Fudan University
Huashan Hospital
Department of Infectious Diseases
Management of Infections in Cirrhosis
Wenhong Zhang, M.D.
Department of Infectious Diseases,
Huashan Hospital, Fudan University
Shanghai, China
Liver cirrhosis and Infections
Stage of liver cirrhosis
Severity of infections
• Liver cirrhosis is associated with defects in the
immune system, which increase the risk and
severity of infections.
Rekha Cheruvattath. J Clin Gastroenterol 2007;41:403–411)
Risk factors of infections in cirrhosis
--Intestinal mucosal barrier and bacterial translocation
Reiner Wiest and Guadalupe Garcia-Tsao. HEPATOLOGY, Vol. 41, No. 3, 2005
Risk factors of infections in cirrhosis
-- DC-mediated transport of bacteria
Reiner Wiest and Guadalupe Garcia-Tsao. HEPATOLOGY, Vol. 41, No. 3, 2005
Risk factors of infections in cirrhosis
-- Bacterial translocation
Cirera I, et al. Journal of Hepatology 34 (2001) 32±37
Risk factors of infections in cirrhosis
-- invasive procedures
Reiner Wiest and Guadalupe Garcia-Tsao. HEPATOLOGY, Vol. 41, No. 3, 2005
Most common infections in cirrhosis
• spontaneous bacterial peritonitis (SBP) (25%)
• urinary tract infection (20%),
• pneumonia (15%) ，
• bacteremia (12%)
• others
Most common causative organisms
Most common organisms isolated
• Gramnegative bacteria (GNB)
– E. Coli
– Klesiella
– Enterobacteriaceae species
• Gram-positive cocci (GPC)
– Pneumonia (mainly Streptococcus pneumoniae)
– Bacteremia associated with invasive procedures (mainly
staphylococci).
Increasing causative organisms
--Fungal infection
• Candida
• Cryptococcus
• Aspergillus
• Coccidiodomycosis
Management of Infections
• SBP and other bacterial infections
• Fungal infections
Treatment of SBP: regimens and indications
AASLD PRACTICE GUIDELINE. Management of Adult Patients with Ascites
Due to Cirrhosis: An Update. HEPATOLOGY, Vol. 49, No. 6, 2009
Antibacterial regimens for SBP
EASL clinical practice guidelines on the management of ascites,
spontaneous bacterial peritonitis, and hepatorenal syndrome in
cirrhosis. Journal of Hepatology 2010 vol. 53 ,397–417
AASLD PRACTICE GUIDELINE. Management of Adult Patients with Ascites
Due to Cirrhosis: An Update. HEPATOLOGY, Vol. 49, No. 6, 2009
Prevention of SBP: regimens
AASLD PRACTICE GUIDELINE. Management of Adult Patients with Ascites
Due to Cirrhosis: An Update. HEPATOLOGY, Vol. 49, No. 6, 2009
Prevention of SBP: regimens and duration
AASLD PRACTICE GUIDELINE. Management of Adult Patients
with Ascites Due to Cirrhosis: An Update. HEPATOLOGY, Vol. 49,
No. 6, 2009
EASL clinical practice guidelines on the management of ascites,
spontaneous bacterial peritonitis, and hepatorenal syndrome in
cirrhosis. Journal of Hepatology 2010 vol. 53 ,397–417
Spectrum of drug resistance to 3rd
generation of cephalosporin
Xavier Ariza et al. Journal of Hepatology 2012 vol. 56,825–832
Drug resistance to 3rd generation of
cephalosporin
Xavier Ariza et al. Journal of Hepatology 2012 vol. 56,825–832
Drug resistance in enterobacteriaceae
Enterococci infection
Antibiotics against GPC
Algorithm for the therapeutic management of
infections when MRSA risk factors are present
Niederman MS. Journal of Infection (2009) 59(S1) S25 S31
Pneumonia
• Community-acquired pneumonia still remains the
most common type with Streptococcus pneumoniae
• In alcoholic cirrhosis, infection with anaerobes,
Hemophilus influenzae, and K.pneumoniae are of
particular concern.
• Hospital-acquired pneumonia is predominantly
caused by gram-negative bacilli and staphylococci.
• Third generation cephalosporins are generally
recommended, with nosocomial pneumonia needing
J Clin Gastroenterol 2007;41:403–411)
Microorganisms Causing Pneumonia
-- by Time After OLT*
Aduen JF, Hellinger WC, Kramer DJ, et al. Mayo Clin Proc. 2005;80(10):1303-1306
Empiric Therapy for for MDR
Pathogens and all Disease Severity
Potential Pathogens
Pathogens listed in previous
slide
+
MDR pathogens
– P aeruginosa
– K pneumoniae (ESBL+)†
– Acinetobacter spp
– MRSA
L pneumophila
Combination Therapy
Antipseudomonal cephalosporin
Antipseudomonal carbepenem
β-lactam/β-lactamase inhibitor
or
or
＋
Antipseudomonal fluoroquinolone or
Aminoglycoside (AMG)
＋
Linezolid or vancomycin*
＋
FQs
ATS/IDSA Guidelines. AJ RCCM. 2005;171:388-416.
Management of Fungal infections(1)
Am J Respir Crit Care Med Vol 183. pp 96–128, 2011
Management of Fungal infections(2)
Am J Respir Crit Care Med Vol 183. pp 96–128, 2011
Management of Fungal infections(3)
Am J Respir Crit Care Med Vol 183. pp 96–128, 2011
Anti-fungal treatment:
considering hepatic toxicities
Infection 2010; 38: 3–11
Conclusions
• Infections in cirrhosis are a common cause of
morbidity and mortality;
• Abnormalities in cellular and humoral immunity and
the increasing use of invasive procedures predispose
these patients to a variety of infections.
• Clinicians should have a low index of suspicion as
prompt detection and the use of appropriate treatment
can improve survival in these patients.
Thank you!