Clinical efficacy of empiric antibiotic therapy in Chinese patients with cirrhosis and bacterial infections: A multicenter study

Background & Aims Bacterial and fungal infections are major drivers of acute decompensation and acute-on-chronic liver failure (ACLF) in cirrhosis, but real-world data on the effectiveness of empiric antibiotic therapy in China are scarce. We evaluated clinical response to empiric antibiotics, identified predictors of non-response, and assessed the impact of response and secondary infection on short-term outcomes in Chinese patients with cirrhosis. Approach & Results In this multicenter retrospective cohort from 24 tertiary centers, 1,401 adults with cirrhosis and bacterial or fungal infections were included. Clinical response to first-line empiric therapy occurred in 913 patients (65%). Non-responders had higher MELD/MELD-Na scores, more organ failures and ACLF, and more intense systemic inflammation. In multivariable models, greater ACLF grade 2–3, systemic inflammatory response syndrome, higher neutrophil-to-lymphocyte ratio, C-reactive protein, bilirubin, culture positivity, and lower albumin and mean arterial pressure independently predicted non-response. Non-response was independently associated with 28-day and 90-day mortality (HR 4.20 and 3.16, respectively), with consistent findings in time-dependent and center-clustered sensitivity analyses. Secondary infection developed in 7.0% of patients, was four-fold more frequent in non-responders (13.9% vs 3.3%), and nearly doubled 90-day mortality, whereas microbiological features at secondary infection did not clearly distinguish second-course responders from non-responders. Comparative analyses revealed substantial center-to-center and China-global differences in etiology, infection profile, and multidrug-resistant (MDR) burden. Conclusions In Chinese patients with cirrhosis, lack of early clinical response to empiric antibiotics independently predicts short-term mortality and is associated with a higher risk of clinically distinct secondary infection. Our findings support risk-adapted, locally informed empiric strategies.