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Management of Infections in Cirrhosis

Fudan University Huashan Hospital Department of Infectious Diseases. Management of Infections in Cirrhosis. Wenhong Zhang, M.D. Department of Infectious Diseases, Huashan Hospital, Fudan University Shanghai, China. Stage of liver cirrhosis. Liver cirrhosis and Infections.

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Management of Infections in Cirrhosis

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  1. Fudan University Huashan Hospital Department of Infectious Diseases Management of Infections in Cirrhosis Wenhong Zhang, M.D. Department of Infectious Diseases, Huashan Hospital, Fudan University Shanghai, China

  2. Stage of liver cirrhosis Liver cirrhosis and Infections • Liver cirrhosis is associated with defects in the immune system, which increase the risk and severity of infections. Severity of infections Rekha Cheruvattath. J Clin Gastroenterol 2007;41:403–411)

  3. Risk factors of infections in cirrhosis--Intestinal mucosal barrier and bacterial translocation Reiner Wiest and Guadalupe Garcia-Tsao. HEPATOLOGY, Vol. 41, No. 3, 2005

  4. Risk factors of infections in cirrhosis-- DC-mediated transport of bacteria Reiner Wiest and Guadalupe Garcia-Tsao. HEPATOLOGY, Vol. 41, No. 3, 2005

  5. Risk factors of infections in cirrhosis-- Bacterial translocation Cirera I, et al. Journal of Hepatology 34 (2001) 32±37

  6. Risk factors of infections in cirrhosis-- invasive procedures Reiner Wiest and Guadalupe Garcia-Tsao. HEPATOLOGY, Vol. 41, No. 3, 2005

  7. Most common infections in cirrhosis • spontaneous bacterial peritonitis (SBP) (25%) • urinary tract infection (20%), • pneumonia (15%) ， • bacteremia (12%) • others

  8. Most common causative organisms Most common organisms isolated • Gramnegative bacteria (GNB) • E. Coli • Klesiella • Enterobacteriaceae species • Gram-positive cocci (GPC) • Pneumonia (mainly Streptococcus pneumoniae) • Bacteremia associated with invasive procedures (mainly staphylococci).

  9. Increasing causative organisms--Fungal infection • Candida • Cryptococcus • Aspergillus • Coccidiodomycosis

  10. Management of Infections • SBP and other bacterial infections • Fungal infections

  11. Treatment of SBP: regimens and indications AASLD PRACTICE GUIDELINE. Management of Adult Patients with Ascites Due to Cirrhosis: An Update. HEPATOLOGY, Vol. 49, No. 6, 2009

  12. Antibacterial regimens for SBP EASL clinical practice guidelines on the management ofascites, spontaneous bacterial peritonitis, and hepatorenalsyndrome in cirrhosis. Journal of Hepatology 2010 vol. 53 ,397–417

  13. AASLD PRACTICE GUIDELINE. Management of Adult Patients with Ascites Due to Cirrhosis: An Update. HEPATOLOGY, Vol. 49, No. 6, 2009

  14. Prevention of SBP: regimens AASLD PRACTICE GUIDELINE. Management of Adult Patients with Ascites Due to Cirrhosis: An Update. HEPATOLOGY, Vol. 49, No. 6, 2009

  15. AASLD PRACTICE GUIDELINE. Management of Adult Patients with Ascites Due to Cirrhosis: An Update. HEPATOLOGY, Vol. 49, No. 6, 2009 Prevention of SBP: regimens and duration EASL clinical practice guidelines on the management ofascites, spontaneous bacterial peritonitis, and hepatorenalsyndrome in cirrhosis. Journal of Hepatology 2010 vol. 53 ,397–417

  16. Spectrum of drug resistance to 3rd generation of cephalosporin Xavier Ariza et al. Journal of Hepatology 2012 vol. 56,825–832

  17. Drug resistance to 3rd generation of cephalosporin Xavier Ariza et al. Journal of Hepatology 2012 vol. 56,825–832

  18. Drug resistance in enterobacteriaceae

  19. Enterococci infection

  20. Antibiotics against GPC

  21. Algorithm for the therapeutic management of infections when MRSA risk factors are present Niederman MS. Journal of Infection (2009) 59(S1) S25 S31

  22. Pneumonia • Community-acquired pneumonia still remains the most common type with Streptococcus pneumoniae • In alcoholic cirrhosis, infection with anaerobes, Hemophilus influenzae, and K.pneumoniae are of particular concern. • Hospital-acquired pneumonia is predominantly caused by gram-negative bacilli and staphylococci. • Third generation cephalosporins are generally recommended, with nosocomial pneumonia needing J Clin Gastroenterol 2007;41:403–411)

  23. Microorganisms Causing Pneumonia-- by Time After OLT* Aduen JF, Hellinger WC, Kramer DJ, et al. Mayo Clin Proc. 2005;80(10):1303-1306

  24. Empiric Therapy for for MDR Pathogens and all Disease Severity Potential Pathogens Pathogens listed in previous slide + MDR pathogens P aeruginosa K pneumoniae (ESBL+)† Acinetobacter spp MRSA L pneumophila Combination Therapy Antipseudomonal cephalosporin or Antipseudomonal carbepenem or β-lactam/β-lactamase inhibitor Antipseudomonal fluoroquinolone or Aminoglycoside (AMG) Linezolid or vancomycin* FQs ＋ ＋ ＋ ATS/IDSA Guidelines. AJ RCCM. 2005;171:388-416.

  25. Management of Fungal infections(1) Am J Respir Crit Care Med Vol 183. pp 96–128, 2011

  26. Management of Fungal infections(2) Am J Respir Crit Care Med Vol 183. pp 96–128, 2011

  27. Management of Fungal infections(3) Am J Respir Crit Care Med Vol 183. pp 96–128, 2011

  28. Anti-fungal treatment: considering hepatic toxicities Infection 2010; 38: 3–11

  29. Conclusions • Infections in cirrhosis are a common cause of morbidity and mortality; • Abnormalities in cellular and humoral immunity and the increasing use of invasive procedures predispose these patients to a variety of infections. • Clinicians should have a low index of suspicion as prompt detection and the use of appropriate treatment can improve survival in these patients.

  30. Thank you!

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