Early Diagnosis and Prevention of Infections in Cirrhosis

Abstract

Strategies to prevent infection and improve outcomes in patients with cirrhosis. HAV, hepatitis A virus; HBV, hepatitis B virus; COVID-19, novel coronavirus disease 2019; NSBB, nonselective β-blocker; PPI, proton pump inhibitors.

Cirrhosis is a risk factor for infections. Majority of hospital admissions in patients with cirrhosis are due to infections. Sepsis is an immunological response to an infectious process that leads to end-organ dysfunction and death. Preventing infections may avoid the downstream complications, and early diagnosis of infections may improve the outcomes. In this review, we discuss the pathogenesis, diagnosis, and biomarkers of infection; the incremental preventive strategies for infections and sepsi; and the consequent organ failures in cirrhosis. Strategies for primary prevention include reducing gut translocation by selective intestinal decontamination, avoiding unnecessary proton pump inhibitors' use, appropriate use of β-blockers, and vaccinations for viral diseases including novel coronavirus disease 2019. Secondary prevention includes early diagnosis and a timely and judicious use of antibiotics to prevent organ dysfunction. Organ failure support constitutes tertiary intervention in cirrhosis. In conclusion, infections in cirrhosis are potentially preventable with appropriate care strategies to then enable improved outcomes.

Keywords

liver failure - infections - antibiotics - morbidity

Lay Summary

Infections in patients with cirrhosis significantly contribute to morbidity and mortality. Infections in cirrhosis frequently lead to organ failures. Therefore, preventing infections may improve the outcomes of patients with cirrhosis by preventing downstream complications. In this article, we discussed several measures, including antibiotic and nonantibiotic-based interventions, to prevent infections in cirrhosis and improve outcomes.

Abbreviations

ACLF, acute-on-chronic liver failure; AKI, acute kidney injury; ARG, antibiotic resistance gene; BI, bacterial infection; BT, bacterial translocation; CLIF-SOFA, chronic liver failure-sequential organ failure assessment; CLP, cecal ligation and puncture; COVID-19, novel coronavirus disease 2019; CRP, C-reactive protein; FA, fatty acid; FMT, fecal microbiota transplantation; G-CSF, granulocyte-colony stimulating factor; GNB, gram-negative bacilli; GPC, gram-positive cocci; HAS, human albumin solution; HO-1, heme oxygenase-1; ICU, intensive care unit; IFN, interferon; iNOS, endotoxin-induced nitric oxide synthase; LPS, lipopolysaccharide; LTB4, leukotriene B4; MDRO, multi-drug resistant organism; MR-proADM, mid-regional pro-adrenomedullin; NAFLD, nonalcoholic fatty liver disease; NASH, nonalcoholic steatohepatitis; NLR, neutrophil-to-lymphocyte ratio; NSBB, Nonselective β-blocker; PCT, procalcitonin; PG, prostaglandin; PGE₂, prostaglandin E_2; PPI, proton pump inhibitor; qSOFA, quick sequential organ failure assessment; recAP, recombinant alkaline phosphatase; SBP, spontaneous bacterial peritonitis; SID, selective intestinal decontamination; SIRS, systemic inflammatory response syndrome; SOFA, sequential organ failure assessment; SSTI, skin and soft tissue infection; UTI, urinary tract infection; TLR, toll-like receptor; TNF, tumor necrosis factor; TREM-1, triggering receptor expressed on myeloid cells-1; WCC, white cell count.

Authors' Contributions

K.R.R. and N.R.P. developed the study concept; A.V.K., K.K., and M.P. wrote the initial draft; A.V.K. and M.P. prepared the figures; J.P.A., M.S., and K.K. prepared the tables; J.P.A., D.N.R., N.R.P., and K.R.R. critically assessed the draft. K.R.R. and A.V.K. are the guarantors of the article. All members approved the final manuscript.

Publication History

Accepted Manuscript online:
07 June 2022

Article published online:
10 August 2022

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