Bacterial infections in cirrhosis: A critical review and practical guidance

Table 1 State of immune dysfunction in patients with cirrhosis

Natural barriers	Fragile, thin and/or edematous skin
	Alteration of GI motility and mucosal permeability
	Alteration of GI bacterial flora, bacterial overgrowth
	↑ GI mucosal ulcerations
Hepatic RES activity	Portosystemic shunting
	Kupffer cells - ↓ number, impaired function
Cellular defense mechanisms	RES - ↓ activation, ↓ chemotaxis, ↓ phagocytosis, ↓ production of pro-inflammatory cytokines (IL-1, IL-6, IL-18, TNF-α)
	PMN - ↓ lifespan, ↓ intracellular killing activity, ↓ phagocytosis, ↓ chemotaxis
Serum factors	↓ Complement levels (C3, C4, CH50)
	↓ Opsonic activity
	↓ Protein C activity
Iatrogenic and treatment-related factors	↑ Invasive procedure and catheters
	Frequent hospitalization
	Immunosuppressive agents (autoimmune hepatitis, post-transplantation)
	Interferon therapy (viral hepatitis)
	Proton pump inhibitors
Other compelling factors	Malnutrition
	Alcohol drinking

Adapted from Bunchorntavakul C, Chavalitdhamrong D. World J Hepatol 2012; 4: 158-168. RES: Reticuloendothelial system; GI: Gastrointestinal; IL: Interleukins; TNF: Tumor necrosis factors; PMN: Polymorphonuclear cells.