Cirrhosis and bacterial infections

Half of cirrhosis patients die within two years after diagnosis, in most cases from cirrhosis related causes; most frequently variceal bleeding closely followed by infections. There seems to exist associations between infection and other complications such as malnutrition, hepatic encephalopathy and variceal bleeding. Cirrhosis patients have an acquired immune deficiency because of dyshomeostasis and malnutrition. All host defence systems are compromised, e.g. the acute phase response, and macrophage, neutrocyte, and lymphocyte functions. Simultaneously, there is increased microbiotic invasion, due to increased nosocomial exposure, intestinal translocation, aspiration, skin lesions, and trauma. Compared to the background population, the mortality of infections is more than 20 times increased in cirrhosis. The incidence of peritonitis, bacteremia, urinary tract infection, pneumonia, meningitis, tuberculosis, liver abscess is increased more than tenfold, and the mortality of each episode 3-10 times higher. The systemic response and accompanying classical symptoms are usually weakened. When positive isolates can be obtained the flora tends to be of an opportunistic nature. Infection should be suspected in any cirrhotic patient with an unexpected deterioration of clinical course. Treatment should be started on suspicion and with large dose broad-spectrum antibiotics (avoiding aminoglycosides). Antibiotic prophylaxis is efficacious at variceal bleeding, recurrent peritonitis, and at very low protein ascites, but otherwise is associated with risk of infection with multi-resistant strains.