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Oleh : Reza OctavianusOleh : Reza OctavianusBacterial infections are a common Bacterial infections are a common complication of cirrhosiscomplication of cirrhosisThe inhospital mortality of cirrhotic The inhospital mortality of cirrhotic patients with infection is approximately patients with infection is approximately 15%, more than twice that of patients 15%, more than twice that of patients without infectionwithout infectionInfection is irectly responsi!le for "#$Infection is irectly responsi!le for "#$5#% of eath in cirrhosis5#% of eath in cirrhosis%epsis %epsis synrome of the systemic synrome of the systemic inflammatory response to infectioninflammatory response to infection%IR%%IR%%epsis %epsis %IR% in response to a proven or %IR% in response to a proven or suspecte micro!ial eventsuspecte micro!ial event%evere %epsis %evere %epsis or&an ysfunctionor&an ysfunction%epsis with hypotension%epsis with hypotension%eptic shoc'%eptic shoc'(ultiple or&an ysfunction synrome(ultiple or&an ysfunction synrome%epsis %epsis annual incience of "##)1##*### or annual incience of "##)1##*### or 1)1## hospital amission for any cause*1)1## hospital amission for any cause*%epsis in cirrhosis %epsis in cirrhosis "#$5#% of hospital "#$5#% of hospital amissionamissionOnce amitte, !etween 15% an "5% of Once amitte, !etween 15% an "5% of cirrhotic patients evelop nosocomial infections cirrhotic patients evelop nosocomial infections compare with an infection rate of 5$+% in the compare with an infection rate of 5$+% in the &eneral hospital population&eneral hospital populationThe severity of the unerlyin& liver isease also The severity of the unerlyin& liver isease also ma'es cirrhotic patients more suscepti!le to the ma'es cirrhotic patients more suscepti!le to the evelopment of sepsisevelopment of sepsisInfections in cirrhosis are mainly cause !y Infections in cirrhosis are mainly cause !y !acteria!acteriaThe main sites of infection are ascites, lun&s, The main sites of infection are ascites, lun&s, urinary tract, an !loourinary tract, an !looThe commonest or&anism is The commonest or&anism is Escherichia coli, Escherichia coli, Staphylococcus aureus, Enterococcus faecalis, Staphylococcus aureus, Enterococcus faecalis, Streptococcus pneumoniae, Pseudomonas Streptococcus pneumoniae, Pseudomonas aureginosa, aureginosa, an an Staphylococcus epidermidisStaphylococcus epidermidis,yto'ine release,yto'ine release-ever, tachycaria, tachypnoea, hypotension, an -ever, tachycaria, tachypnoea, hypotension, an microcirculatory alterationsmicrocirculatory alterationsRe cell eforma!ility is altere an they !ecome Re cell eforma!ility is altere an they !ecome we&e in the pulmonary circulationwe&e in the pulmonary circulation.p to "#% ecrease in the macrovascular volume.p to "#% ecrease in the macrovascular volume/ascular resistance chan&es mar'ely reuce /ascular resistance chan&es mar'ely reuce splanhnic !loo flow splanhnic !loo flow s'in an restin& s'eletal s'in an restin& s'eletal musclemuscle0nti$inflammatory an antiapoptotic in 0nti$inflammatory an antiapoptotic in enothelial cellsenothelial cells%epsis %epsis reuce protein , activationreuce protein , activation1nhance procoa&ulant an proinflammatory 1nhance procoa&ulant an proinflammatory responsesresponses2on$survivors of septic illnesses have 2on$survivors of septic illnesses have persistently reuce serum protein , !elow a persistently reuce serum protein , !elow a critical level of approximately 3#% of normalcritical level of approximately 3#% of normalOpposin& platelet a&&re&ation an terminatin& Opposin& platelet a&&re&ation an terminatin& free raical chain reactionsfree raical chain reactions0 'ey meiator contri!utin& to hypotension0 'ey meiator contri!utin& to hypotension2O excess in sepsis is prouce !y the inuci!le 2O excess in sepsis is prouce !y the inuci!le form of nitric oxie synthase 42O%5form of nitric oxie synthase 42O%52O% 2O% 2O2O

6ar&e amounts of superoxie with 6ar&e amounts of superoxie with

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720720,irrhotics have increase levels of enotoxin,irrhotics have increase levels of enotoxin8lasma T2-$a an I6$3 levels were hi&her in cirrhotic patients with early !acterial infection than non$cirrhotic patients68% inuce proinflammatory cyto'ine prouction !y monocyte was more mar'e in cirrhotics than in controlsThe liver synthesises precursors 4zymo&ens5 of The liver synthesises precursors 4zymo&ens5 of coa&ulation factors, an cirrhosis is associate coa&ulation factors, an cirrhosis is associate with ecrease synthesis of the factors /II,9,/, with ecrease synthesis of the factors /II,9,/, an IIan II,irrhotic patients with sepsis present &reater ,irrhotic patients with sepsis present &reater coa&ulation a!normalities than their coa&ulation a!normalities than their counterparts without sepsiscounterparts without sepsis8rotein , is reuce in fulminat liver failure8rotein , is reuce in fulminat liver failure2O prouction is usually increase in cirrhosis2O prouction is usually increase in cirrhosis68% inuces 2O% 68% inuces 2O% increase increase prouction of T2-$a an nitratesprouction of T2-$a an nitrates8lasma nitrate an nitric concentrations 8lasma nitrate an nitric concentrations are correlate with those enotoxinsare correlate with those enotoxins7efine as the mi&ration of via!le microor&anism from7efine as the mi&ration of via!le microor&anism from the intestinal lumen to mesenteric lymph noes anthe intestinal lumen to mesenteric lymph noes an other extraintestinal sites other extraintestinal sitesIn cirrhotic patients, !acterial translocation wasIn cirrhotic patients, !acterial translocation was si&nificantly increase only in ,hil , patients in whomsi&nificantly increase only in ,hil , patients in whom the rate was "#% compare with :% in ,hil B anthe rate was "#% compare with :% in ,hil B an "% in ,hil 0 patients "% in ,hil 0 patientsBacterial translocation !ecomes clinically si&nificantBacterial translocation !ecomes clinically si&nificant when it prouces reco&sina!le conitions such aswhen it prouces reco&sina!le conitions such as spontaneous !acterial peritonitis 4%B85,spontaneous !acterial peritonitis 4%B85, !acteraemia,or post sur&ical infection !acteraemia,or post sur&ical infectionThir &eneration cephalosporins &iven iv for Thir &eneration cephalosporins &iven iv for five ays five ays ,efotaxime up to ; &)ay in uinolone such as oral norfloxacin ;## m&)ay, an !e assese for liver m&)ay, an !e assese for liver transplantation 4level of evience ? I 0,15transplantation 4level of evience ? I 0,15,iprofloxacin ,iprofloxacin + ays iv)< ays iv@5 ays oral+ ays iv)< ays iv@5 ays oral0moxicillin),lavulani aci 0moxicillin),lavulani aci Treatment failure 41#%5 is associate with a Treatment failure 41#%5 is associate with a poor pro&nosis an hospital mortality of 5#$poor pro&nosis an hospital mortality of 5#$:#%:#%0nti!iotics shoul !e chan&e accorin& to in 0nti!iotics shoul !e chan&e accorin& to in vitro suscep!ility or empirically in culture vitro suscep!ility or empirically in culture ne&ative casesne&ative casesAastrointestinal !lees Aastrointestinal !lees patients with patients with controlle !leein&, the incience of controlle !leein&, the incience of spesis was si&nificantly lower versus spesis was si&nificantly lower versus those with uncontrolle !leein&*those with uncontrolle !leein&*Aastrountestinal !lees Aastrountestinal !lees 0 su!se>uent 0 su!se>uent prospective stuy confirme the hi&h prospective stuy confirme the hi&h fre>uency of infection in patients with fre>uency of infection in patients with variceal !lee, an foun that infection variceal !lee, an foun that infection preicte variceal re!leein&preicte variceal re!leein&It is recommene that patients with It is recommene that patients with &astrointestinal !leein& !e &iven anti!iotic &astrointestinal !leein& !e &iven anti!iotic prophylaxis 4level of evience ? I 0,15prophylaxis 4level of evience ? I 0,158rophylactic anti!iotics as seconary 8rophylactic anti!iotics as seconary prevention of variceal !leein& can reuce the prevention of variceal !leein& can reuce the incience of early re$!leein& 4level of evience incience of early re$!leein& 4level of evience ? II 715? II 715Beta !loc'ers non$specific Beta !loc'ers non$specific reuce !acterial reuce !acterial translocation in cirrhotic rats 4level of evience translocation in cirrhotic rats 4level of evience ? II 75? II 750l!umin :0l!umin :,an !in an then eliver toxins to ,an !in an then eliver toxins to removal sitesremoval sites,an increase the protein concentration of ,an increase the protein concentration of extracellular compartments such as extracellular compartments such as ascites, improvin& opsonic activityascites, improvin& opsonic activityBloo volume expansionBloo volume expansion0l!umin :0l!umin :,efotaxime or ,efotaxime with al!umin ,efotaxime or ,efotaxime with al!umin prevente the rise in renin,ecrease the prevente the rise in renin,ecrease the incience of renal failure,an improve incience of renal failure,an improve mortality from uinolone resistant !acteriaIn a recent survey, uinolone resistant Aram ne&ative !acilli over a two year perio!acilli over a two year perioRelate to lon& term treatment with norfloxacin: Relate to lon& term treatment with norfloxacin: 5#% of culture positive %B8 in patients on 5#% of culture positive %B8 in patients on prophylaxis was ue to such microor&anism prophylaxis was ue to such microor&anism versus 13% in patients not receivin& versus 13% in patients not receivin& prophylaxisprophylaxisThere is an increase li'elihoo of infections There is an increase li'elihoo of infections from Aram positive !acteria in patients who from Aram positive !acteria in patients who have receive %B8 prophylaxishave receive %B8 prophylaxisIn a recent stuy, the relative prevalence of In a recent stuy, the relative prevalence of infections from Aram positive !acteria in infections from Aram positive !acteria in patients who receive norfloxacin prophylaxis patients who receive norfloxacin prophylaxis was su!stantially increaseD in particular, was su!stantially increaseD in particular, !acteremia was entirely ue to Aram positive !acteremia was entirely ue to Aram positive !acteria!acteria8ro'inetic a&ents 8ro'inetic a&ents ,isaprie,isaprie8ro!iotics 8ro!iotics 6acto!acillus6acto!acillus2on$selective Beta Bloc'ers 2on$selective Beta Bloc'ers 8ropranolol8ropranolol

TE02F GO.TE02F GO.