Comparison of Efficacy and Safety of Ceftazidime Avibactam Versus Extended Infusions of High Dose Meropenem in Patients of ACLF With Nosocomial Infections.

Hypothesis - We hypothesize that ceftazidime-avibactum would be superior and an effective carbapenem sparing agent compared to extended high dose carbapenems as empirical therapy in management of nosocomial infections caused by carbapenem resistant organisms in patients with ACLF.

Aim -To compare the efficacy and safety of Ceftazidime avibactam and extended infusions of high dose Meropenem as emperical antibiotic in patients of ACLF with nosocomial infections caused by carbapenem resistant organisms.

Primary objective:

• To compare the efficacy of Ceftazidime avibactam over extended infusions of high dose carabapenem as emperical antibiotic in achieving clinical response at day 3 in patients of ACLF with suspected nosocomial infections.

Secondary objectives:

• To study the spectrum of nosocomial infections, bacterial DNA and resistance genes in the context of nosocomial infections in ACLF
• Proportion of patients requiring escalation/de-escalation of antibiotics at day 3
• Incidence of clinical and microbiologic response at day 5 and day 7
• Time to escalation of antibiotics in both groups
• Transfer to icu, mortality, and progression of organ failures and worsening of AARC scores by grade I, SOFA score by point 2.
• Microbiologic outcome (Eradication/Persistence)
• To identify biomarkers of host response to empirical antibiotic regimen
• Transplant free survival at day 15 and day 28
• Proportion of patients made eligible for transplant day 7. A prospective, Randomized Control Trial. Single centre, Open label, Block randomization will be done, it will be implemented by IWRS method. This study will be conducted in Department of Hepatology, ILBS.

Inclusion criteria

• Age ≥ 18 years
• ACLF as per APASL criteria
• ACLF patients with nosocomial infections caused by carbapenem resistant organism (defined as suspected or documented evidence of infection after 48 hours of hospitalization) requiring antibiotics.

Exclusion criteria

• Severe septic shock with MOF requiring escalation of antibiotics
• Patients having known allergies to meropenem or Ceftazidime Avibactam
• Culture sensitivity showing isolate non susceptible to study drug being investigated.
• Already on either regimen, receiving meropenem or Ceftazidime Avibactam >48 hours.
• On mechanical ventilator support PF ratio < 300.
• Patients on immunosuppression medication
• HCC or other malignancies
• CKD
• CAD
• Pregnancy or Lactation
• Post Liver Transplantation
• Refusal to consent
• PLWHA