Diagnosis and management of bacterial infections in decompensated cirrhosis

Abstract

Bacterial infections are one of the most frequent complications in cirrhosis and result in high mortality rates. Patients with cirrhosis have altered and impaired immunity, which favours bacterial translocation. Episodes of infections are more frequent in patients with decompensated cirrhosis than those with compensated liver disease. The most common and life-threatening infection in cirrhosis is spontaneous bacterial peritonitis followed by urinary tract infections, pneumonia, endocarditis and skin and soft-tissue infections. Patients with decompensated cirrhosis have increased risk of developing sepsis, multiple organ failure and death. Risk factors associated with the development of infections are severe liver failure, variceal bleeding, low ascitic protein level and prior episodes of spontaneous bacterial peritonitis (SBP). The prognosis of these patients is closely related to a prompt and accurate diagnosis. An appropriate treatment decreases the mortality rates. Preventive strategies are the mainstay of the management of these patients. Empirical antibiotics should be started immediately following the diagnosis of SBP and the first-line antibiotic treatment is third-generation cephalosporins. However, the efficacy of currently recommended empirical antibiotic therapy is very low in nosocomial infections including SBP, compared to community-acquired episodes. This may be associated with the emergence of infections caused by Enterococcus faecium and extended-spectrum β-lactamaseproducing Enterobacteriaceae, which are resistant to the first line antimicrobial agents used for treatment. The emergence of resistant bacteria, underlines the need to restrict the use of prophylactic antibiotics to patients with the greatest risk of infections. Nosocomial infections should be treated with wide spectrum antibiotics. Further studies of early diagnosis, prevention and treatment are needed to improve the outcomes in patients with decompensated cirrhosis.

Left-sided infective endocarditis in patients with liver cirrhosis

“…Cirrhotic patients, particularly those with advanced disease, have leukocyte dysfunction and phagocytic defects that make them prone to focal and systemic bacterial infections (1,2) that can affect their prognosis. These infections frequently produce bacteremias which can develop to endocarditis, but to date, the incidence and prognostic implications of left-sided infective endocarditis (LsIE) in patients with liver cirrhosis (LC) is not well known (3).…”

CT findings in acute peritonitis: a pattern-based approach

“…Clinical criteria are positive culture of ascitic fluid, neutrophilic count of at least 250 cells for mm 3 in the ascitic fluid, and no obvious intra-abdominal source of infection. SBP may be caused by the combination of long-term bacteremia due to deficient defense mechanisms in the host, intrahepatic shunting, and decreased bactericidal activity that occurs in ascites (12).…”

Multiresistant bacterial infections in liver cirrhosis: Clinical impact and new empirical antibiotic treatment policies

“…Infection can accentuate the preexisting circulatory dysfunction present in advanced cirrhosis leading to the development of hepatorenal syndrome and can also induce an excessive pro-inflammatory response that could contribute to develop multiple organ failure (acute-on-chronic liver failure) and septic shock [9] . Thus, prompt diagnosis and appropriate treatment of infection is crucial in the management of patients with cirrhosis [10,11] .…”