likely to have infection due to multidrug-resistant pathogens. Initial empiric therapy in such
cases should include an antipseudomonal cephalosporin (e.g., cefepime) or antipseudomonal
carbepenem (e.g., imipenem) or piperacillin/tazobactam plus an antipseudomonal fluoroqui-
nolone (ciprofloxacin or levofloxacin) plus vancomycin or linezolid if MRSA risk factors are
present or there is a high incidence locally (70). Because of increased risks of aminoglycoside-
induced nephrotoxicity and ototoxicity, the use of these agents should be avoided in cirrhotic
patients if possible (30).
OTHER INFECTIONS
VibrioInfections
Vibriobacteria are gram-negative halophilic inhabitants of marine and estuarine environments.
Typical infections caused by these organisms include gastroenteritis, wound infections, and
septicemia. Infection usually occurs following consumption of contaminated food or water or
by cutaneous inoculation through wounds. The most common pathogens includeV. cholerae,
V. parahaemolyticus, andV. vulnificus. Preexisting liver disease is a major risk factor forVibrio
infections and has been associated with a fatal outcome in both wound infections and primary
septicemia (71).V. vulnificus, the most virulent of the noncholera vibrios, can rapidly invade
the bloodstream from the gastrointestinal tract. Classic clinical features ofV. vulnificussepsis
include the abrupt onset of chills and fever followed by hypotension with subsequent
development of disseminated skin lesions within 36 hours of onset. The skin lesions progress
to hemorrhagic vesicles or bullae and then to necrotic ulcers (72). This syndrome is highly
associated with a history of consuming raw oysters. The mortality rate exceeds 50%.
Recommended antibiotic therapy includes using an expanded-spectrum cephalosporin plus a
tetracycline (e.g., cefotaxime or ceftazidime plus doxycycline) or a fluoroquinolone (e.g.,
ciprofloxacin) (72).
Endocarditis
Infective endocarditis is a relatively unusual complication of cirrhosis. In the pastE. coliand
S. pneumoniae were commonly implicated in these infections. More recent studies have
identifiedS. aureusas the most common pathogen along with other gram-positive bacteria
such as theViridansstreptococci andEnterococcusspecies (73,74).Streptococcus bovisbiotypes
[recently reclassified asStreptococcus gallolyticus(S. bovisI),Streptococcus lutetiensis(S. bovisII/
- andStreptococcus pasteuriannus(S. bovisII/2)] are emerging as another important cause of
bacteremia and endocarditis in patients with chronic liver disease (75,76). Endocarditis caused
byS. bovisis commonly associated with bivalvular involvement and a high rate of embolic
events.
Spontaneous Bacterial Empyema
Spontaneous bacterial empyema is an infection of a preexisting hydrothorax in cirrhotic
patients. Although the majority of these patients have ascites, the presence of ascites is not a
prerequisite for spontaneous bacterial empyema. Spontaneous bacterial peritonitis is present in
approximately half of patients who develop empyema. The most common causes of
Table 2 Risk Factors for Nosocomial Pneumonia Due to Resistant Bacteria
Antimicrobial therapy in preceding 90 days
Current hospital stay>¼5 days
High frequency of antibiotic resistance in the community or hospital unit
Hospitalization2 days in preceding 90 days
Residence in nursing home or extended care facility
Home infusion therapy (including antibiotics)
Chronic dialysis within 30 days
Home wound care
Family member with multi-drug resistant pathogen
Immunosuppressive disease and/or therapy
Source: Adapted from Ref. 70.
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