Bacterial infections in cirrhosis: A critical review and practical guidance

Table 2 Types of infection and suggested empirical antibiotic therapy in patients with cirrhosis

Types of infection	Common responsible bacteria	Suggested empirical antibiotic
SBP, spontaneous bacteremia, SBE	Enterobacteriaceae	1st line: Cefotaxime or ceftriaxone or BL-BI IV
	S. pneumoniae	Options: Ciprofloxacin PO for uncomplicated SBP1; carbapenems IV for nosocomial
	S. viridans	infections in areas with a high prevalence of ESBL
		BL-BI may prefer in those with suspicious for enterococcal infection2
Pneumonia	Enterococci	Community-acquired: ceftriaxone or BL-BI IV + macrolide or levofloxacin IV/PO
	S. pneumoniae	Nosocomial and health care-associated infections: Meropenem or cetazidime IV +
	H. infuenzae	ciprofloxacin IV (IV vancomycin or linezolid should be added in patients with risk
	M. pneumoniae	factors for MRSA3)
	Legionella spp.
	Enterobacteriaceae
	P. aeruginosa
	S. aureus
Urinary tract infection	Enterobacteriaceae	1st line: Ceftriaxone or BL-BI IV in patients with sepsis. Ciprofloxacin or
	E. faecalis	cotrimoxazole PO in uncomplicated infections
	E. faecium	Options: In areas with a high prevalence of ESBL, IV carbapenems for nosocomial infections and sepsis (+ IV glycopeptides for severe sepsis); and nitrofurantoin PO for uncomplicated cases
Skin and soft tissue infections	S. aureus	Community-acquired: Ceftriaxone + cloxacillin IV or BL-BI IV
	S. pyogenes	Nosocomial: Meropenem or cetazidime IV + glycopeptides IV
	Enterobacteriaceae
	P. aeruginosa
	Vibrio vulnificus
	Aeromonas spp.
Meningitis	S. pneumoniae	Community-acquired: Cefotaxime or ceftriaxone IV + vancomycin IV
	Enterobacteriaceae	Ampicillin IV should be added if L. monocytogenes is suspected4
	L. monocytogenes	Nosocomial: Meropenem + vancomycin IV
	N. meningitidis

Adapted from Fernandez J, Gustot T. J Hepatol 2012; 56 (Suppl 1): S1-12.

¹Quinolones should not be used in patients submitted to long-term norfloxacin prophylaxis or in geographical areas with a high prevalence of quinolone-resistant Enterobacteriaceae;

²Risk factors for Enterococci: Quinolone prophylaxis, hospital-acquired infection;

³Risk factors for MRSA: Ventilator-associated pneumonia, previous antibiotic therapy, nasal MRSA carriage;

⁴Risk factors for L monocytogenes: Hemochromatosis, detection of gram-positive bacilli/coccobacilli in cerebrospinal fluid. BL-BI: Beta-lactam/beta-lactamase inhibitors (e.g., amoxicillin/clavulanic acid, ampicillin/sulbactam, and piperacillin/tazobactam); MRSA: Methicillin-resistant Staphylococcus aureus; ESBL: Extended spectrum beta-lactamases; SBP: Spontaneous bacterial peritonitis; SBE: Spontaneous bacterial empyema; IV: Intravenous; S. pneumoniae: Streptococcus pneumoniae; S. viridans: Streptococcus viridans; H. infuenzae: Haemophilus influenzae; M. pneumoniae: Mycoplasma pneumoniae; P. aeruginosa: Pseudomonas aeruginosa; S. aureus: Staphylococcus aureus; E. faecalis: Enterococcus faecalis; E. faecium: Enterococcus faecium; S. pyogenes: Streptococcus pyogenes; L. monocytogenes: Listeria monocytogenes; N. meningitidis: Neisseria meningitidis.