the severity of liver disease, and individuals with cirrhosis are more likely to have a diagnosis
of sepsis when compared with patients without a diagnosis of cirrhosis (52). The most
commonly identified sources of bacteremia have been spontaneous bacterial peritonitis,
urinary tract infections, pneumonia, soft tissue infections, and biliary tract infections (51,53).
The pathogens identified in blood cultures from bacteremic patients mirror those responsible
for the primary source infections.E. coli,Klebsiella pneumoniae,Aeromonas hydrophilaand other
enteric gram-negative aerobes are common causes of bacteremic infections. Most gram-
positive bacteremias are due toS. aureus,S. pneumoniae, or other aerobic streptococcal species.
Bloodstream infection is associated with a poor prognosis despite appropriate antibiotic
therapy. Mortality rates commonly exceed 50% (51,54). Poor outcome is independent of the
type of bacteremia (54), but in-hospital mortality has been correlated with the absence of fever,
an elevated serum creatinine, and marked leukocytosis (53). Cirrhotic patients with suspected
bacteremia should receive empiric therapy directed against the most common gram-negative
and gram-positive pathogens in this setting. Antibiotic selection should take into consideration
local microbial susceptibility patterns. Usual therapeutic options would include expanded-
spectrum cephalosporins, piperacillin/tazobactam, or a fluoroquinolone such as levofloxacin
or moxifloxacin.
Cirrhotic patients who undergo endoscopic procedures for gastrointestinal hemorrhage
or transhepatic procedures are at increased risk of bacteremia. Endoscopic variceal
sclerotherapy or band ligation for bleeding esophageal varices is associated with a reported
risk of bacteremia ranging from 5% to 30% (55–57). Although the bacteremia associated with
these procedures may be brief, cirrhotic patients are susceptible to infections from transient
bacteremia. Gastrointestinal hemorrhage itself is an independent risk factor for bacteremia and
other infections in cirrhotic patients. Antibiotic administration has been shown to reduce
infectious complications and mortality in cirrhotic patients who are hospitalized for
gastrointestinal hemorrhage (58–61). Antibiotic prophylaxis is recommended for all cirrhotic
inpatients with gastrointestinal bleeding (62,63). Fluoroquinolone antibiotics were used in
most trials with a median treatment duration of seven days.
PNEUMONIA
Respiratory tract infections account for approximately 20% of the infectious diseases that are
diagnosed in hospitalized cirrhotic patients (21,23,64).S. pneumoniaecontinues to rank first
among bacterial pathogens causing community-acquired pneumonia (CAP) in adults (65).
Chronic liver disease has long been recognized as a risk factor for bacteremic pneumococcal
pneumonia (66). The mortality rate for pneumococcal bacteremia in cirrhotic patients may
exceed 50% despite appropriate antibiotic therapy (67). Other organisms commonly respon-
sible for CAP includeMycoplasma pneumoniae,Chlamydia pneumoniae,Legionella pneumophila,
andHaemophilus influenzae. Cirrhosis has been associated with an increased risk of severe CAP
caused byAcinetobacter baumannii(68). Sputum and blood samples should be obtained for
appropriate diagnostic studies, including gram-stain (sputum) and cultures (sputum and
blood). Chronic severe liver disease and/or admission to the intensive care unit are clinical
indications for pneumococcal urinary antigen testing in patients suspected to have CAP (69).
Appropriate empiric therapy while awaiting the results of cultures and other tests would
include an expanded-spectrum cephalosporin plus a macrolide or a beta-lactam/betalactamase-
inhibitor plus a macrolide or a fluoroquinolone (69).
Health care–associated and hospital-acquired pneumonia may be caused by a wide
variety of bacteria. Common pathogens include aerobic gram-negative bacilli, such as
Pseudomonas aeruginosa,E. coli,K. pneumoniae,Serratia marcescens,Enterobacterspecies,Proteus
species, andAcinetobacterspecies.S. aureusandS. pneumoniaepredominate among gram-
positive pathogens, and the incidence of methicillin-resistantS. aureus(MRSA) nosocomial
pneumonia is increasing. A number of risk factors have been identified for nosocomial
pneumonia caused by multidrug-resistant bacteria (70) (Table 2).
Recommended initial empiric antibiotic therapy for nosocomial pneumonia in patients
with no risk factors for multidrug-resistant pathogens orP. aeruginosawould be ceftriaxone or
a fluoroquinolone or ampicillin/sulbactam or ertapenem. Patients with any risk factors listed
in Table 2 or with onset of nosocomial pneumonia after four days of hospitalization are more
Infections in Cirrhosis in Critical Care 345