Bacterial infections in cirrhosis: A critical review and practical guidance

Table 4 Vaccinations and other preventive measures for bacterial infections in patients with cirrhosis

Avoidance
Raw/uncooked foods, especially seafood
Close contact to at-risk animals or sick people
Wound exposure to flood or seawater
Vaccination[87]
Influenza	Recommended yearly for all patients with chronic liver disease
Pneumococcal (polysaccharide)	Recommended for all cirrhotic patient
	Booster dose after 3-5 yr
Hepatitis A	Recommended for all non-immune, cirrhotic patient, 2 injections 6-12 mo apart
	Anti-HAV should be checked 1-2 mo after the second dose
Hepatitis B	Recommended for all cirrhotic patient without serological markers of HBV (e.g., negative HBsAg, anti-HBs, and anti-HBc antibodies)
	3 injections (at month 0, 1 and 6)
	Anti-HBs should be checked 1-2 mo after the last dose
	Patients with advanced cirrhosis should receive 1 dose of 40 μg/mL (Recombivax HB) administered on a 3-dose schedule or 2 doses of 20 μg/mL (Engerix-B) administered simultaneously on a 4-dose schedule at 0, 1, 2 and 6 mo
Other vaccines, e.g., Td, Tdap, MMR, varicella	Recommendations are as same as general adult population
Prophylactic antibiotics
Secondary prophylaxis for SBP[32,41]	Recommended for all cirrhotic patients who recovered from SBP
	Norfloxacin 400 mg PO daily
	Alternatives: TMP/SMX 1 double-strength tablet or ciprofloxacin 500 mg PO daily
Primary prophylaxis in GI bleeding[32,41]	Recommended for all cirrhotic patients with GI hemorrhage
	Norfloxacin 400 mg PO twice daily or ceftriaxone 1 g IV daily for 7 d
	IV ceftriaxone is preferred, in patients with advanced cirrhosis as defined by the presence of at least two of the following: Ascites, severe malnutrition, encephalopathy or bilirubin > 3 mg/dL
Primary prophylaxis in patients with low ascitic fluid protein[32,41]	Recommended for cirrhotic patients with ascitic fluid protein < 1.5 g/dL and at least one of the following is present: Serum creatinine > 1.2 mg/dL, blood urea nitrogen > 25 mg/dL, serum sodium < 130 mEq/L or Child-Pugh > 9 points with bilirubin > 3 mg/dL
Prophylaxis before undergoing endoscopic and surgical procedures	Prophylactic antiobiotics are recommended for the moderate-high risk invasive endoscopic or surgical procedures (choice of antibiotics should be individualized)
	Prophylactic antibiotics are not routinely recommended for diagnostic endoscopy, elective variceal band ligation or sclerotherapy, and abdominal paracentesis

HBV: Hepatitis B virus; SBP: Spontaneous bacterial peritonitis; Td: Tetanus-Diphtheria; Tdap: Tetanus-Diphtheria-Pertussis; MMR: Measles/Mumps/Rubella; GI: Gastrointestinal; TMP/SMX: Trimethoprim/sulfamethoxazole; PO: Per oral; IV: Intravenous.