BACTERIAL INFECTIONS INCIRRHOTIC PATIENTS
Ibrahim Ali Ibrahim Abd Elmoneim;
Abstract
Patients with cirrhosis have an increased risk of developing bacterial infection, sepsis, and death. Also, Bacterial infections are a common cause of acute decompensation of cirrhosis and trigger the onset of various complications (coagulopathy, hepatorenal syndrome, hepatic encephalopathy, variceal bleeding).
The most common infections in cirrhotics are spontaneous bacterial peritonitis (SBP) (25%), followed by urinary tract infection (UTI) (20%), pneumonia (15%), bacteremia (12%) following a therapeutic procedure, cellulitis, and spontaneous bacteremia.
Enterobacteriaceae and non-enterococcal streptococci cause the majority of spontaneous infections in cirrhosis. As a consequence, β-lactams and quinolones have been widely used in their treatment and prevention. This feature and the increasing level of invasiveness to which patients with cirrhosis are currently submitted have induced important changes in the epidemiology of bacterial infections in cirrhosis. Spontaneous and secondary infections caused by non-classical pathogens or multidrug resistant bacteria are nowadays increasingly reported in this population.
Since the presentation and the initial course of a bacterial infection in some patients with cirrhosis may be subtle and not very specific, clinical suspicion is important. Therefore, in order to detect a possible infection, a complete work-up (paracentesis, urinary sediment, chest X-ray, ascitic fluid PMN count and blood, ascitic fluid, and urine cultures should be performed at admission and whenever a hospitalized patient deteriorates clinically.Clinical risk factors include poor liver function, variceal bleeding, low protein ascites, prior episode of SBP, existence of severe co-morbidity and hospitalization.
In patients with cirrhosis the combination of PCT and CRP increased the sensitivity and negative predictive value in the detection of infections, compared with CRP on its own, by 10 and 5% respectively. CRP and/or PCT screening is highly recommended in those patients with sudden impairment of the liver function, diuretic-resistant ascites, deteriorating renal function, increasing jaundice or encephalopathy.
Recently, the application of DST (Direct antimicrobial Susceptibility Testing) based on MALDI-TOF from positive blood cultures has been proposed for early detection of resistant bacteria and their antibiotic susceptibility.
The choice of initial empirical antibiotics should be based on the type, severity and origin of infection (community-acquired, nosocomial or health care-associated) and on the local epidemiological data about antibiotic resistance. If the causative organism is identified (about 50% of cases), antibiotic regimen should be narrowed to decrease the likelihood of emergence of antibiotic resistance.
In cirrhosis antibiotic prophylaxismay play a certain role. It comprises two distinct approaches. Short-term prophylaxis aims to protect against development of a presumed bacteremia, usually following an invasive procedure. In contrast, long-term antibiotic prophylaxis is used to protect patients with increased susceptibility either temporarily or permanently against pathogens invading through any portal of entry. This second type of prophylaxis is rather controversial.
It is becoming increasingly important to develop non-antibiotic strategies to decrease bacterial translocation(BT) and to reduce the incidence of infection in patients with cirrhosis. These non-antibiotic strategies include the use of probiotics, prokinetic agents and supplementation with oral bile acids and areas of future research.
The most common infections in cirrhotics are spontaneous bacterial peritonitis (SBP) (25%), followed by urinary tract infection (UTI) (20%), pneumonia (15%), bacteremia (12%) following a therapeutic procedure, cellulitis, and spontaneous bacteremia.
Enterobacteriaceae and non-enterococcal streptococci cause the majority of spontaneous infections in cirrhosis. As a consequence, β-lactams and quinolones have been widely used in their treatment and prevention. This feature and the increasing level of invasiveness to which patients with cirrhosis are currently submitted have induced important changes in the epidemiology of bacterial infections in cirrhosis. Spontaneous and secondary infections caused by non-classical pathogens or multidrug resistant bacteria are nowadays increasingly reported in this population.
Since the presentation and the initial course of a bacterial infection in some patients with cirrhosis may be subtle and not very specific, clinical suspicion is important. Therefore, in order to detect a possible infection, a complete work-up (paracentesis, urinary sediment, chest X-ray, ascitic fluid PMN count and blood, ascitic fluid, and urine cultures should be performed at admission and whenever a hospitalized patient deteriorates clinically.Clinical risk factors include poor liver function, variceal bleeding, low protein ascites, prior episode of SBP, existence of severe co-morbidity and hospitalization.
In patients with cirrhosis the combination of PCT and CRP increased the sensitivity and negative predictive value in the detection of infections, compared with CRP on its own, by 10 and 5% respectively. CRP and/or PCT screening is highly recommended in those patients with sudden impairment of the liver function, diuretic-resistant ascites, deteriorating renal function, increasing jaundice or encephalopathy.
Recently, the application of DST (Direct antimicrobial Susceptibility Testing) based on MALDI-TOF from positive blood cultures has been proposed for early detection of resistant bacteria and their antibiotic susceptibility.
The choice of initial empirical antibiotics should be based on the type, severity and origin of infection (community-acquired, nosocomial or health care-associated) and on the local epidemiological data about antibiotic resistance. If the causative organism is identified (about 50% of cases), antibiotic regimen should be narrowed to decrease the likelihood of emergence of antibiotic resistance.
In cirrhosis antibiotic prophylaxismay play a certain role. It comprises two distinct approaches. Short-term prophylaxis aims to protect against development of a presumed bacteremia, usually following an invasive procedure. In contrast, long-term antibiotic prophylaxis is used to protect patients with increased susceptibility either temporarily or permanently against pathogens invading through any portal of entry. This second type of prophylaxis is rather controversial.
It is becoming increasingly important to develop non-antibiotic strategies to decrease bacterial translocation(BT) and to reduce the incidence of infection in patients with cirrhosis. These non-antibiotic strategies include the use of probiotics, prokinetic agents and supplementation with oral bile acids and areas of future research.
Other data
| Title | BACTERIAL INFECTIONS INCIRRHOTIC PATIENTS | Other Titles | الإلتهابات البكتيرية في مرضى تليف الكبد | Authors | Ibrahim Ali Ibrahim Abd Elmoneim | Issue Date | 2015 |
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