Infectious Complications in Critically Ill Liver Failure Patients

Amanda Cheung, MD; Sajal Tanna, MD, MPH; Michael G. Ison, MD, MS


Semin Respir Crit Care Med. 2018;39(5):578-587. 

In This Article

Prevention of Infection

Nosocomial infections are significantly higher in patients in the ICU, particularly those requiring CVCs and mechanical ventilation.[37] One in four hospitalized patients will develop a secondary infection including respiratory infections related to aspiration and mechanical ventilation, UTI often associated with bladder catheterization, and C. difficile typically associated with recent receipt of antibiotics; furthermore, these secondary infections lead to significantly increased mortality (OR: 4.4) independent of liver disease severity.[37]

Thus, measures should be taken to minimize the risks of secondary infections. Patients with altered mentation or upper GI bleeding should be monitored closely to minimize the risk of aspiration and subsequent infection. Adequate precautions should be taken in patients with endotracheal tubes, urinary catheters, and CVCs. Institution of programs to ensure appropriate insertion, adequate maintenance, and prompt removal of catheters and lines, when appropriate, has been shown to minimize these types of infections significantly.[109–111]

Judicious use of antibiotics is needed to minimize the emergence of multiresistant bacteria and the risk of CDI. Implementation of an antibiotic stewardship program is an important step toward achieving this goal.[112] Key elements to a successful program include differentiation between true infection and colonization, selection of prophylactic antibiotics based on local resistance patterns and patient risk factors, appropriate use of antibiotics based on available culture data, and implementation of rapid diagnostic tools to allow for de-escalation of antibiotics as quickly as possible.[113]

Spontaneous Bacterial Peritonitis Prophylaxis

Primary Prophylaxis. The use of oral norfloxacin (no longer available in the United States) or ciprofloxacin as primary prophylaxis in patients with low protein (<1.5 g/dL) ascites decreases the risk of a first episode of SBP (OR: 0.18) and mortality (OR: 0.6).[114] However, the routine use of antibiotics leads to increased resistance and should only be used in patients at a high risk of developing SBP. The American Association for the Study of Liver Diseases (AASLD) guidelines suggest SBP prophylaxis in patients with low protein ascites and concomitant impaired renal function (creatinine ≥ 1.2, blood urea nitrogen ≥ 25, Na ≤ 130) or liver failure (Child–Pugh score ≥ 9 and bilirubin ≥ 3).[66]

Prophylaxis in the Setting of Gastrointestinal Bleed. Cirrhotic patients presenting with upper GI bleeding, particularly those with failure to control bleeding and transfusion requirements, are at an increased risk of developing SBP.[115] Antibiotic prophylaxis in cirrhotic patients presenting with GI bleeding has been shown to decrease the rate of bacterial infections, specifically SBP, days of hospitalization, and overall mortality.[116,117] IV ceftriaxone is superior to oral fluoroquinolones in preventing SBP likely due to the possibility of decreased absorption in the setting of an active upper GI bleed and the presence of fluoroquinolone-resistant or gram-positive bacteria.[115]

Secondary Prophylaxis. The risk of recurrent SBP after a single episode is estimated to be 43 and 69% at 6 and 12 months, respectively.[118] Oral fluoroquinolone prophylaxis is a method of selective intestinal decontamination that decreases the risk of recurrent SBP (20 vs. 68%), particularly with gram-negative rods (3 vs. 60%).[119] All patients with prior episodes of SBP should receive prophylaxis with an oral fluoroquinolone.[64,66] Trimethoprim/sulfamethoxazole may be used for prophylaxis in patients with a fluoroquinolone allergy, prior episode of SBP while already on a fluoroquinolone for prophylaxis, or prior episode of SBP with a documented fluoroquinolone-resistant organism. Intermittent dosing of ciprofloxacin and trimethoprim/sulfamethoxazole has previously been suggested, but more recent evidence suggests that this may promote the development of resistance; thus, daily dosing is the preferred dosing for SBP prophylaxis.[66]