Management of Infections in Cirrhosis

1
Management of Infections in Cirrhosis
Fudan University Huashan Hospital Department of
Infectious Diseases

• Wenhong Zhang, M.D. Department of Infectious
  Diseases,
• Huashan Hospital, Fudan University
• Shanghai, China

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Liver cirrhosis and Infections
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
200741403411)
3
Risk factors of infections in cirrhosis--Intestin
al mucosal barrier and bacterial translocation
Reiner Wiest and Guadalupe Garcia-Tsao.
HEPATOLOGY, Vol. 41, No. 3, 2005
4
Risk factors of infections in cirrhosis --
DC-mediated transport of bacteria
Reiner Wiest and Guadalupe Garcia-Tsao.
HEPATOLOGY, Vol. 41, No. 3, 2005
5
Risk factors of infections in cirrhosis --
Bacterial translocation
Cirera I, et al. Journal of Hepatology 34 (2001)
3237
6
Risk factors of infections in cirrhosis --
invasive procedures
Reiner Wiest and Guadalupe Garcia-Tsao.
HEPATOLOGY, Vol. 41, No. 3, 2005
7
Most common infections in cirrhosis

• spontaneous bacterial peritonitis (SBP) (25)
• urinary tract infection (20),
• pneumonia (15) ,
• bacteremia (12)
• others

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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).

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Increasing causative organisms --Fungal infection

• Candida
• Cryptococcus
• Aspergillus
• Coccidiodomycosis

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Management of Infections

• SBP and other bacterial infections
• Fungal infections

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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
12
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
,397417
13
AASLD PRACTICE GUIDELINE. Management of Adult
Patients with Ascites Due to Cirrhosis An
Update. HEPATOLOGY, Vol. 49, No. 6, 2009
14
Prevention of SBP regimens
AASLD PRACTICE GUIDELINE. Management of Adult
Patients with Ascites Due to Cirrhosis An
Update. HEPATOLOGY, Vol. 49, No. 6, 2009
15
Prevention of SBP regimens and duration
EASL clinical practice guidelines on the
management of ascites, spontaneous bacterial
peritonitis, and hepatorenal syndrome in
cirrhosis. Journal of Hepatology 2010 vol. 53
,397417
16
Spectrum of drug resistance to 3rd generation of
cephalosporin
Xavier Ariza et al. Journal of Hepatology 2012
vol. 56,825832
17
Drug resistance to 3rd generation of cephalosporin
Xavier Ariza et al. Journal of Hepatology 2012
vol. 56,825832
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Drug resistance in enterobacteriaceae
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(No Transcript)
20
Enterococci infection
21
Antibiotics against GPC
22
Algorithm for the therapeutic management of
infections when MRSA risk factors are present
Niederman MS. Journal of Infection (2009) 59(S1)
S25 S31
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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 200741403411)
24
Microorganisms Causing Pneumonia-- by Time After
OLT
Aduen JF, Hellinger WC, Kramer DJ, et al. Mayo
Clin Proc. 200580(10)1303-1306
25
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 or Antipseudomonal
carbepenem or ß-lactam/ß-lactamase
inhibitor


Antipseudomonal fluoroquinolone
or Aminoglycoside (AMG)
Linezolid or
vancomycin FQs



ATS/IDSA Guidelines. AJ RCCM. 2005171388-416.
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Management of Fungal infections(1)
Am J Respir Crit Care Med Vol 183. pp 96128, 2011
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Management of Fungal infections(2)
Am J Respir Crit Care Med Vol 183. pp 96128, 2011
28
Management of Fungal infections(3)
Am J Respir Crit Care Med Vol 183. pp 96128, 2011
29
Anti-fungal treatment considering hepatic
toxicities
Infection 2010 38 311
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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.

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Thank you!