Management of bacterial and fungal infections in end stage liver disease and liver transplantation: Current options and future directions

Abstract

Patients with liver cirrhosis are susceptible to infections due to various mechanisms, including abnormalities of humoral and cell-mediated immunity and occurrence of bacterial translocation from the intestine. Bacterial infections are common and represent a reason for progression to liver failure and increased mortality. Fungal infections, mainly caused by Candida spp., are often associated to delayed diagnosis and high mortality rates. High level of suspicion along with prompt diagnosis and treatment of infections are warranted. Bacterial and fungal infections negatively affect the outcomes of liver transplant candidates and recipients, causing disease progression among patients on the waiting list and increasing mortality, especially in the early post-transplant period. Abdominal, biliary tract, and bloodstream infections caused by Gram-negative bacteria [e.g., Enterobacteriaceae and Pseudomonas aeruginosa (P. aeruginosa)] and Staphylococcus spp. are commonly encountered in liver transplant recipients. Due to frequent exposure to broad-spectrum antibiotics, invasive procedures, and prolonged hospitalizations, these patients are especially at risk of developing infections caused by multidrug resistant bacteria. The increase in antimicrobial resistance hampers the choice of an adequate empiric therapy and warrants the knowledge of the local microbial epidemiology and the implementation of infection control measures. The main characteristics and the management of bacterial and fungal infections in patients with liver cirrhosis and liver transplant recipients are presented.

Keywords: Liver cirrhosis, Liver transplant recipients, Bacterial infections, Fungal infections, Multidrug resistant organisms, Management

Core tip: Infections are frequent in patients with liver cirrhosis, liver transplant candidates, and liver transplant recipients and are associated with increased morbidity and mortality. Knowledge of the risk factors, etiology, and type of infections is paramount for the management of severe bacterial and fungal infections in these patient populations. Increasing rates of infections due to multidrug-resistant pathogens have been reported worldwide and particularly affect liver transplant recipients. The type of bacterial and fungal infections along with their risk factors, management, and future research in patients with liver cirrhosis and liver transplant recipients are presented in the review.