Infectious Complications in Critically Ill Liver Failure Patients

Abstract

Infections remain a leading cause of morbidity and mortality among patients with liver failure. A number of factors, including relative immune dysfunction and systemic inflammation, bacterial translocation, gut dysbiosis, small intestine bacterial overgrowth, altered bile acid pools, and changes in pH due to acid suppression, contribute to the high rates of infection in this population. Though a range of infections can complicate the course of cirrhotic patients, spontaneous bacterial peritonitis (SBP), cholangitis, and cholecystitis in addition to other infections (i.e. pneumonia, urinary tract infection, bacteremia, and Clostridioides difficile colitis) are more common in this population and will be reviewed in this article. Preventative strategies are directed at minimizing the risk of SBP through the use of targeted antimicrobial prophylaxis. Lastly, the critically ill cirrhotic patient may present with an acute need for liver transplantation. Thus, careful assessment for ongoing infection should be performed and treated to optimize outcomes of transplant, if needed.

Controlling infections in hospitalized pretransplant candidates

“…Increased risk of infection in patients with advanced liver disease is felt to be due, in part, to hypocomplementemia and ascites with inability to opsonize the organisms that translocate from the gastrointestinal tract into the peritoneum and bloodstream. Additionally, there is mounting evidence for cirrhosis-associated immune dysregulation with deleterious effects on innate and adaptive immunologic responses [36]. Fungal peritonitis with organisms such as Candida spp., Cryptococcus and Aspergillus are associated with poor outcomes.…”

Diagnosis, Treatment, and Prevention of Acute-on-Chronic Liver Failure with Bacterial Infections

“…Until bacterial culture results are available, empirical antibiotics should be selected according to the type and site of infection, local epidemiology and bacterial resistance. [23,32,33]. In patients with ACLF, common bacteria are Gram-negative, such as Escherichia coli and Klebsiella pneumoniae, and Gram-positive, such as Staphylococcus aureus and Enterococcus, are also seen [23,34].…”

Prophylactic Anti-Cytomegalovirus Hyperimmunoglobulin in Critically Ill Liver Transplant Patients: Impact on Early Immunology and Survival

“…In order to avoid futility in patients being "too sick" for transplant, a profound interdisciplinary risk assessment using reliable prognostic factors is mandatory [7]. Nonetheless, owing to an enhanced susceptibility to severe immunological and septic complications, the postoperative course in this specific LT-subset remains highly demanding [3][4][5], thus requiring the implementation of effective immunoprotective concepts beyond adjustment of immunosuppressive treatment [8,9].…”