Challenges and recommendations when selecting empirical antibiotics in patients with cirrhosis

Table 1 Empiric antibiotic recommendations in patients with cirrhosis, according to source, severity and type of infection

Infection	AASLD	EASL
Spontaneous infections (peritonitis, bacteremia1, empyema)	Community acquired: Third-generation cephalosporins	Community acquired: Third-generation cephalosporins or piperacillin/tazobactam
		Healthcare-associated: Area dependent: Like nosocomial infections if high prevalence of MDRO or sepsis
	Nosocomial: Piperacillin/tazobactam and daptomycin (if known VRE in past or evidence of GI colonization) or meropenem if known to harbor MDR gram-negative organisms	Nosocomial: Carbapenems alone or carbapenems and daptomycin, vancomycin or linezolid if high prevalence of MDR gram-positive bacteria or sepsis
Pyelonephritis/urinary tract infection	Uncomplicated pyelonephritis: Fluoroquinolones (ciprofloxacin or levofloxacin). Severe pyelonephritis: Third-generation cephalosporins (e.g., ceftriaxone). If recent antibiotic exposure: Piperacilin/tazobactam or carbapenem	Community acquired: Uncomplicated: Ciprofloxacin or cotrimoxazole. If sepsis: Third-generation cephalosporins or piperacillin/tazobactam. Healthcare-associated: Area dependent: Like nosocomial infections if high prevalence of MDROs or if sepsis. Nosocomial: Uncomplicated: Fosfomycin or nitrofurantoin. If sepsis: Meropenem and teicoplanin or vancomycin
Pneumonia	Community acquired: (1) Non-severe: B-lactam and macrolide or respiratory fluoroquinolones; and (2) Severe: B-lactam and macrolide or B-lactam and fluoroquinolones. Vancomycin can be added if patient has prior respiratory isolation of MRSA. Hospital acquired (not ventilator associated): (1) Non-severe (not septic, not intubated): One of the following: Piperacillin/tazobactam or cefepime or levofloxacin. Vancomycin can be added if MRSA was isolated in the last 90 d or if antibiotics were used in the last 90 d; and (2) Severe (presence of sepsis or requiring intubation). One of the following: Piperacilin tazobactam or cefepime or meropenem and levofloxacin. Vancomycin can be added if MRSA was isolated in the last 90 d or if antibiotics were used in the last 90 d. Pseudomonas coverage: If there is prior respiratory isolation of pseudomonas of recent use of parenteral antibiotics or hospitalization	Community acquired: Piperacillin/tazobactam or ceftriaxone and macrolide or levofloxacin or moxifloxacin. Healthcare-associated: Area dependent: Like nosocomial infections if high prevalence of MDROs or if sepsis. Nosocomial: Ceftazidime or meropenem and levofloxacin ± glycopeptides or linezolid
Cellulitis	Moderate (with systemic signs of infection): Penicillin or ceftriaxone or cefazolin or clindamycin. Severe (failed antibiotics, presence of sepsis): Vancomycin and piperacillin/tazobactam	Community acquired: Piperacillin/tazobactam or third-generation cephalosporins and oxacillin. Healthcare-associated: Area dependent: Like nosocomial infections if high prevalence of MDROs or if sepsis. Nosocomial: Third-generation cephalosporin or meropenem and oxacillin or glycopeptides or daptomycin or linezolid

¹European Association for the Study of the Liver refers only to spontaneous bacterial peritonitis and spontaneous bacterial empyema.

AASLD: American Association for the Study of the Liver; EASL: European Association for the Study of the Liver; GI: Gastrointestinal; MDR: Multidrug-resistant; MDROs: Multidrug-resistant microorganisms; MRSA: Methicillin-resistant Staphylococcus aureus; VRE: Vancomycin-resistant enterococcus.