Review
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Feb 28, 2016; 8(6): 307-321
Published online Feb 28, 2016. doi: 10.4254/wjh.v8.i6.307
Bacterial infections in cirrhosis: A critical review and practical guidance
Chalermrat Bunchorntavakul, Naichaya Chamroonkul, Disaya Chavalitdhamrong
Chalermrat Bunchorntavakul, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Bangkok 10400, Thailand
Naichaya Chamroonkul, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
Disaya Chavalitdhamrong, Division of Gastroenterology, Department of Internal Medicine, Harbor-UCLA Medical, Torrance, CA 90509, United States
Author contributions: Bunchorntavakul C conceptualized, searched and reviewed literature, created the figures and tables, drafted and reviewed the paper; Chamroonkul N searched and reviewed literature, drafted and reviewed the paper; Chavalitdhamrong D conceptualized and reviewed the paper.
Conflict-of-interest statement: The authors have nothing to disclose.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Chalermrat Bunchorntavakul, MD, Assistant Professor of Medicine, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Rajavithi Road, Ratchathewi, Bangkok 10400, Thailand. dr.chalermrat@gmail.com
Telephone: +66-2-3548081 Fax: +66-2-3548179
Received: August 18, 2015
Peer-review started: August 21, 2015
First decision: October 13, 2015
Revised: January 11, 2016
Accepted: January 27, 2016
Article in press: January 29, 2016
Published online: February 28, 2016
Abstract

Bacterial infection is common and accounts for major morbidity and mortality in cirrhosis. Patients with cirrhosis are immunocompromised and increased susceptibility to develop spontaneous bacterial infections, hospital-acquired infections, and a variety of infections from uncommon pathogens. Once infection develops, the excessive response of pro-inflammatory cytokines on a pre-existing hemodynamic dysfunction in cirrhosis further predispose the development of serious complications such as shock, acute-on-chronic liver failure, renal failure, and death. Spontaneous bacterial peritonitis and bacteremia are common in patients with advanced cirrhosis, and are important prognostic landmarks in the natural history of cirrhosis. Notably, the incidence of infections from resistant bacteria has increased significantly in healthcare-associated settings. Serum biomarkers such as procalcitonin may help to improve the diagnosis of bacterial infection. Preventive measures (e.g., avoidance, antibiotic prophylaxis, and vaccination), early recognition, and proper management are required in order to minimize morbidity and mortality of infections in cirrhosis.

Keywords: Bacteria, Infection, Sepsis, Bacteremia, Liver cirrhosis, Vaccination, Spontaneous peritonitis, Immune dysfunction

Core tip: Bacterial infection is common and accounts for major morbidity and mortality in cirrhosis. Patients with cirrhosis are immunocompromised and increased susceptibility to develop spontaneous bacterial infections, hospital-acquired infections, and a variety of infections from uncommon pathogens. Once infection develops, the excessive response of pro-inflammatory cytokines on a pre-existing hemodynamic derangement in cirrhosis further predispose the development of serious complications such as shock, acute-on-chronic liver failure, renal failure, and death. The incidence of resistant bacteria has continually increased, especially in healthcare-associated settings. Preventive measures, early recognition and proper management are necessary to minimize morbidity and mortality of infections in cirrhosis.