Bacterial Infections in Cirrhosis

Patients with cirrhosis are highly susceptible for bacterial infections and their severe courses. Infections occur more often in advanced stage of liver disease, impair hepatic function, trigger the onset of complications, and are significant factors of mortality as well. Gastrointestinal hemorrhage confers a higher risk for infections and infections play important role in provoking of variceal bleeding episodes and can also be associated with the failure to control bleeding. In the past, the dominant pathogens were Gram-negative bacteria, but nowadays participation of Gram-positive strains has been increasing. Occurrence of opportunistic bacteria is far from rare. Spreading of resistant organisms and appearance of Clostridium difficile associated disease related with higher mortality are increasing problem due to the consequence of repeated antibiotic treatment of recurring infections, multiple hospitalizations and use of long-term antibiotic prophylaxis. In cirrhosis, immunodeficiency is multifactorial and progresses with the disease severity. Thus bacteria commonly get into the circulation from the infection ports causing frequent and prolonged bacteremia. Circulating bacteria colonize and proliferate in different organs inducing secondary focal infections. Intestinal tract considered a significant portal of entry. Translocation of the gut microflora mainly related to the development of spontaneous bacterial peritonitis. It is reasonable to assume that spontaneous bacteremia leads to other systemic infections but this is yet to be outlined adequately. Identification of infectious episodes are challenging due to the lack of typical signs and courses up to fifty percent of the cases. Early recognition and effective treatment of infections are essential in decreasing the high mortality.  Correspondence to: Maria Papp, M.D., Ph.D., 2nd Department of Medicine, Division of Gastroenterology, University of Debrecen, Nagyerdei krt. 98, H-4032 Debrecen, Hungary, Phone/Fax: 36-52-255-152, e-mail: [email protected]. Complimentary Contributor Copy Zsuzsanna Vitalis and Maria Papp 64 List of Abbreviations ACLF: acute-on-chronic liver failure ARF: acute renal failure BT: bacterial translocation CIRCI: critical illness related corticosteroid insufficiency CRP: C-reactive protein CDAD: Clostridium difficile associated diseases ESBL: extended-spectrum beta-lactamase GNB: Gram-negative bacteria GPC: Gram-positive cocci HE: hepatic encephalopathy, Hp: haptoglobin HRS: hepatorenal syndrome IE: infective endocarditis LBP: lipopolysaccharide-binding protein MALDI-TOF MS: Matrix Assisted Laser Desorption Ionization – Time of Flight Mass Spectometry MBL: mannose-binding lectin MRSA: methicillin-resistant Staphylococcus aureus NSAID: non-steroidal anti-inflammatory drug NOD2: nucleotid-binding oligomerization domain containing 2 PCT: procalcitonin PMN: polymorphonuclear leukocyte/ neutrophil RAI: relative adrenal insufficiency RES: reticuloendothelial system SBE: spontaneous bacterial empyema SBP: spontaneous bacterial peritonitis TLR: toll-like receptor UTI: urinary tract infection WBC: white blood cell Financial support: Maria Papp was supported by the Janos Bolyai Research Scholarship of the Hungarian Academy of Sciences and Internal Research Grant of University of