed in ward patients, with the ICU cohort as comparator. Results Baseline rectal MDRO colonization was common in both the ward and ICU (23% vs 17%; p =0.38), increasing over time with similar rates at 1 year (39% vs 43%; p =0.13). XDROs emerged during follow-up in both settings. In ward, baseline (52% vs 19%; p<0.0001) or follow-up (55% vs 11%; p <0.0001) colonization was associated with MDRO infection by the colonizing strain and higher mortality (60% vs 22%; p <0.0001). Baseline (HR 9.6; p <0.0001) and follow-up colonization (HR 4.4; p <0.0001) predicted infection; colonization at either time point predicted mortality (HR 2.07; p <0.0001). Recent acute-on-chronic liver failure (ACLF) predicted colonization (HR 2.5; p <0.0001) and infection (HR 2.8; p <0.0003). Conclusion Multidrug-resistant organism colonization is frequent and clinically relevant outside the intensive care unit in cirrhosis, predicting infection and mortality. Extending targeted surveillance and antibiotic stewardship beyond critical care may help reduce infection-related morbidity and mortality. IMPACT AND implications This study demonstrates that rectal colonization with multidrug-resistant organisms (MDROs) is both common and clinically significant in patients with decompensated cirrhosis outside the ICU. These findings are highly relevant for hepatologists, infectious disease clinicians, and epidemiologists, as colonized ward patients faced a substantially increased risk of developing infections from their colonizing strain and experienced worse outcomes, particularly those with recent ACLF. Practically, incorporating colonization status into empirical antibiotic decision-making and evaluating targeted MDRO surveillance strategies beyond the ICU could enhance early management and improve risk stratification. While further work is needed to assess feasibility and cost-effectiveness, our results provide a strong evidence base to inform the development of surveillance-driven approaches in routine cirrhosis care. Funding ISCIII, PI16/00885.