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©The Author(s) 2018.
World J Gastroenterol. Oct 14, 2018; 24(38): 4311-4329
Published online Oct 14, 2018. doi: 10.3748/wjg.v24.i38.4311
Published online Oct 14, 2018. doi: 10.3748/wjg.v24.i38.4311
Table 1 Main studies reporting the characteristics and mortality rates associated with infections in patients with liver cirrhosis
Year | Prevalence of infections (%); patient n | Main infection sites (%) | Most common pathogens (%) | Mortality rates (%) | Ref. |
2018 | NR; n = 312 | Only BSI included; primary (32), SBP (16), UTI (11) | GNB (53) | 25 | [28] |
2017 | 61; n = 852 | Only BSI included; primary (60), abdominal (33), UTI (7), pneumonia (6) | GNB (60) | 23 | [22] |
2015 | 38; n = 401 | Pneumonia (22), UTI (21), SBP (19) | E. coli (72) | 31 | [23] |
2012 | 51; n = 207 | UTI (52), SBP (23), BSI (21) | GPB (56) | 24 | [19] |
2010 | 33; n = 150 | UTI (37), pneumonia (22), BSI (13) | GNB (62) | 37 | [18] |
2007 | 45; n = 233 | UTI (43), pneumonia (25), SBP (16) | GNB (65) | 18 | [20] |
2003 | 25; n = 135 | UTI (31), SBP (26), pneumonia (25) | NR | 9 | [25] |
2002 | 22; n = 70 | BSI (16), CVC-BSI (9), liver abscess (3) | GPB (67) | 29 | [24] |
2002 | 32; n = 507 | SBP (24), UTI (19), pneumonia (14), CVC-BSI (8) | GPB (47) | 22 | [17] |
2001 | 34; n = 361 | UTI (41), SBP (23), BSI (21), pneumonia (17) | E. coli (25) | 15 | [8] |
1994 | 39; n = 132 | SBP (44), UTI (26), pneumonia (16) | GNB (65), E. coli (62) | 29 | [27] |
1993 | 47; n = 170 | SBP (31), UTI (25), pneumonia (21) | GNB (72) | 17 | [26] |
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] |
Table 3 Management of infections in liver transplant recipients
Population/ infection | Risk factor and type of infection | Management | Ref. |
Liver transplant candidates/all infections | Donor-derived. Active/latent infections. Vaccine-preventable infection. | Donor screening. Careful patient history and physical examination. Identification of infections requiring therapy. Immunization. | [160-165] |
Liver transplant recipients/bacterial | Nosocomial infections (ICU, invasive devices). Recurrent infections (anatomical defects). Immunosuppression. | Peri-transplant antibiotic prophylaxis (< 48 h). Prompt diagnostic workup (uncommon presentations, opportunisms). Source control when needed. | [76,83,160] |
Liver transplant candidates and recipients/MDRO | Colonization (MRSA, VRE, CRE) linked to increased risk of infections. Risk of transmission between patients and across wards. | Surveillance cultures (CRE, VRE, MRSA) and decolonization (MRSA). Infection control (hand hygiene, isolation, contact precautions). | [102,112,164] |
Table 4 Treatment options for multidrug resistant organisms in liver transplant recipients
Pathogens | Recommendation | Antimicrobial regimens | Ref. |
MDR Gram-positives | |||
MRSA | Nasal decolonization with mupirocin. Daptomycin highly bactericidal in BSI; non effective in pulmonary infections. Linezolid and tigecycline bacteriostatic. | Vancomycin1/linezolid OR Daptomycin OR Tigecycline OR Novel anti-MRSA cephalosporins (ceftaroline, ceftobiprole)2. | [107-111] |
VRE | Daptomycin highly bactericidal in BSI; non effective in pulmonary infections. Linezolid and tigecycline bacteriostatic. | Linezolid OR Daptomycin OR Tigecycline. | [113,121,122] |
MDR Gram-negatives | |||
ESBL-producing Enterobacteriaceae | Conflicting data on carbapenem superiority vs BLBLI. Meropenem recommended for high inoculum infections and unstable patients. | Carbapenems OR Piperacillin/tazobactam. | [175-177] |
Carbapenem-resistant Enterobacteriaceae | Test antimicrobial susceptibility (also on colonizing strains). Some evidence of better outcomes with combination therapy vs monotherapy. New molecules promising but scarce data in LT. | Ceftazidime/avibactam, OR Combination regimen (at least two active drugs) including colistin/polymixin B, tigecycline, aminoglycosides1 (gentamycin, amikacin), IV fosfomycin, high-dose prolonged infusion carbapenems. For uncomplicated UTI, consider monotherapy (aminoglycosides, fosfomycin). | [127,137,138,175,178] |
MDR P. aeruginosa | Test antimicrobial susceptibility. New molecules promising but scarce data in LT. | Combination regimen (at least two active drugs) including colistin, an anti-pseudomonal beta-lactam (if susceptible), aminoglycosides1, fosfomycin OR Ceftolozane/tazobactam, ceftazidime/avibactam | [175,179,180] |
- Citation: Righi E. Management of bacterial and fungal infections in end stage liver disease and liver transplantation: Current options and future directions. World J Gastroenterol 2018; 24(38): 4311-4329
- URL: https://www.wjgnet.com/1007-9327/full/v24/i38/4311.htm
- DOI: https://dx.doi.org/10.3748/wjg.v24.i38.4311