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Bacterial infections in end-stage liver disease: current challenges and future directions
  1. Jasmohan S Bajaj1,
  2. Jacqueline G O'Leary2,
  3. Florence Wong3,
  4. K Rajender Reddy4,
  5. Patrick S Kamath5
  1. 1Department of Medicine, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA
  2. 2Department of Medicine, Baylor University Medical Center, Dallas, Texas, USA
  3. 3Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  4. 4Department of Medicine, Canada University of Pennsylvania, Philadelphia, Pennsylvania, USA
  5. 5Department of Medicine, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
  1. Correspondence to Dr Jasmohan S Bajaj, Associate Professor, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, 1201 Broad Rock Boulevard, Richmond, VA 23249, USA; jasmohan{at}gmail.com

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Introduction

Bacterial infections continue to be a leading cause of mortality andacute-on-chronic liver failure in end-stage liver disease (ESLD). The consequences of infection include prolonged hospitalisation, acute kidney injury (AKI), death, de-listing from liver transplant and susceptibility to further infections. The diagnosis of infections in cirrhosis is fraught due to the background of a partial systemic inflammatory response syndrome (SIRS) state and negative cultures in 30-50% of patients. Furthermore, the lack of multi-center studies limits the generalisability of currently available results. The modulation of infections by the underlying immune state, gut barrier function and super-imposed medications such as beta-blockers, proton pump inhibitors and antibiotics is required. A rational approach to the diagnosis and prevention of AKI associated with infection, withjudicious use of crystalloids and albumin, is also needed. Changes in bacteriology including emergence of multi-resistant organisms and Clostridium difficile have also recently changed the approach for prophylaxis and therapy of infections. Effective strategies for the prevention, diagnosis, and management of infections in ESLD form a large unmet need. A systematic approach to study the epidemiology, bacteriology, resistance patterns, and procedure and medication utilisation specific to ESLD is needed to improve outcomes.

Bacterial infections in patients with end-stage liver disease affect candidacy for liver transplantation. Up to one-third of all hospitalised patients with cirrhosis are infected.1–5 With sepsis, mortality increases to more than 50% and is associated with significant costs.6 A recent systematic review demonstrated a fourfold increased risk of death in infected cirrhotic patients compared with their non-infected counterparts.7 More importantly, intensive care unit (ICU) mortality of patients with cirrhosis has remained unchanged over 50 years, unlike disease states such as cardiac failure where mortality has decreased.8 Therefore the prevention, diagnosis …

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