Righi E. Management of bacterial and fungal infections in end stage liver disease and liver transplantation: Current options and future directions. World J Gastroenterol 2018; 24(38): 4311-4329 [PMID: 30344417 DOI: 10.3748/wjg.v24.i38.4311]
Corresponding Author of This Article
Elda Righi, MD, PhD, Doctor, Department of Infectious Diseases, Santa Maria della Misericordia University Hospital, 50, Colugna Street, Udine 33100, Italy. elda.righi@libero.it
Research Domain of This Article
Infectious Diseases
Article-Type of This Article
Review
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Delayed diagnosis and therapy. Lack of clinical signs and suspicion. Frequent concomitant SBP. High mortality.
Suspect if peritonitis is not improved after 48 h of empirical antibiotic treatment. Perform fungal cultures (ascites and blood).
[44,45,52,53]
Antifungal prophylaxis
Factors influencing mortality less known. Mortality higher than SBP due to delayed diagnosis.
Indicated for SBP (high risk, previous episode, GI bleeding). No clear indication for fungal infections. Consider in: ICU patients without improvement > 48 h, high prevalence (> 5%) regions, risk factors (corticosteroids, prolonged microbial use, CVC, TPN, high APACHE score, dialysis).
[48,54]
Antifungal treatment
Recommendations for fungal infections in LC.
Prompt initiation. Echinocandins as first-line treatment (e.g., fungemia, nosocomial SFP or critically ill with CA-SFP). Fluconazole indicated if less severe infections. De-escalation if patient is stable and sensitivity tests available.
[52-54]
Table 3 Management of infections in liver transplant recipients
Peri-transplant antibiotic prophylaxis (< 48 h). Prompt diagnostic workup (uncommon presentations, opportunisms). Source control when needed.
[76,83,160]
Liver transplant candidates and recipients/MDRO
Colonization (MRSA, VRE, CRE) linked to increased risk of infections. Risk of transmission between patients and across wards.
Surveillance cultures (CRE, VRE, MRSA) and decolonization (MRSA). Infection control (hand hygiene, isolation, contact precautions).
[102,112,164]
Table 4 Treatment options for multidrug resistant organisms in liver transplant recipients
Pathogens
Recommendation
Antimicrobial regimens
Ref.
MDR Gram-positives
MRSA
Nasal decolonization with mupirocin. Daptomycin highly bactericidal in BSI; non effective in pulmonary infections. Linezolid and tigecycline bacteriostatic.
Vancomycin1/linezolid OR Daptomycin OR Tigecycline OR Novel anti-MRSA cephalosporins (ceftaroline, ceftobiprole)2.
[107-111]
VRE
Daptomycin highly bactericidal in BSI; non effective in pulmonary infections. Linezolid and tigecycline bacteriostatic.
Linezolid OR Daptomycin OR Tigecycline.
[113,121,122]
MDR Gram-negatives
ESBL-producing Enterobacteriaceae
Conflicting data on carbapenem superiority vs BLBLI. Meropenem recommended for high inoculum infections and unstable patients.
Carbapenems OR Piperacillin/tazobactam.
[175-177]
Carbapenem-resistant Enterobacteriaceae
Test antimicrobial susceptibility (also on colonizing strains). Some evidence of better outcomes with combination therapy vs monotherapy. New molecules promising but scarce data in LT.
Ceftazidime/avibactam, OR Combination regimen (at least two active drugs) including colistin/polymixin B, tigecycline, aminoglycosides1 (gentamycin, amikacin), IV fosfomycin, high-dose prolonged infusion carbapenems. For uncomplicated UTI, consider monotherapy (aminoglycosides, fosfomycin).
[127,137,138,175,178]
MDR P. aeruginosa
Test antimicrobial susceptibility. New molecules promising but scarce data in LT.
Combination regimen (at least two active drugs) including colistin, an anti-pseudomonal beta-lactam (if susceptible), aminoglycosides1, fosfomycin OR Ceftolozane/tazobactam, ceftazidime/avibactam
[175,179,180]
Citation: Righi E. Management of bacterial and fungal infections in end stage liver disease and liver transplantation: Current options and future directions. World J Gastroenterol 2018; 24(38): 4311-4329