2.6 Infections in Cirrhosis

Infections in Cirrhosis — Structured Summary

Lecture: 2.6 – Infections in Cirrhosis | Speaker: Prof. Sanjaya Satapathy, MD, FAASLD

1. Main Clinical Topics Discussed

• Infections as a leading cause of morbidity and mortality in cirrhosis
• Spontaneous Bacterial Peritonitis (SBP): diagnosis, management, and prophylaxis
• Bloodstream infections (bacteremia) in cirrhosis
• Empiric antibiotic selection and antimicrobial stewardship
• Invasive fungal infections in advanced liver disease
• Infection-driven AKI and hepatorenal syndrome (HRS)
• Infection's role in liver transplant decision-making

2. Key Learning Points, Guidelines, and Recommendations

General Principles

• Core clinical rule: Any acute decompensation in a cirrhotic patient should be treated as infection until proven otherwise
• Infections are the most common trigger of acute-on-chronic liver failure and frequently mimic disease progression

Spontaneous Bacterial Peritonitis (SBP)

• Definition: Infection of ascitic fluid without an identifiable surgical/treatable intra-abdominal source
• Diagnostic criterion: Ascitic fluid PMN count ≥ 250 cells/mm³, regardless of symptoms or culture result
• Negative culture does NOT exclude SBP and should never delay treatment
• Paracentesis before antibiotics — even a single antibiotic dose can sterilize cultures and obscure diagnosis
• All hospitalized patients with ascites require diagnostic paracentesis, irrespective of symptoms

#### Indications for Paracentesis

• GI bleeding, AKI, encephalopathy, leukocytosis, fever, or any unexplained clinical deterioration

#### Albumin Therapy in SBP

• Indicated when any ONE of the following is present:

- Creatinine > 1 mg/dL

- BUN > 30 mg/dL

- Total bilirubin > 4 mg/dL

• Dosing: 1.5 g/kg IV on Day 1 → 1 g/kg IV on Day 3
• Benefit: Reduces hepatorenal syndrome (HRS), AKI, and mortality

#### SBP Variants

SBP Prophylaxis

• Secondary prevention (prior SBP): Lifelong prophylaxis — non-negotiable
• Primary prevention: Low-protein ascites with renal dysfunction; GI bleeding (short-term)
• Agents: Norfloxacin, ciprofloxacin, or trimethoprim-sulfamethoxazole (based on local resistance patterns)

Bloodstream Infections (Bacteremia)

• Significantly higher incidence in cirrhosis due to immune dysfunction, bacterial translocation, and healthcare exposure
• Presentations often atypical — fever and leukocytosis may be absent
• Both gram-negative and gram-positive organisms are common, especially in hospitalized/ICU patients

Empiric Antibiotic Strategy

• Start broad, start early — delays consistently associated with worse outcomes
• Tailor to local resistance patterns and patient-specific risk factors (prior antibiotics, recent hospitalization, ICU status)
• De-escalate promptly once culture sensitivities return — key antimicrobial stewardship principle

Invasive Fungal Infections

• Risk factors: ICU admission, prolonged broad-spectrum antibiotic exposure, acute-on-chronic liver failure, renal failure
• Key organisms: *Candida* spp. (bloodstream/intra-abdominal); *Aspergillus* spp. (critically ill/ventilated patients)
• Red flags for fungal infection:

- Persistent fever despite appropriate antibiotics

- Progressive