Title: Antimicrobial resistance in patients with decompensated liver cirrhosis and bacterial
infections in a tertiary center in Northern Germany
Version: 1 Date: 27 Apr 2021
Reviewer's report:
This study was conducted at a tertiary center in Northern Germany to assess the antimicrobial
resistance profile of bacteria among patients with liver cirrhosis. The authors gathered
the microbiological data from blood, urine, and ascites for seven years and described the
microorganisms and antimicrobial susceptibility they found. Finally, they concluded that both
the number of infections due to gram-positive organisms and the number of pathogens resistant
to third-generation cephalosporins increased during the study period. Below are some of my
comments.
Major issues
Materials and methods section
1. Why did you exclude HIV-positive patients?
2. I think it is difficult to determine whether a patient has an infection based on culture positivity
alone. In particular, I would recommend assessing urinary tract infections based on both clinical
symptoms and culture positivity. You should probably clarify whether culture specimens from
patients with infections or pathogens from patients whose clinical samples were positive for
bacteria were included. If only patients with infections were included, then you need to state your
definition of contamination of blood culture and contamination of a urine culture. Suppose your
primary outcome was to describe the type and susceptibility of the organisms detected from the
clinical samples. In that case, it would not be necessary to determine whether the microorganisms
were infectious or not.
3. Line 129, you need a reference for the definition.
4. Lines 146-147, you need a reference for the definition.
5. What is the definition of severe resistance? I don’t see it in your paper.
6. Why did you divide your research period into 2012-2014 and 2015-2018?
Result section
1. I think you need to evaluate whether the 33 cases with Staphylococcus epidermidis and S.
haemolyticus in table 2 were cases of infection or contamination. I am concerned that your
conclusion that for empirical treatment, antimicrobial agents with gram-positive coverage for
contamination pathogens should be selected may lead to increased use of antimicrobial agents.
I really think that you should include only cases of infection.
2. Did you include culture-negative UTI in this study? I think this study only included culture-
positive patients. Please revise the sentence at line 262.
Discussion section
1. The basic premise in the selection of empirical treatments is that community-onset infections
differ from hospital-onset infections. Also, the more hospital exposure a person has, the higher
the risk of resistant organisms. I think it is important to describe the data carefully only for cases
of infectious disease.
2. From the results of this study, I think it is hard to say that infections due to gram-positive
organisms are increasing. On the other hand, the increase in strains resistant to third-generation
cephalosporins is a worldwide trend and may also be the case at your research facility. Under
these circumstances, we need to be cautious in concluding that there is no increase in MDR.
Moreover, there is a need to discuss how you reached this result.
Minor issues:
1. In general, the name of the species should be italicized.
2. Line 46, “further analyses distinguish ###”  I’m sorry I can’t understand what you want to say.
3. Line 73, please provide the full name of the BSI.
4. Line 77, you wrote “international studies### in Germany###.” Are they international studies
or local studies in Germany?
5. Line 85, what numbers are increasing?
6. Line 268, 270, “ampicillin/sulbactam/vancomycin,
piperacillin/tazobactam/vancomycin” is hard to read. Ampicillin/sulbactam plus vancomycin is
the preferred expression.
7. Line 295, 3rd should be changed to third.
Title: Antimicrobial resistance in patients with decompensated liver cirrhosis and bacterial
infections in a tertiary center in Northern Germany
Version: 1 Date: 27 Apr 2021
Reviewer's report:
This study was conducted at a tertiary center in Northern Germany to assess the antimicrobial
resistance profile of bacteria among patients with liver cirrhosis. The authors gathered
the microbiological data from blood, urine, and ascites for seven years and described the
microorganisms and antimicrobial susceptibility they found. Finally, they concluded that both
the number of infections due to gram-positive organisms and the number of pathogens resistant
to third-generation cephalosporins increased during the study period. Below are some of my
comments.
Major issues
Materials and methods section
1. Why did you exclude HIV-positive patients?
2. I think it is difficult to determine whether a patient has an infection based on culture positivity
alone. In particular, I would recommend assessing urinary tract infections based on both clinical
symptoms and culture positivity. You should probably clarify whether culture specimens from
patients with infections or pathogens from patients whose clinical samples were positive for
bacteria were included. If only patients with infections were included, then you need to state your
definition of contamination of blood culture and contamination of a urine culture. Suppose your
primary outcome was to describe the type and susceptibility of the organisms detected from the
clinical samples. In that case, it would not be necessary to determine whether the microorganisms
were infectious or not.
3. Line 129, you need a reference for the definition.
4. Lines 146-147, you need a reference for the definition.
5. What is the definition of severe resistance? I don’t see it in your paper.
6. Why did you divide your research period into 2012-2014 and 2015-2018?
Result section
1. I think you need to evaluate whether the 33 cases with Staphylococcus epidermidis and S.
haemolyticus in table 2 were cases of infection or contamination. I am concerned that your
conclusion that for empirical treatment, antimicrobial agents with gram-positive coverage for
contamination pathogens should be selected may lead to increased use of antimicrobial agents.
I really think that you should include only cases of infection.
2. Did you include culture-negative UTI in this study? I think this study only included culture-
positive patients. Please revise the sentence at line 262.
Discussion section
1. The basic premise in the selection of empirical treatments is that community-onset infections
differ from hospital-onset infections. Also, the more hospital exposure a person has, the higher
the risk of resistant organisms. I think it is important to describe the data carefully only for cases
of infectious disease.
2. From the results of this study, I think it is hard to say that infections due to gram-positive
organisms are increasing. On the other hand, the increase in strains resistant to third-generation
cephalosporins is a worldwide trend and may also be the case at your research facility. Under
these circumstances, we need to be cautious in concluding that there is no increase in MDR.
Moreover, there is a need to discuss how you reached this result.
Minor issues:
1. In general, the name of the species should be italicized.
2. Line 46, “further analyses distinguish ###”  I’m sorry I can’t understand what you want to say.
3. Line 73, please provide the full name of the BSI.
4. Line 77, you wrote “international studies### in Germany###.” Are they international studies
or local studies in Germany?
5. Line 85, what numbers are increasing?
6. Line 268, 270, “ampicillin/sulbactam/vancomycin,
piperacillin/tazobactam/vancomycin” is hard to read. Ampicillin/sulbactam plus vancomycin is
the preferred expression.
7. Line 295, 3rd should be changed to third.
Please review this paper.
user
Title: Antimicrobial resistance in patients with decompensated liver cirrhosis and bacterial
infections in a tertiary center in Northern Germany
Version: 1 Date: 27 Apr 2021
Reviewer's report:
This study was conducted at a tertiary center in Northern Germany to assess the antimicrobial
resistance profile of bacteria among patients with liver cirrhosis. The authors gathered
the microbiological data from blood, urine, and ascites for seven years and described the
microorganisms and antimicrobial susceptibility they found. Finally, they concluded that both
the number of infections due to gram-positive organisms and the number of pathogens resistant
to third-generation cephalosporins increased during the study period. Below are some of my
comments.
Major issues
Materials and methods section
1. Why did you exclude HIV-positive patients?
2. I think it is difficult to determine whether a patient has an infection based on culture positivity
alone. In particular, I would recommend assessing urinary tract infections based on both clinical
symptoms and culture positivity. You should probably clarify whether culture specimens from
patients with infections or pathogens from patients whose clinical samples were positive for
bacteria were included. If only patients with infections were included, then you need to state your
definition of contamination of blood culture and contamination of a urine culture. Suppose your
primary outcome was to describe the type and susceptibility of the organisms detected from the
clinical samples. In that case, it would not be necessary to determine whether the microorganisms
were infectious or not.
3. Line 129, you need a reference for the definition.
4. Lines 146-147, you need a reference for the definition.
5. What is the definition of severe resistance? I don’t see it in your paper.
6. Why did you divide your research period into 2012-2014 and 2015-2018?
Result section
1. I think you need to evaluate whether the 33 cases with Staphylococcus epidermidis and S.
haemolyticus in table 2 were cases of infection or contamination. I am concerned that your
conclusion that for empirical treatment, antimicrobial agents with gram-positive coverage for
contamination pathogens should be selected may lead to increased use of antimicrobial agents.
I really think that you should include only cases of infection.
2. Did you include culture-negative UTI in this study? I think this study only included culture-
positive patients. Please revise the sentence at line 262.
Discussion section
1. The basic premise in the selection of empirical treatments is that community-onset infections
differ from hospital-onset infections. Also, the more hospital exposure a person has, the higher
the risk of resistant organisms. I think it is important to describe the data carefully only for cases
of infectious disease.
2. From the results of this study, I think it is hard to say that infections due to gram-positive
organisms are increasing. On the other hand, the increase in strains resistant to third-generation
cephalosporins is a worldwide trend and may also be the case at your research facility. Under
these circumstances, we need to be cautious in concluding that there is no increase in MDR.
Moreover, there is a need to discuss how you reached this result.
Minor issues:
1. In general, the name of the species should be italicized.
2. Line 46, “further analyses distinguish ###”  I’m sorry I can’t understand what you want to say.
3. Line 73, please provide the full name of the BSI.
4. Line 77, you wrote “international studies### in Germany###.” Are they international studies
or local studies in Germany?
5. Line 85, what numbers are increasing?
6. Line 268, 270, “ampicillin/sulbactam/vancomycin,
piperacillin/tazobactam/vancomycin” is hard to read. Ampicillin/sulbactam plus vancomycin is
the preferred expression.
7. Line 295, 3rd should be changed to third.
assistant