Bacterial Infection in Liver Cirrhosis

Dr. Hany M A Assistant lecturer of tropical Mdicine

Are bacterial infections a problem in cirrhosis?

Bacterial infections

Bacterial infection is one of the most frequent, leading to other morbidities and higher percentages of mortality.

30 to 50 % of hospitalized cirrhotic patients are concerned by bacterial infections

Spontaneous Bacterial Peritonitis (SBP) ( bacteremia) Urinary Tract Infection (UTI) ( bacteremia) 25 % of death directly due to bacterial infection

Pulmonary infection

Others
(peritoneal tuberculosis)

Abnormal presentation
Recognition of infection is made more difficult by the absence of the normal clinical feature of infection like:

fever, rigors, hypotension, and leucocytosis So:

The only clues may be deterioration of hepatic precoma or coma or renal function

Factors play important roles in the development of bacterial infections in cirrhosis :

1-The severity of liver disease 2- gastrointestinal haemorrhage 3-Invasive technique:
Catheter, Canula, Endoscopy, Ryle, Sungestaken, Liver biopsy? & Paracentesis

4-Admission to ICU 5-Low ascitic albumin 6-Increase total serum bilirubin

Most common infection

spontaneous bacterial peritonitis (31%)
[

urinary tract infection (25%)

[

Pneumonia (21%)
[

skin infections (11%)

Gram-negative enteric organisms, especially E coli, are the most commonly identified pathogens.

WHY?
This increased susceptibility is due to multiple immune system defects including: 1-complement deficiency. 2-Reduced chemoattractant activity. 3-decreased polymorphonuclear leukocyte activity. 4-Impaired bactericidial function of IgM.

5-Reduced reticuloendothelial activity and kupffer cell activity.

Clinical presentation
Bacterial infections must be suspected with: 1. Symptoms or signs of peritonitis. 2. Non response of ascites to treatment. 3. Unexplained development of encephalopathy.

4. Unexplained deterioration of renal functions.

Bacterial infections in cirrhotics have few symptoms. So, They need an active search through:

1. Chest X-ray.
2. Urine culture.

3. Blood culture.
4. Paracentesis, if there is ascites.

BACTERIAL INFECTION AND VARICEAL HAEMORRHAGE

Bacterial infections are frequently associated with upper gastrointestinal bleeding in cirrhotic patients. Moreover, bacterial infections are more common in cirrhotic patients with acute variceal bleeding than in those admitted to hospital with other forms of decompensation, such as encephalopathy.

Bacterial infections and/or endotoxaemia are associated with 1-variceal bleeding 2-Failure to control variceal bleeding 3-More early variceal rebleeding

due to
abnormalities in coagulation,

vasodilatation of the systemic vasculature and

worsening of the liver function

Recent advances in management strategies

early management in cirrhosis have helped to prevent the development and downward spiral of the sepsis syndrome& improve the prognosis of these patients.

These include : .The use of prophylactic antibiotics in patients with gastrointestinal bleed to prevent infection and .The use of albumin in patients with spontaneous bacterial peritonitis to reduce the incidence of renal impairment

Short term Primary prophylaxis

- To prevent infection after GI bleeding. - Selective decontamination by oral norfloxacin. - The regimen is 800 mg/day for 7 days. - It resulted in significant decrease in I. The incidence of infection (14% vs 45%) II. The mortality rate (15%-24)

Long term Secondary prophylaxis

- For patients recovered from an episode of SBP . - Oral norfloxacin, 400 mg/day. - Till absence of ascites, transplantation or death. - Decreased recurrence of SBP (20% vs 68%).

- May lead to quinolone resistant infection.

Treatment of spontaneous bacterial infections in cirrhotics

Empiric antibiotic coverage should be predominantly against Enterobacteriaiceae and non-enterococcal Streptococcus organisms and should penetrate the peritoneal space. The "top" choice remains cefotaxime, primarily because of its efficacy, lack of superinfection, and lack of renal toxicity. The standard dose should be a minimum of 2 grams every 12 hours for a minimum of 5 days.