Management of bacterial and fungal infections in end stage liver disease and liver transplantation: Current options and future directions

Table 2 Management of fungal infections in patients with liver cirrhosis

Type	Characteristics	Management	Ref.
SFP, fungemia, disseminated fungal infection (mainly Candida spp.)	Delayed diagnosis and therapy. Lack of clinical signs and suspicion. Frequent concomitant SBP. High mortality.	Suspect if peritonitis is not improved after 48 h of empirical antibiotic treatment. Perform fungal cultures (ascites and blood).	[44,45,52,53]
Antifungal prophylaxis	Factors influencing mortality less known. Mortality higher than SBP due to delayed diagnosis.	Indicated for SBP (high risk, previous episode, GI bleeding). No clear indication for fungal infections. Consider in: ICU patients without improvement > 48 h, high prevalence (> 5%) regions, risk factors (corticosteroids, prolonged microbial use, CVC, TPN, high APACHE score, dialysis).	[48,54]
Antifungal treatment	Recommendations for fungal infections in LC.	Prompt initiation. Echinocandins as first-line treatment (e.g., fungemia, nosocomial SFP or critically ill with CA-SFP). Fluconazole indicated if less severe infections. De-escalation if patient is stable and sensitivity tests available.	[52-54]

SFP: Spontaneous fungal peritonitis; SBP: Spontaneous bacterial peritonitis; GI: Gastrointestinal; CVC: Central venous catheter; TPN: Total parenteral nutrition; APACHE: Acute Physiology and Chronic Health Evaluation; LC: Liver cirrhosis; CA: Community-acquired.