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

Infectious Work-up and Exclusion for Undergoing Liver Transplantation

Patients with ACLF who are listed for liver transplantation move higher on the waiting list as their MELD increases because of critical illness. Readiness for liver transplantation from an infectious perspective should be determined in conjunction with a transplant infectious disease specialist. Patients with active, uncontrolled infection are not suitable for transplantation. For patients diagnosed with pneumonia, SBP, UTI, or BSI, infections need to be adequately treated before attempting liver transplantation. After initiation of appropriate antimicrobial therapy, demonstration of clinical improvement with resolution of infection should be demonstrated by repeat negative cultures or imaging.[120] Patients with active CDI should not undergo transplantation until diarrhea has resolved. Patients with bacteremia or infective endocarditis should complete therapy before undergoing liver transplantation. Patients with SBP who clinically improve with antibiotics can proceed to transplant as long as there is a thorough evaluation of the abdominal cavity prior to performing the hepatectomy. Active infections with tuberculosis, nontuberculous mycobacteria, histoplasmosis, blastomycosis, coccidiomycosis, cryptococcosis, or invasive fungal infection are a contraindication to transplantation; however, reconsideration for transplant can be given once the infection has been adequately treated and there is clinical, radiographic, and microbiological resolution of these infections.[120,121] Asymptomatic bacteruria and funguria are not contraindications to transplant. Latent tuberculosis or positive Strongyloides serology without an evidence of active infection are not barriers to transplantation, but therapy should be planned before or immediately after transplant to avoid posttransplant infections.[122,123]