New determinants of prognosis in bacterial infections in cirrhosis

Abstract

Despite major advances in the knowledge and management of liver diseases achieved in recent decades, decompensation of cirrhosis still carries a high burden of morbidity and mortality. Bacterial infections are one of the main causes of decompensation. It is very important for clinical management to be aware of the population with the highest risk of poor outcome. This review deals with the new determinants of prognosis in patients with cirrhosis and bacterial infections reported recently. Emergence of multiresistant bacteria has led to an increasing failure rate of the standard empirical antibiotic therapy recommended by international guidelines. Moreover, it has been recently reported that endothelial dysfunction is associated with the degree of liver dysfunction and, in infected patients, with the degree of sepsis. It has also been reported that relative adrenal insufficiency is frequent in the non-critically ill cirrhotic population and it is associated with a higher risk of developing infection, severe sepsis, hepatorenal syndrome and death. We advise a change in the standard empirical antibiotic therapy in patients with high risk for multiresistant infections and also to take into account endothelial and adrenal dysfunction in prognostic models in hospitalized patients with decompensated cirrhosis.

Keywords: Bacterial; Bacterial infections; Drug resistance; Endothelial dysfunction; Liver cirrhosis; Relative adrenal insufficiency.

Figure 1

Proposed algorithm for the empirical treatment of infections in cirrhosis.¹Risk factors for multiresistant bacteria in Health care associated infections are long-term norphloxacin prophylaxis or previous infection by multiresistant (MR) bacteria within 6 mo; ²Piperaziline/tazobactam in areas of low MR bacteria but high Enterococcus faecalis prevalence. Meropenem and glycopeptides in areas with high prevalence of extended-spectrum β-lactamase-producing Enterobacteriaceae and methicillin-resistant Staphylococcus aureus. SBP: Spontaneous bacterial peritonitis; SBE: Spontaneous bacterial empyema; SB: Spontaneous bacteremia; PPZ/TZB: Piperaziline/tazobactam.

Figure 2

Correlation between von Willebrand factor and degree of sepsis. SIRS: Systemic inflammatory response syndrome. (thanks Hepatology journal for permission to reproduce the figure).

Figure 3

Hypothalamic-pituitary-adrenal axis in the critical illness. CRH: Corticotrophin releasing hormone; ADH: Antidiuretic hormone; ACTH: Adrenocorticotropic hormone. Original work of the authors.

Figure 4

Probability of development of severe sepsis and septic shock in patients with and without relative adrenal insufficiency. Probability of developing new episodes of severe sepsis or septic shock in patients with relative adrenal insufficiency (RAI) (continuous line) or with normal adrenal function (doted line) during 3 mo follow-up. Probability was significantly higher in patients with RAI. (thanks Hepatology journal for permission to reproduce the figure).

Figure 5

Probability of survival at 3 mo in patients with and without relative adrenal insufficiency. Probability of survival at 3 mo in patients with relative adrenal insufficiency (RAI) (continuous line) or with normal adrenal function (doted line). Probability was significantly higher in patients with RAI. (thanks Hepatology journal for permission to reproduce the figure).