Bacterial infections other than spontaneous bacterial peritonitis in cirrhosis

Table 1 Immune dysfunction in cirrhotic patients

Natural barriers	Fragile, thin and/or edematous skin Alteration of gastrointestinal motility, mucosal permeability and bacterial flora ↑ Gastrointestinal mucosal ulcerations
Hepatic RES activity	Portosystemic shunting Kupffer cells –↓ number, impaired function
Cellular defense mechanisms	RES –↓ activation, ↓ chemotaxis, ↓ phagocytosis, ↓ production of pro-inflammatory cytokines PMN –↓ lifespan, ↓ intracellular killing activity, ↓ phagocytosis, ↓ chemotaxis
Serum factors	↓ Complement levels (C3, C4, CH50) ↓ Opsonic activity ↓ Protein C activity
Iatrogenic and treatment-related factors	Invasive procedure and catheters Medications: immunosuppressive agents, proton pump inhibitors
Other compelling factors	Malnutrition Alcohol drinking

RES: Reticuloendothelial system; PMN: Polymorphonuclear neutrophil.