Bacterial infections in cirrhosis: A critical review and practical guidance

Table 3 Common manifestations and risk factors of bacterial pathogens in patients with cirrhosis

Pathogens	Common clinical syndrome	Risk factors	Remarks
Aeromonas spp. (A. hydrophila, A. sobria, A. aquariorum)[120-126]	SBP, bacteremia, SSTI, enterocolitis	Contaminated food and water	Increased incidence
		Diabetes	High mortality (20%-60%), especially when
		Most reports were from East Asia	presence of hypotension on admission
Campylobacter spp.[127,128]	Bacteremia, SBP	Alcoholic	Increased incidence
			High mortality (10% in bacteremia)
Clostridium spp. (C. perfringens, C. bifermentans, C. septicum)[4,129,130]	SSTI	Diabetes	Increased incidence
			Very high mortality (54%-65%)
Clostridium difficile[108,131-133]	ATB-associated diarrhea and colitis	Broad-spectrum ATB	Increased incidence
		Hospitalization	Higher mortality (14%) when compare to non-cirrhotics
		PPIs	Increased cost and length of hospital stay
Enterococcus spp. (E. faecium, E. faecalis, E. galinarum)[134-136]	SBP, bacteremia, UTI, endocarditis, biliary tract infection	Healthcare-associated infection	Increased incidence
		Quinolone prophylaxis	High mortality (30% in bacteremia; 60% in SBP)
			Increased incidence of VRE colonization and infection in liver transplant setting
Listeria monocytogenes[137,138]	SBP, bacteremia, meningitis	Hemochromatosis	Increased incidence
Mycobacterium TB[2,139,140]	Pulmonary TB, TB peritonitis, TB lymphadenitis, disseminated TB	Alcoholic	Increased incidence, especially extrapulmonary forms (>
		Developing countries	50% of TB peritonitis cases in the United States had
		Exposed to TB case	underlying cirrhosis)
			High mortality (22%-48%)
			Increased risk for multi-drug resistant TB
			Increased risk for anti-TB-induced hepatotoxicity
Pasteurella multocida[141-143]	SBP, bacteremia septic arthritis, meningitis	Presence of ascites (TB peritonitis)	Increased incidence
		Domestic animal (cats or dogs) bites or scratches	High mortality (10%-40% in bacteremia)
Staphylococcus aureus[45,144,145]	SSTI, UTI, SBP, bacteremia, endocarditis	Alcoholic	Increased incidence of MRSA carriage and infection
		Invasive procedures	High mortality (30% in bacteremia)
		Hospitalization	Removal of the eradicable focus was associated with
			decreased mortality
Streptococcus bovis[146,147]	Bacteremia, SBP meningitis, endocarditis, septic arthritis	Quinolone prophylaxis	Increased incidence
		Colonic lesion(s): Adenoma or	High mortality (up to 40% in bacteremia with
		adenocarcinoma (presence in	advanced cirrhosis)
		18%-40% of cases)	Colonic lesion(s) was present in 18%-40% of cases
		Alcoholic
Streptococcus group B[148-150]	SSTI, bacteremia, SBP, meningitis, pneumonia	Post endoscopic sclerotherapy and banding ligation	Increased incidence
			High mortality (10%-25% in SBP and bacteremia;
			45% in meningitis)
Streptococcus pneumoniae[89-92]	Pneumonia, SBP bacteremia, SSTI, meningitis	Alcoholic	Increased incidence of invasive pneumococcal disease
		Post-splenectomy	High mortality (10%-20%)
		Not vaccinated
Vibrio spp. (V. vulnificus, non-o1 V. cholera, V. parahemolyticus)[151-153]	SSTI, bacteremia, gastroenteritis, diarrhea, SBP	Hemochromatosis	Increased incidence
		Exposed to seawater and undercooked seafoods	Very high mortality (50%-60% in bacteremia; 24% in SSTI)
		Most reports were from East Asia
Yersinia spp. (Y. enterocolitica, Y. pseudotuberculosis)[154,155]	Bacteremia, SBP, hepatosplenic abscesses	Hemochromatosis	Increased incidence (in hemochromatosis)
		Exposed to animals and	High mortality (50% in bacteremia)
		contaminated foods

SBP: Spontaneous bacterial peritonitis; SSTI: Skin and soft tissue infection; UTI: Urinary tract infection; ATB: Antibiotics; PPIs: Proton-pump inhibitors; TB: Tuberculosis; MRSA: Methicillin-resistant Staphylococcus aureus; A. hydrophila: Aeromonas hydrophila; A. sobria: Aeromonas sobria; A. aquariorum: Aeromonas aquariorum; C. perfringens: Clostridium perfringens; C. bifermentans: Clostridium bifermentans; C. septicum: Clostridium septicum; E. faecium: Enterococcus faecium; E. faecalis: Enterococcus faecalis; E. galinarum: Enterococcus galinarum; Mycobacterium TB: Mycobacterium tuberculosis; V. vulnificus: Vibrio vulnificus; V. cholera: Vibrio cholera; V. parahemolyticus: Vibrio parahemolyticus; Y. enterocolitica: Yersinia enterocolitica; Y. pseudotuberculosis: Yersinia pseudotuberculosis; VRE: Vancomycin-resistant Enterococci.