Bloodstream infections in patients with liver cirrhosis

Abstract

Bloodstream infections are a serious complication in patients with liver cirrhosis. Dysregulated intestinal bacterial translocation is the predominant pathophysiological mechanism of infections in this setting. For this reason enteric Gram-negative bacteria are commonly encountered as the first etiological cause of infection. However, through the years, the improvement in the management of cirrhosis, the recourse to invasive procedures and the global spread of multidrug resistant pathogens have importantly changed the current epidemiology. Bloodstream infections in cirrhotic patients are characterized by high mortality rate and complications including metastatic infections, infective endocarditis, and endotipsitis (or transjugular intrahepatic portosystemic shunt-related infection). For this reason early identification of patients at risk for mortality and appropriated therapeutic management is mandatory. Liver cirrhosis can significantly change the pharmacokinetic behavior of antimicrobials. In fact hypoproteinaemia, ascitis and third space expansion and impairment of renal function can be translated in an unpredictable drug exposure.

Keywords: bacteremia; bloodstream infections; epidemiology; liver cirrhosis; pathophysiology; therapeutic management.

Figure 1.

Changing in the epidemiology of bacterial infections in cirrhosis during the last fifteen years, intestinal bacterial translocation seems to the predominant pathophysiological mechanism of infections in patients with liver cirrhosis. According with this hypothesis, enteric Gram negative bacteria are commonly considered the first etiological cause of infection. Through the years, the improvement in the management of LC and the recourse to invasive procedures (i.e. central venous catheter and transjugular intrahepatic portosystenuc shunt) increased the risk of healthcare associated or hospital acquired BSIs. As a consequence, staphylococci have been increasingly reported over the past 10 years. The use of antibiotic prophylaxis, generally with fluoroquinolones, and the progressive use of antibiotics with broader spectrum has had an impact on both sources, exercising a selective pressure on both gut and hospital environment, resulting in an increasing rates of multi-drug-resistant (MDR) bacteria and fungi.