The effect of ciprofloxacin in the prevention of bacterial infection in patients with cirrhosis after upper gastrointestinal bleeding

Objectives: Cirrhotic patients with upper gastrointestinal bleeding are prone to bacterial infection. The aim of this study was to investigate the efficacy of prophylactic intestinal decontamination with oral ciprofloxacin for the prevention of bacterial infections in cirrhotic patients with upper gastrointestinal bleeding.
Methods: A total of 120 cirrhotic patients with acute upper gastrointestinal bleeding were enrolled. Sixty patients received ciprofloxacin 500 mg twice daily given orally or through nasogastric tube immediately after upper gastrointestinal endoscopic examination; drug administration continued for 7 days. The remaining 60 patients, who received placebo, served as controls.
Results: The incidence of proven bacterial infection in the ciprofloxacin-treated group was significantly lower than that of placebo group (10% vs 45%,   p < 0.001  ). The incidences of bacteremia, spontaneous bacterial peritonitis, and urinary tract infection in the ciprofloxacin-treated group were significantly lower than those in the placebo group (  0% vs 23%, 3.3% vs 13%, and 5% vs 18%, respectively  ;   p < 0.05  , respectively). Multivariate logistic regression analysis showed that a lack of prophylactic treatment with ciprofloxacin and severity of cirrhosis were the independent significant predictors for cirrhotic patients with acute gastrointestinal bleeding with infection.
Conclusions: Prophylactic intestinal decontamination with oral ciprofloxacin is effective in the prevention of bacterial infections in patients with cirrhosis who were suffering from acute upper gastrointestinal hemorrhage.     

Risk factors and survival of early bleeding after esophageal variceal ligation

BACKGROUND/AIMS: In cirrhotic patients, esophageal variceal bleeding (EVB) is still unpredictable and continues despite initial adequate treatment that is associated with great mortality. Bacterial infections are frequently diagnosed in cirrhotic patients with gastrointestinal bleeding (GIB). The aims of this study were to analyze the clinical risk factors and survival of early bleeding after endoscopic variceal ligation (EVL). METHODOLOGY: A total of 96 cirrhotic patients with esophageal varices who received elective or emergent EVL procedure were analyzed. The variables for risk factors analysis included bacterial infection, hepatocellular carcinoma (HCC) with or without portal vein thrombosis, etiology of cirrhosis, Child-Pugh status, and basic laboratory data. There were 19 patients with bleeding episode or rebleeding within 14 days after EVL. The remaining 77 patients were without bleeding event after EVL. RESULTS: Patients with Child C cirrhosis (odds ratio, 7.27; 95% CI, 2.20-24.07, P = 0.001) and bacterial infection (odds ratio, 130.29; 95% CI, 14.70-1154, P < 0.001) were independently associated with the early bleeding after EVL. However, there was no significant difference in long-term survival between patients with and without early bleeding after EVL. CONCLUSIONS: Bacterial infection and end-stage liver cirrhosis (Child C) are the independent risk factors for early bleeding after EVL. We should closely monitor the symptoms/signs of infection and empirical antibiotics should be administered once infection is suspected or documented, especially in cirrhotic patients with poor liver reserve.     

Infectious complications of cirrhosis

Infectious complications in cirrhotic patients can cause severe morbidity and mortality. Bacterial infections are estimated to cause up to 25% of deaths in cirrhotic patients. The most frequent are urinary tract infection, spontaneous bacterial peritonitis, respiratory tract infection, and bacteremia. It has been said that cirrhosis is the most common form of acquired immunodeficiency, exceeding even AIDS. The specific risk factors for infection in cirrhotic patients are low serum albumin, gastrointestinal bleeding, intensive care unit admission for any cause, and therapeutic endoscopy. Certain infectious agents are more virulent and more common in patients with liver disease. These include Vibrio, Campylobacter, Yersinia, Plesiomonas, Enterococcus, Aeromonas, Capnocytophaga, and Listeria species, as well as organisms from other species. Spontaneous bacterial peritonitis is a frequent, severe, life-threatening complication of patients with ascites. Current observations and recommendations regarding treatment and prophylaxis are reviewed. A brief synopsis of miscellaneous infections encountered in cirrhotic patients is also included.     

Risk factors for the development of bacterial infections in hospitalized patients with cirrhosis

OBJECTIVE: Bacterial infection is a frequent and severe complication of cirrhosis. Cirrhotic patients admitted for gastrointestinal bleeding are at high risk of such a complication and have been targeted in trials of antibiotic prophylaxis. However, it has not been shown that these patients are at a higher risk than cirrhotic patients hospitalized for other reasons. This prospective study was performed to assess the risk of bacterial infection in unselected hospitalized cirrhotic patients and to evaluate possible risk factors for this complication. METHODS: One hundred-forty hospitalized cirrhotic patients without clinical evidence of infection at the time of initial presentation were followed-up prospectively for manifestations of infection. RESULTS: Twenty-eight (20%) patients developed an infection during their hospitalization. Infections without a specific site (39%) and spontaneous bacterial peritonitis (32%) were the most common diagnoses. Univariate analysis showed that patients who developed an infection were more likely to have a low serum albumin level, to be admitted for gastrointestinal bleeding, to stay in the intensive care unit, and to undergo therapeutic endoscopy. Logistic regression identified admission for gastrointestinal bleeding (odds ratio (OR) = 4.3, 95% confidence interval (CI) = 1.7-10.9) and a low serum albumin (OR = 1.3, 95% CI = 1.03-1.22) as the only two variables independently associated with the development of an infection. CONCLUSION: The present study indicates that patients with severe cirrhosis who are admitted for gastrointestinal bleeding have a higher risk of developing a bacterial infection during their hospitalization than other cirrhotic patients.     

Bacterial infections complicating liver disease

Bacterial infection is a serious and often fatal complication of patients with liver disease and can prove fatal either directly or by precipitation of gastrointestinal bleeding, renal failure, or hepatic encephalopathy. At greatest risk are patients with alcoholic cirrhosis or decompensated chronic liver disease, or cases of acute liver disease who progress to fulminant hepatic failure or subacute hepatic necrosis. Infection appears to be unusual in patients with primary biliary cirrhosis. The site and type of infection is unrelated to the aetiology of the liver disease. Bacteraemia, pneumonia, urinary tract infection and spontaneous bacterial peritonitis are most common but infective endocarditis and meningitis, especially with pneumococci, are easily overlooked. Clinical suspicion of infection must be high as the only indication may be a general deterioration in the patients' clinical state, increasing encephalopathy or renal impairment. In the case of patients with fulminant hepatic failure, infection may precipitate the initial or recurrent encephalopathy and contributes to death in 10% of fatal cases. Spontaneous bacterial peritonitis is now recognized to occur in the absence of clinical features of peritonitis. The PMN content of the ascitic fluid may provide the only indication of infection and is the most readily available screening test. The most common types of organism responsible for all types of infection are Gram-negative enteric and streptococci, especially pneumococci, while infection with anaerobes is rare. Risk factors for infection include decompensated alcoholic liver disease, fulminant hepatic failure, gastrointestinal bleeding, invasive practical procedures and impaired host defence mechanisms against infection. Of the host defence mechanisms, impaired function of the reticuloendothelial system, complement, and PMNs represent the most common and serious defects. Defects of humoral immunity are present in ascitic fluid from patients with cirrhosis and are probably a major reason for development of spontaneous bacterial peritonitis. Diuresis improves these functions and reduces the risk of peritonitis. Treatment of infections even with the appropriate antibiotic is still associated with a high mortality but the use of adjuvant gut sterilization is promising, particularly in cases infected with Gram-negative enteric organisms. Infusions of fresh frozen plasma, blood and cryoprecipitate improve some systemic host defences and may be beneficial in the treatment and reduction of risk of infection.     

Combined Upper and Lower Gastrointestinal Endoscopy: A Prospective Study in Alcoholic and Nonalcoholic Cirrhosis

Upper gastrointestinal hemorrhage is one of the more important complications of cirrhosis. Most of the available data regarding the prevalence of upper and lower gastrointestinal sites of bleeding in cirrhotic patients have been obtained in individuals with alcoholic cirrhosis evaluated in the course of an acute gastrointestinal bleeding episode. Few data exist, however, as to the prevalence of either potential bleeding sites or of normal endoscopic findings in hemodynamically stable individuals with cirrhosis of any etiology. Five hundred ten cirrhotic subjects, who were evaluated for possible liver transplantation (OLTx) between January 1985 and June 1987, were included in this study. Seventy-five had alcoholic cirrhosis and 435 had nonalcoholic cirrhosis of various etiologies. Of these 510 patients, 412 underwent combined upper and lower gastrointestinal endoscopy and 98 underwent upper gastrointestinal endoscopy alone. Gastritis, gastric and duodenal ulcer disease were found significantly (each at least p less than 0.025) more often in patients with alcoholic liver disease than in those with nonalcoholic liver disease. The prevalence of the various lower gastrointestinal lesions in both groups was similar. Of particular interest is the fact that in alcoholic cirrhotics, the prevalence of gastritis, gastric ulcer and duodenal ulcer disease was unrelated to the degree of portal hypertension, whereas in the nonalcoholic cirrhotics the prevalence of gastritis and duodenal ulcer disease but not gastric ulcer disease was associated significantly with the degree of portal hypertension as assessed by the presence or absence of large esophageal varices, ascites, and hepatic encephalopathy.     

The impact of bacterial infections on survival of patients with decompensated cirrhosis

Introduction. Bacterial infection in cirrhotic patients is a severe complication that requires early recognition and specific therapeutic care.Material and methods. In this review the various aspects of diagnosis and management of infections that may impact survival in cirrhosis are analyzed.Results. Active search for infections allows early detection and its treatment with suitable antibiotics has reduced mortality rates in spontaneous bacterial peritonitis, the main infection in patients with decompensated cirrhosis. Other common infections, such as bacteremia and septicemia or urinary tract, lung, skin and soft tissue infections must be thoroughly investigated so that antibiotic treatment can be started early. As intestinal bacterial translocation is one of the most important mechanisms for development of bacterial infections, selective intestinal decontamination is able to prevent these infections in populations at risk. After the first episode of spontaneous bacterial peritonitis, poorly absorbed oral antibiotics, such as quinolones, must be started and continued. Moreover, when there is upper gastrointestinal bleeding, infection prevention should be based on oral administration of quinolones or intravenous administration of cephalosporins, both for seven days, to avoid morbidity and early lethality. With the advent of resistance to commonly used antibiotics and recent reports of multiresistant bacteria, there is a need for stricter control when administering antibiotics to cirrhotic patients.Conclusion. Existing knowledge of therapy and prophylaxis for bacterial infections in cirrhotic patients, which undoubtedly improve survival, should be disseminated and applied in clinical practice for the benefit of the population at large.     

Bacterial infection in cirrhotic patients and its relationship with alcohol

OBJECTIVE: Infections are regarded as a major complication and an important cause of death in cirrhotics. Alcohol is a predisposing factor to infections in such patients. This study was undertaken to compare the frequency and evolution of bacterial infection among alcoholic and nonalcoholic cirrhotics. METHODS: To observe this relationship, we retrospectively studied a cohort of 382 cirrhotic inpatients, 201 of whom were alcoholic (alcohol intake > or =80 g/day for > or =10 yr) and 181 of whom were nonalcoholic. RESULTS: A total of 128 (33.5%) patients presented with infection upon hospitalization, 78 of whom were alcoholic and 50 of whom were nonalcoholic (p = 0.02). A total of 157 cases of infection were diagnosed, with spontaneous bacterial peritonitis as the most prevalent one (54.1%), followed by pneumonia (18.5%), infection of the soft parts (10.8%), and urinary tract infection (7.0%). Infection and deaths were more frequent in patients with Child-Pugh C than in those with Child-Pugh A/B (p = 0.003, p = 0.0002 respectively). Alcoholic patients with Child-Pugh A/B were more susceptible to infection compared to nonalcoholic patients (p = 0.02), although no difference was noted as to the number of deaths (p = 0.1). With regard to patients with Child-Pugh C, no statistical difference was found in the infections or deaths among alcoholics and nonalcoholics (p = 0.8, p = 0.8). CONCLUSIONS: Our findings suggest that, despite the fact that bacterial infections are more common in cirrhotic alcoholics, its seems that the mortality rate is associated more with the severity than with the etiology of the hepatic disease.     

Parenteral antibiotic prophylaxis of bacterial infections does not improve cost-efficacy of oral norfloxacin in cirrhotic patients with gastrointestinal bleeding

Objective: Selective intestinal decontamination with norfloxacin is useful in the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding. However, bleeding cirrhotic patients with ascites, encephalopathy, or shock are at high risk to develop bacterial infections in spite of prophylactic norfloxacin. The aim of this study was to assess whether the addition of intravenous ceftriaxone could improve the efficacy of prophylaxis with norfloxacin in these patients.
Methods: Fifty-six cirrhotic patients with gastrointestinal hemorrhage and ascites, encephalopathy, or shock were randomized into two groups: Group 1 (  n = 28  ) received oral norfloxacin 400 mg/12 h for 7 days, and group 2 (  n = 28  ) received norfloxacin plus intravenous ceftriaxone 2 g daily during the first 3 days of admission.
Results: Ten patients were excluded because of community-acquired infection, surgery, or death within the first 24 h. The incidence of bacterial infections during hospitalization was 18.1% in group 1 and 12.5% in group 2 (   p = NS  ). The incidence of severe infections (spontaneous bacterial peritonitis, bacteremia, or pneumonia) was also similar in both groups: 9% in group 1 versus 8.3% in group 2 (   p = NS  ). There were no statistical differences between the two groups with respect to duration of hospitalization or mortality. The cost of antibiotic therapy (including prophylaxis and treatment of infections) was significantly higher in group 2.
Conclusions: These results suggest that the addition of intravenous ceftriaxone during the first 3 days of hospitalization does not improve the cost-efficacy of oral norfloxacin in the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding and high risk of infection.     

Clinical significance of serum procalcitonin levels in patients with acute or chronic liver disease

OBJECTIVE: To evaluate the diagnostic value of serum procalcitonin levels in patients with acute or chronic liver disease, with or without bacterial infections and to correlate the results with the clinical outcome and the laboratory findings for these patients. METHODS: One hundred and six consecutive hospitalized patients with liver disease were evaluated for procalcitonin levels on admission. Fifteen of them (14.2%) had acute alcoholic hepatitis on cirrhotic background (group A), 20 (18.9%) had alcoholic cirrhosis without hepatitis and/or bacterial infection (group B), 16 (15.1%) had decompensated cirrhosis with proved bacterial infection (group C), 42 (39.6%) had uncomplicated viral hepatitis-related cirrhosis (group D) and 13 (12.3%) had acute icteric viral hepatitis (group E). Serum procalcitonin levels were measured using an immunoluminometric assay. Statistical analysis was based on Student's t-test and the non-parametric Kruskall-Wallis test (P<0.05). RESULTS: Serum procalcitonin levels were significantly higher in cirrhotic patients with bacterial infection (9.80+/-16.80 ng/ml) than in those without bacterial infection (0.21+/-0.13 ng/ml, P=0.001), whereas they were within normal range (<0.5 ng/ml) in all patients with uncomplicated cirrhosis, irrespective of the cause of cirrhosis. Seven of 15 group A patients (46.2%) and 4/13 group E patients (30.8%), all of them cirrhotics, had procalcitonin levels higher than 0.5 ng/ml on admission, without established bacterial infection. CONCLUSION: Serum procalcitonin levels remain below the threshold of 0.5 ng/ml in all patients with uncomplicated cirrhosis, irrespective of the cause of the disease, while they are significantly elevated when bacterial infection complicates the course of the disease. A significant proportion of patients with acute alcoholic hepatitis on a cirrhotic background as well as of patients with acute on chronic viral hepatitis, without bacterial infection, exhibit serum procalcitonin levels above 0.5 ng/ml, suggesting that this cut-off value is probably not enough to discriminate between patients with or without bacterial infection within these subgroups of patients with liver disease.     

Infection and hemostasis in decompensated cirrhosis: a prospective study using thrombelastography

Bacterial infections are common complications in decompensated cirrhosis, but their relationship with hemostasis has not been studied. We prospectively assessed whether infection affects hemostasis in cirrhosis using routine hemostasis tests and thrombelastography (TEG), a global test of hemostatic function. Eighty-four cirrhotic patients (Child-Pugh B: 26; C: 58) without overt bleeding or blood-product transfusion were prospectively evaluated with routine hemostasis tests and TEG on admission and/or the first day with signs of infection and 5 days later. There were 30 patients with infection; 15 had infection on admission, and 15 developed infection in hospital. In the patients who developed infection in hospital, there was a significant deterioration in all routine hemostasis tests except platelet count (PLT) and in all TEG parameters, on the first day of infection compared with 7 +/- 3 days previously. The same parameters significantly improved from the first day of infection to day 5 and after (P <.02) only in the 22 patients whose infection resolved, while the r, k, and alpha TEG parameters significantly worsened in the 8 patients with persistent infection. In those who developed infection in hospital and were cured (n = 11), the 5-day parameters did not differ from their preinfection values. In conclusion, bacterial infections frequently impair hemostasis in decompensated cirrhotic patients. Successful treatment of infection usually restores hemostasis parameters to preinfection levels in 5 days. Thus, infection may have a role in the bleeding diathesis of cirrhosis.     

Long-term prognosis of cirrhotics with an upper gastrointestinal bleeding episode: Does infection play a role?

Background and Aim:  We evaluated the effect of infection on the short- and long-term outcome of cirrhotic patients with upper gastrointestinal bleeding (UGIB), in a series of patients not submitted to antibiotic prophylaxis.
Methods:  The cirrhotic patients hospitalized for UGIB were prospectively followed up until the last visit, death, or transplantation. A standard screening protocol was used for bacterial infection at admission.
Results:  In total, 205 patients were included in the study. Antibiotics were administered in 79 (38.5%) patients and an infection was documented in 64 (31.4%) patients. In total, 130 (63.4%) patients died after a mean (SD) follow up of 23.8 (30.9) months. Six-week mortality was higher in the infected patients ( P  < 0.0001). The mortality of patients who were alive 6 weeks after admission was not different between the infected and non-infected patients. Antibiotic use or bacterial infection, the Child–Pugh score, hepatocellular carcinoma, and creatinine were the independent predictors of 6-week mortality. Age and the Child–Pugh score were the only predictors of mortality of the patients who had survived for more than 6 weeks after acute bleeding. In total, 51 (24.9%) patients rebled, 37 (18.1%) within 5 days of admission. Rebleeding was more frequent (41.8% vs 14.3%, P  < 0.0001) in infected patients, mostly due to differences in early rebleeding (31.6% vs 9.5%, P  = 0.0001).
Conclusion:  Bacterial infection is associated with failure to control UGIB and early mortality in cirrhotic patients, but does not seem to affect the outcome of patients who overcome the bleeding episode.     

Bacterial Endocarditis in Patients with Chronic Liver Disease

Objective: Although patients with cirrhosis have an increased susceptibility for bacterial infections, endocarditis complicating cirrhosis has been reported only infrequently. In this study, our objective was to determine whether, bacterial endocarditis is, in fact, a complicating factor in cirrhosis. Methods: We retrospectively studied all cases of bacterial endocarditis that occurred over the last 15 yr in patients with known cirrhosis. Results: Ten patients (three males, seven females) were identified, whose mean age was 55 yr (range 29–65 yr). Bacterial organisms included Staphylococcus aureus , coagulase-positive (eight patients), Peptostreptococcus (one patient), and Enterococcus (one patient). Underlying liver disease consisted of alcobolism (five patients), autoimmune chronic active hepatitis (two), cryptogenic cirrhosis (two), and primary biliary cirrhosis (one). Distribution of heart valves affected were mitral valve (six), aorta (two), and there were two involving both mitral and aortic valves. Echocardiograms revealed vegetation in 50% of the patients. Laboratory studies were markedly abnormal, with mean values of albumin 2.4 mg/dl, creatinine 2.5 mg/dl, BUN 76.5 mg/dl, and total bilirubin 8.2 mg/dl. Potential associated sources of infection were upper gastrointestinal bleeding (four), pneumonia (two), and one each of spontaneous bacterial peritonitis, hip replacement, heart catheterization, and abdominal abscess. the outcome was poor, with death in eight of 10 patients. Conclusions: Bacterial endocarditis may complicate cirrhosis, may be more frequent in females, typically involves the mitral valve, and probably is due to Staphy-lococcus aureus .     

Bacterial infection in patients with advanced cirrhosis: a multicentre prospective study

AIMS: To evaluate the prevalence, incidence and clinical relevance of bacterial infection in predominantly non-alcoholic cirrhotic patients hospitalised for decompensation. PATIENTS/METHODS: A total of 405 consecutive admissions in 361 patients (249 males and 112 females; 66 Child-Pugh class B and 295 class C) were analysed. Blood, urine, ascitic and pleural fluid cultures were performed within the first 24 hours, during hospitalisation whenever infection was suspected, and again before discharge. RESULTS: Over a one year period, 150 (34%) bacterial infections (89 community- and 61 hospital-acquired) involving urinary tract (41%), ascites (23%), blood (21%) and respiratory tract (17%) were diagnosed. The prevalence of bacterial peritonitis was 12%. Infections were asymptomatic in 69 cases (46%) and 130 (87%) involved a single site. Enteric flora accounted for 62% of infections, Escherichia Coli being the most frequent pathogen (25%). Community-acquired infections were associated with more advanced liver disease (Child-Pugh mean score 10.2+/-2.1 versus 9.5+/-1.9, p<0.05), renal failure (p<0.05), and high white blood cell count (p<0.01). Hospital-acquired infections occurred more frequently in patients admitted for gastrointestinal bleeding (p<0.05). The in-hospital mortality was significantly higher in infected than in non-infected patients (15% versus 7%, p<0.05), and infection emerged as an independent variable affecting survival. Moreover bacterial infection accounted for a significantly prolonged hospital stay. CONCLUSIONS: Bacterial infection, regardless of the aetiology, is a severe complication of decompensated cirrhosis, and, although frequently asymptomatic, accounts for both longer hospital stay and increased mortality.     

Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage

BACKGROUND & AIMS: Oral norfloxacin is the standard of therapy in the prophylaxis of bacterial infections in cirrhotic patients with gastrointestinal hemorrhage. However, during the last years, the epidemiology of bacterial infections in cirrhosis has changed, with a higher incidence of infections caused by quinolone-resistant bacteria. This randomized controlled trial was aimed to compare oral norfloxacin vs intravenous ceftriaxone in the prophylaxis of bacterial infection in cirrhotic patients with gastrointestinal bleeding. METHODS: One hundred eleven patients with advanced cirrhosis (at least 2 of the following: ascites, severe malnutrition, encephalopathy, or bilirubin >3 mg/dL) and gastrointestinal hemorrhage were randomly treated with oral norfloxacin (400 mg twice daily; n = 57) or intravenous ceftriaxone (1 g/day; n = 54) for 7 days. The end point of the trial was the prevention of bacterial infections within 10 days after inclusion. RESULTS: Clinical data were comparable between groups. The probability of developing proved or possible infections, proved infections, and spontaneous bacteremia or spontaneous bacterial peritonitis was significantly higher in patients receiving norfloxacin (33% vs 11%, P = .003; 26% vs 11%, P = .03; and 12% vs 2%, P = .03, respectively). The type of antibiotic used (norfloxacin), transfusion requirements at inclusion, and failure to control bleeding were independent predictors of infection. Seven gram-negative bacilli were isolated in the norfloxacin group, and 6 were quinolone resistant. Non-enterococcal streptococci were only isolated in the norfloxacin group. No difference in hospital mortality was observed between groups. CONCLUSIONS: Intravenous ceftriaxone is more effective than oral norfloxacin in the prophylaxis of bacterial infections in patients with advanced cirrhosis and hemorrhage.     

Role of prophylactic antibiotics in cirrhotic patients with variceal bleeding

Bacterial infections are common in cirrhotic patients with acute variceal bleeding,occurring in 20%within48 h.Outcomes including early rebleeding and failure to control bleeding are strongly associated with bacterial infection.However,mortality from variceal bleeding is largely determined by the severity of liver disease.Besides a higher Child-Pugh score,patients with hepatocellular carcinoma are particularly susceptible to infections.Despite several hypotheses that include increased use of instruments,greater risk of aspiration pneumonia and higher bacterial translocation,it remains debatable whether variceal bleeding results in infection or vice versa but studies suggest that antibiotic prophylaxis prior to endoscopy and up to 8 h is useful in reducing bacteremia and spontaneous bacterial peritonitis.Aerobic gram negative bacilli of enteric origin are most commonly isolated from cultures,but more recently,gram positives and quinolone-resistant organisms are increasingly seen,even though their clinical significance is unclear.Fluoroquinolones(including ciprofloxacin and norfloxacin)used for short term(7 d)have the most robust evidence and are recommended in most expert guidelines.Short term intravenous cephalosporin(especially ceftriaxone),given in a hospital setting with prevalent quinolone-resistant organisms,has been shown in studies to be beneficial,particularly in high risk patients with advanced cirrhosis.     

Presence of Bacterial Infection in Bleeding Cirrhotic Patients Is Independently Associated with Early Mortality and Failure to Control Bleeding

Bacterial infection is strongly associated with gastrointestinal bleeding in cirrhotic patients and seems to be related with the failure to control bleeding. The aims of this study were to assess the influence of infections on the failure to control bleeding and death in cirrhotic patients without antibiotic prophylaxis. Ninety-one consecutive bleeding cirrhotic patients were analyzed. Bleeding was managed using somatostatin with sclerotherapy for active bleeding. Screening for bacterial infection (analysis and culture of blood, urine, ascitic and other fluids, together with chest radiography) was made at time 0 and when clinical signs suggested infection. The cause of bleeding was variceal in 72 (79%) patients. Failure to control bleeding occurred in 24 (26%) patients, and 10 (11%) of the patients died. Compared with the group without infection, failure to control bleeding (65% vs 15%; P < 0.001) and mortality (40% vs 3%; P < 0.001), were observed more frequently in patients with infection. Multivariate analysis showed that bacterial infection (OR = 9.7; P < 0.001) and the presence of shock (OR = 3.5; P < 0.05) were independently associated with failure to control bleeding. Bacterial infection (OR = 12.6; P < 0.01), encephalopathy (OR = 6.9; P < 0.05), and shock (OR = 5.8; P < 0.05) were identified as predictive of death. In conclusion, in bleeding cirrhotic patients bacterial infection is associated with failure to control bleeding as well as mortality.     

Bacterial infections in cirrhosis.

Hospitalized patients with cirrhosis are at increased risk of developing bacterial infections, the most common being spontaneous bacterial peritonitis (SBP) and urinary tract infections. Independent predictors of the development of bacterial infections in hospitalized cirrhotic patients are poor liver synthetic function and admission for gastrointestinal hemorrhage. Short term (seven-day) prophylaxis with norfloxacin reduces the rate of infections and improves survival and should therefore be administered to all patients with cirrhosis and variceal hemorrhage. Cirrhotic patients who develop abdominal pain, tenderness, fever, renal failure or hepatic encephalopathy should undergo diagnostic paracentesis, and those who meet the criterion for SBP (eg, an ascites neutrophil count greater than 250/mm3) should receive antibiotics, preferably a third-generation cephalosporin. In addition to antibiotic therapy, albumin infusions have been shown to reduce the risk of renal failure and mortality in patients with SBP, particularly in those with renal dysfunction and hyperbilirubinemia at the time of diagnosis. Patients who recover from an episode of SBP should be given long term prophylaxis with norfloxacin and should be assessed for liver transplantation.     

Bacterial infections in liver cirrhosis

The incidence of bacterial infections in cirrhotic patients admitted to hospital is very high. In several studies, 30% to 50% of cirrhotics presented bacterial infections at admission, or developed this type of complication during hospitalization. Most bacterial infections in cirrhotic patients are hospital-acquired. Between 15% to 35% of cirrhotics admitted to hospital develop nosocomial infections; these figures contrast sharply with the hospital-acquired infection rate in the general hospital population (5% to 7%). Urinary tract infections (12% to 29%), spontaneous bacterial peritonitis (7% to 23%), respiratory tract infections (6% to 10%) and bacteraemia (4% to 9%) are the most frequent bacterial infectious complications seen in cirrhotic patients. However, since spontaneous bacterial peritonitis is the most characteristic bacterial infection in cirrhosis, this report will focus (mainly) on this infectious complication.     

Bacterial infections in patients with acute hemorrhage due to portal hypertension--personal experience

Acute haemorrhage from the upper gastrointestinal tract is a frequent and serious complication which affects 20-60% patients with cirrhosis of the liver and portal hypertension. It is assumed that bacterial infections can be the direct cause of haemorrhage but accurate data on the influence of infection on the development and course of haemorrhage are lacking. Acute haemorrhage as a result of portal hypertension has a very high mortality, 30-50%, and an early relapse of haemorrhage occurs in as many as 40% of these patients. Most recent meta-analyses indicate that bacterial infection is an independent prognostic factor in failure of haemostasis and has a significant impact on the mortality of these patients. The authors examined for the presence of bacterial infection (blood, urine, throat, ascites) 25 patients with cirrhosis of the liver and acute haemorrhage as a result of portal hypertension and compared the results with a group of 25 patients with cirrhosis of the liver and portal hypertension without acute haemorrhage. According to the results in patients with acute haemorrhage due to portal hypertension there is a significantly higher incidence of bacterial infections than in patients with cirrhosis of the liver and portal hypertension without acute haemorrhage. The results confirm the necessity to administer antibiotic prophylaxis to cirrhotic patients with varicose bleeding, not only to patients with symptoms and evidence of infection but also in their absence. Antibiotic prophylaxis extends the survival period of these patients.