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Prevention and treatment of infections in patients with cirrhosis. |
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Prevention and treatment of infections in patients with cirrhosis.
Best Pract Res Clin Gastroenterol. 2007;21(1):77-93.
Ghassemi S, Garcia-Tsao G.
Division
of Digestive Diseases, Yale University School of Medicine, VA CT
Healthcare System, 333 Cedar St - 1080 LMP, P.O. Box 208019, New Haven,
CT 06520, USA.
Patients with cirrhosis have altered immune
defenses and are considered immunocompromised individuals. Changes in
gut motility, mucosal defense and microflora allow for translocation of
enteric bacteria into mesenteric lymph nodes and the blood stream.
Additionally, the cirrhotic liver is ineffective at clearing bacteria
and associated endotoxins from the blood thus allowing for seeding of
the sterile peritoneal fluid.
Thus, hospitalised cirrhotic patients,
particularly those with gastrointestinal hemorrhage, are at high risk
of developing bacterial infections, the most common being spontaneous
bacterial peritonitis. Given the significant morbidity and mortality
associated with spontaneous bacterial peritonitis and the fact that
half of the cases are community acquired, all hospitalised cirrhotic
patients should have a diagnostic paracentesis to exclude infection.
Those admitted with gastrointestinal bleed and a negative paracentesis
require short-term prophylaxis with norfloxacin. A third generation
cephalosporin is the treatment of choice for spontaneous bacterial
peritonitis and, once the acute infection is resolved, secondary
prophylaxis with oral norfloxacin is warranted. Patients who develop
renal dysfunction at the time of active infection have the highest
mortality and require adjunctive albumin therapy. This article reviews
the pathogenesis of SBP, the evidence behind the antibiotics used, the
rationale for adjunctive albumin therapy in the setting of acute renal
failure, and the role of prophylactic antibiotics in specific high-risk
populations.
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