Management of bacterial and fungal infections in cirrhosis: The MDRO challenge

Abstract

Bacterial infections are frequent in cirrhotic patients with acute decompensation or acute-on-chronic liver failure and can complicate the clinical course. Delayed diagnosis and inappropriate empirical treatments are associated with poor prognosis and increased mortality. Fungal infections are much less frequent, usually nosocomial and associated with extremely high short-term mortality. Early diagnosis and adequate empirical treatment of infections is therefore key in the management of these patients. In recent decades, antibiotic resistance has become a major worldwide problem in patients with cirrhosis, warranting a more complex approach to antibiotic treatment that includes the use of broad-spectrum antibiotics, new administration strategies, novel drugs and de-escalation policies. Herein, we review epidemiological changes, the main types of multidrug-resistant organisms, mechanisms of resistance, new rapid diagnostic tools and currently available therapeutic options for bacterial and fungal infections in cirrhosis.

Abundance of Lipopolysaccharide Heptosyltransferase I in Human Gut Microbiome and Its Association With Cardiovascular Disease and Liver Cirrhosis

“…Our data suggested that HpeI-encoding Enterobacterales increased in the gut of the patients with LC. Other studies showed that E. coli , Klebsiella pneumoniae , and other Enterobacterales are the most common and are responsible for up to 50% in patients with cirrhosis ( Fernández et al, 2021 ). While both bacteria from Enterobacterales and Burkholderiales increased in the gut of CVD patients.…”

Management of Multidrug-Resistant Infections in Cirrhosis

“…In recent decades, AMR has become a significant global problem in patients with cirrhosis. 4 A large US study found that patients with cirrhosis' risk of dying from sepsis increased by 28% between 2002 and 2010, 5 and it has been proposed that this may be related to the increasing spread of multidrug-resistant organisms (MDROs). 6…”

“…17,18 The prevalence of bacterial infections in patients with cirrhosis is 5-6 times that of the general population. 4…”

“…Bacterial infections (BI) may precipitate variceal hemorrhage, variceal rebleeding, hepatic encephalopathy (HE), hyponatremia, acute kidney injury/hepatorenal syndrome, and acuteon-chronic liver failure (ACLF). 4,19 In a multi-center European study, BI was the most frequent precipitant of acute decompensation (AD) with ACLF (AD-ACLF) (proven BI 44%, suspected BI 5.9%), and was likely the most frequent precipitant of AD without ACLF (AD-No ACLF) (proven BI 22%, suspected BI 6.9%), followed closely by alcoholic hepatitis. 20…”

New concepts and perspectives in decompensated cirrhosis

“…The first of these addresses the challenge of infection with multidrug resistant organisms. 8 The novel concept of disease modifying approaches to the treatment of cirrhosis as an unmet need is discussed in the next chapter. 9 The following chapter deals with the very common scenario where the clinical team is working beyond clinical guidelines to try and save the lives of the patients with decompensated cirrhosis.…”