Multidrug Resistant Infections in Cirrhosis Patients

Infections are the most frequent event in cirrhotic patients who develop acute-on-chronic liver failure. This implies long term internment and is associated with high mortality rate of approximately 32%. Cirrhosis is associated with impaired immune response, alterations in gut microbiota that lead to pathological bacterial translocation (BT). Spontaneous bacterial peritonitis (SBP) is the most typical infection observed in cirrhosis patients. Changes in the bacterial flora of cirrhosis patients, wide-scale use of quinolones in the prophylaxis of SBP have increased the prevalence of infections caused by multi drug resistant bacteria (MDR). SBP is classified into community-acquired (SBP <72 hours after hospital admission without use of antibiotics within 7 days of presentation), healthcare-associated infections and nosocomial infection (onset of signs and symptoms of SBP >72 hours after hospital admission). The efficacy of traditionally antibiotic therapy has been low in nosocomial infections (up to 40%), and multi drug resistance has been observed in up to 22% of isolated germs in nosocomial SBP. Nosocomial SBP has been associated with poor outcomes. Therefor the European Guidelines recommend the use of a broad empirical spectrum antibiotic in these situations. Broad-spectrum antimicrobial agents, such as carbapenems associated with glycopeptides or piperacillin-tazobactam, should be considered for the initial treatment for nosocomial infections and also of healthcare-associated infections when there is high suspicion of MDR bacteria. Community-acquired infections can be managed with the use of cephalosporin. We present a clinical case of a cirrhotic patient with decompensated disease who has been admitted in our Gastroenterology Unit of Garcia de Orta Hospital, Almada Portugal, with the diagnosis of hepatic encephalopathy and a high suspicion of infection.