bacterial infection in cirrhosis

7/27/2019 Bacterial Infection in Cirrhosis

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Bacterial Infection in

Liver Cirrhosis

Dr. Hany M A

Assistantlecturer of tropical Mdicine


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Arebacterialinfections a

problem in

cirrhosis?


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Bacterial infections

Bacterial infection is one of the most frequent,

leading to other morbidities and higher

percentages of mortality.


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30 to 50 % of hospitalized cirrhotic

patients are concerned by bacterialinfections


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Spontaneous Bacterial Peritonitis (SBP)

( bacteremia)

Urinary Tract Infection (UTI)

( bacteremia)

Pulmonary

infection

Others

(peritoneal

tuberculosis)

25 % of death

directly due to

bacterial

infection


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Abnormal presentation

Recognition of infection is made more difficult by

the absence of the normal clinical feature of

infection like:

fever, rigors, hypotension, and leucocytosis

So:

The only clues may be deterioration of

hepatic precoma or coma or renal function


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Factors play important roles in the

development of bacterial infections incirrhosis :

1-The severity of liver disease

2- gastrointestinal haemorrhage3-Invasive technique:Catheter, Canula, Endoscopy, Ryle, Sungestaken, Liver

biopsy? & Paracentesis

4-Admission to ICU5-Low ascitic albumin6-Increase total serum bilirubin


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Most common infection

spontaneous bacterial peritonitis(31%)

urinary tract infection

(25%)

Pneumonia

(21%)

skin infections

(11%)

[

[

[


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Gram-negative enteric organisms,

especially E coli, are the most

commonly identifiedpathogens.


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WHY?

This increased susceptibility is due to multiple immune

system defects including:

1-complement deficiency.

2-Reduced chemoattractant activity.

3-decreased polymorphonuclear leukocyte activity.

4-Impaired bactericidial function of IgM.

5-Reduced reticuloendothelial activity and kupffer cell

activity.


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Clinical presentation

Bacterial infections must be suspected with:

1. Symptoms or signs of peritonitis.

2. Non response of ascites to treatment.

3. Unexplained development of

encephalopathy.

4. Unexplained deterioration of renal

functions.


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Bacterial infections in cirrhotics have few

symptoms.So, They need an active search through:

1. Chest X-ray.

2. Urine culture.

3. Blood culture.

4. Paracentesis, if there is ascites.


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BACTERIAL INFECTION AND VARICEAL

HAEMORRHAGE

Bacterial infections are frequently

associated with upper gastrointestinal

bleeding in cirrhotic patients.

Moreover, bacterial infections are more

common in cirrhotic patients with acute

variceal bleeding than in those admitted to

hospital with other forms ofdecompensation, such as encephalopathy.


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Bacterial infections and/or endotoxaemia are

associated with

1-variceal bleeding

2-Failure to control variceal bleeding

3-More early variceal rebleeding

due to

abnormalities in coagulation,

vasodilatation of the systemic vasculature and

worsening of the liver function.


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Recent advances in management

strategies

early management in cirrhosis have helped

to prevent the development and downward

spiral of the sepsis syndrome& improve the

prognosis of these patients.


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These include :

.Theuse of prophylactic antibiotics in

patients with gastrointestinal bleed to

prevent infection

and

.The use of albumin in patients with

spontaneous bacterial peritonitisto reducethe incidence of renal impairment


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Short term

Primary prophylaxis

- To prevent infection after GI bleeding.

- Selective decontamination by oral norfloxacin.

- The regimen is 800 mg/day for 7 days.

- It resulted in significant decrease in

I. The incidence of infection (14% vs 45%)

II. The mortality rate (15%-24)


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Long term

Secondary prophylaxis

- For patients recovered from an episode of SBP .

- Oral norfloxacin, 400 mg/day.

- Till absence of ascites, transplantation or

death.

- Decreased recurrence of SBP (20% vs 68%).

- May lead to quinolone resistant infection.


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Treatment of spontaneous

bacterial infections in cirrhotics

Empiric antibiotic coverage should be

predominantly against Enterobacteriaiceae and

non-enterococcal Streptococcus organisms and

should penetrate the peritoneal space. The "top"choice remains cefotaxime, primarily because of

its efficacy, lack of superinfection, and lack of

renal toxicity. The standard dose should be a

minimum of 2 grams every 12 hours for aminimum of 5 days.


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bacterial infection in cirrhosis

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