Infections in Cirrhotics: Types, Microbiological Spectrum and Risk Factors—5-Year Cohort Study


Cirrhosis is an immunocompromised state that leads to various infections, with an estimated 30% mortality. Pakistan already has a high morbidity and mortality related to complications of cirrhosis. Where the data on infection among cirrhotics is scanty, this study aimed to determine the frequency, microbiological spectrum and various risk factors of infections in cirrhosis of liver. This is a prospective cohort study conducted at a tertiary care hospital. The microbiological spectrum and frequency of infections was determined in cirrhotics. Various risk factors for infection among cirrhotics were evaluated like upper gastrointestinal bleed, use of proton pump inhibitors, malnutrition and severity of cirrhosis. Out of eleven hundred and forty-one patients with cirrhosis of liver, four hundred and ninety (42.94%) patients had infections. All kinds of infections like peritoneal, respiratory, urinary tract and skin were present in cirrhosis of liver where ascitic fluid infections (AFI) were the commonest i.e. 44.89%. The risk factors for bacterial infections among patients with cirrhosis of liver were upper gastrointestinal bleeding (odd ratio = 4.57, p = 0.0001), use of proton pump inhibitors (odd ratio = 2.57, p = 0.0001), degree of malnutrition (odd ratio = 10.34, p = 0.0001) and severity of cirrhosis (odd ratio = 12.99, p = 0.000). All types of infections occurred with varying frequency in cirrhosis of liver. Upper gastrointestinal bleeding, severity of cirrhosis, use of high dose proton pump inhibitors and severe malnutrition are important risk factors for infections among cirrhotics.

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Naqvi, I. , Mahmood, K. , Talib, A. , Ubaid, M. and Mahmood, A. (2014) Infections in Cirrhotics: Types, Microbiological Spectrum and Risk Factors—5-Year Cohort Study. Open Journal of Gastroenterology, 4, 105-117. doi: 10.4236/ojgas.2014.43017.

Conflicts of Interest

The authors declare no conflicts of interest.


[1] Tandon, P. and Garcia-Tsao, G. (2008) Bacterial Infections, Sepsis, and Multiorgan Failure in Cirrhosis. Seminars in Liver Disease, 28, 26-42.
[2] Fernandez, J., Navasa, M., Gómez, J., et al. (2002) Bacterial Infections in Cirrhosis: Epidemiological Changes with Invasive Procedures and Norfloxacin Prophylaxis. Hepatology, 35, 140-148.
[3] Arvaniti, V., D’Amico, G., Fede, G., et al. (2010) Infections in Patients with Cirrhosis Increase Mortality 4-Fold and Should Be Used in Determining Prognosis. Gastroenterology, 139, 1246-1256.
[4] Borzio, M., Salerno, F., Piantoni, L., et al., (2001) Bacterial Infection in Patients with Advanced Cirrhosis: A Multicentre Prospective Study. Digestive and Liver Disease, 33, 41-48.
[5] Bernard, B., Grange, J.D., Khac, E.N., Amiot, X., et al. (1999) Antibiotic Prophylaxis for the Prevention of Bacterial Infections in Cirrhotic Patients with Gastrointestinal Bleeding: A Meta-Analysis. Hepatology, 29, 1655-1661.
[6] Goulis, J., Armonis, A., Patch, D., Sabin, C., Greenslade, L. and Burroughs, A.K. (1998) Bacterial Infection Is Independently Associated with Failure to Control Bleeding in Cirrhotic Patients with Gastrointestinal Hemorrhage. Hepatology, 27, 1207-1212.
[7] Vivas, S., Rodriguez, M., Palacio, M.A., Linares, A., Alonso, J.L. and Rodrigo, L. (2001) Presence of Bacterial Infection in Bleeding Cirrhotic Patients Is Independently Associated with Early Mortality and Failure to Control Bleeding. Digestive Diseases and Sciences, 46, 2752-2757.
[8] Bernard, B., Cadranel, J.F., Valla, D., Escolano, S., Jarlier, V. and Opolon, P. (1995) Prognostic Significance of Bacterial Infection in Bleeding Cirrhotic Patients: A Prospective Study. Gastroenterology, 108, 1828-1834.
[9] Hou, M.C., Lin, H.C., Liu, T.T., et al. (2004) Antibiotic Prophylaxis after Endoscopic Therapy Prevents Rebleeding in Acute Variceal Hemorrhage: A Randomized Trial. Hepatology, 39, 746-753.
[10] Wong, F., Bernardi, M., Balk, R., et al. (2005) Sepsis in Cirrhosis: Report on the 7th Meeting of the International Ascites Club. Gut, 54, 718-725.
[11] Navasa, M. and Rodés, J. (2004) Bacterial Infections in Cirrhosis. Liver International, 24, 277-280.
[12] Vilstrup, H. (2003) Cirrhosis and Bacterial Infections. Romanian Journal of Gastroenterology, 12, 297-302.
[13] Talwani, R., Gilliam, B.L. and Howell, C. (2011) Infectious Diseases and the Liver. Clinics in Liver Disease, 15, 111-130.
[14] Wasmuth, H.E., Kunz, D., Yagmur, E., et al. (2005) Patients with Acute on Chronic Liver Failure Display “Sepsis-Like” Immune Paralysis. Journal of Hepatology, 42, 195-201.
[15] Ono, Y., Watanabe, T., Matsumoto, K., et al. (2004) Opsonophagocytic Dysfunction in Patients with Liver Cirrhosis and Low Responses to Tumor Necrosis Factor-Alpha and Lipopolysaccharide in Patients’ Blood. Journal of Infection and Chemotherapy, 10, 200-207.
[16] Wiest, R. and Garcia-Tsao, G. (2005) Bacterial Translocation (BT) in Cirrhosis. Hepatology, 41, 422-433.
[17] Caruntu, F.A. and Benea, L. (2006) Spontaneous Bacterial Peritonitis: Pathogenesis, Diagnosis, Treatment. Journal of Gastrointestinal and Liver Diseases, 15, 51-56.
[18] Runyon, B.A. and Hoefs, J.C. (1984) Culture-Negative Neutrocytic Ascites: A Variant of Spontaneous Bacterial Peritonitis. Hepatology, 4, 1209.
[19] Runyon, B.A. (1990) Monomicrobial Non Neutrocytic Bacterascites: A Variant of Spontaneous Bacterial Peritonitis. Hepatology, 12, 710.
[20] Runyon, B.A., Hoefs, J.C. and Canawati, H.N. (1986) Polymicrobial Bacterascites. A Unique Entity in the Spectrum of Infected Ascitic Fluid. Archives of Internal Medicine, 146, 2173.
[21] Cadranel, J.F., Denis, J., Pauwels, A., et al. (1999) Prevalence and Risk Factors of Bacteriuria in Cirrhotic Patients: A Prospective Case Control Multicenter Study in 244 Patients. Journal of Hepatology, 31, 464-468.
[22] Mohan, P., Ramu, B., Bhaskar, E., et al. (2011) Prevalence and Risk Factors for Bacterial Skin Infection and Mortality in Cirrhosis. Annals of Hepatology, 10, 15-20.
[23] Cabellos, C., Viladrich, P.F., Ariza, J., Maiques, J.M., Verdaguer, R. and Gudiol, F. (2008) Community-Acquired Bacterial Meningitis in Cirrhotic Patients. Clinical Microbiology and Infection, 14, 35-40.
[24] Ruizdel-Arbor, L., Urman, J., Fermandez, J., et al. (2003) Cardiovascular, Renal and Hepatic Hemodynamic Derangement in Cirrhotic Patients with Spontaneous Bacterial Peritonitis. Hepatology, 38, 1210-1218.
[25] Lehner, S., Stemmler, H.J., Mück, A., et al. (2010) Prognostic Parameters and Risk Stratification in Intensive Care Patients with Severe Liver Diseases. Journal of Gastrointestinal and Liver Diseases, 19, 399-404.
[26] Morgan, M.Y., Madden, A.M., Soulsby, C.T. and Morris, R.W. (2006) Derivation and Validation of a New Global Method for Assessing Nutritional Status in Patients with Cirrhosis. Hepatology, 44, 823-835.
[27] Preda, C.M., Ghita, R., Ghita, C., et al. (2011) A Retrospective Study of Bacterial Infections in Cirrhosis. Journal of Clinical Medicine, 6, 185.
[28] Fasolato, S., Angeli, P., Dallagnese, L., Maresio, G., et al. (2007) Renal Failure and Bacterial Infections in Patients with Cirrhosis: Epidemiology and Clinical Features. Hepatology, 45, 223-229.
[29] Ferreira, T., Sevá-Pereira, T., Almeida, J., Fioravante, M., Yamanaka, A., et al. (2012) Impact of Infection in Hospitalized Cirrhotic Patients in a University Hospital. Open Journal of Gastroenterology, 2, 124-130.
[30] Khan, A.A., Rehman, K.U., Haider, Z. and Shafqat, F. (2002) Sero-Markers of Hepatitis B and C in Patients with Cirrhosis. Journal of the College of Physicians and Surgeons Pakistan, 12, 105-107.
[31] Andre, F. (2000) Hepatitis B Epidemiology in Asia: The Middle East and Africa. Vaccine, 18, S20-S22.
[32] Butt, S., Ahmed, P., Liaqat, P. and Ahmed, H. (2009) A Study of Malnutrition among Liver Disease Patients. Pak Nut, 8, 1465-1471.
[33] Ling, S., Tai, M., Lee Goh, K., Taib, S.M., Rampal, S. and Mahadeva, S. (2010) Anthropometric, Biochemical and Clinical Assessment of Malnutrition in Malaysian Patients with Advanced Cirrhosis. Nutrition Journal, 9, 27.
[34] Attia, K.A., Ackoundou-N’guessan, K.C., N’driyoman, A.T., Mahassadi, A.K., et al. (2008) Child-Pugh-Turcott versus Meld Score for Predicting Survival in a Retrospective Cohort of Black African Cirrhotic Patients. World Journal of Gastroenterology, 14, 286-291.
[35] Kamani, L., Mumtaz, K., Ahmed, U.S., Ali, A.W. and Jaffery, W. (2008) Outcomes in Culture Positive and Culture Negative Ascitic Fluid Infection in Patients with Viral Cirrhosis: Cohort Study. BMC Gastroenterology, 8, 59.
[36] Iqbal, S., Iman, U.N., Aslam, N. and Rahman, S.U. (2005) Incidence of Spontaneous Bacterial Peritonitis in Liver Cirrhosis, Causative Organisms and Antibiotic Sensitivity. Journal of Postgraduate Medical Institute, 84, 614-618.
[37] Navasa, M., Rimola, A. and Rodés, J. (1997) Bacterial Infections in Liver Disease. Seminars in Liver Disease, 17, 323-333.
[38] Cruz, R.R., Tanajura, D., Almeida, D., Cruz, M. and Paraná, R. (2006) Urinary Tract Infection in Non-Hospitalized Patients with Cirrhosis and No Symptoms of Urinary Tract Infection: A Case Series Study. The Brazilian Journal of Infectious Diseases, 10, 380-383.
[39] Levy, M., Dromer, F., Brion, N., Leturdu, F. and Carbon, C. (1988) Community-Acquired Pneumonia. Importance of Initial Noninvasive Bacteriologic and Radiographic Investigations. Chest, 93, 43-48.
[40] Shakil, A.O., Korula, J., Kanel, G.C., Murray, N.G.B. and Reynolds, T.B. (1996) Diagnostic Features of Tuberculous Peritonitis in the Absence and Presence of Chronic Liver Disease: A Case Control Study. American Journal of Medicine, 100, 179-185.
[41] Al Muneef, M., Memish, Z., Al Mahmoud, S., Al Sadoon, S., Bannatyne, R. and Khan, Y. (2001) Tuberculosis in the Belly: A Review of Forty-Six Cases Involving the Gastrointestinal Tract and Peritoneum. Scandinavian Journal of Gastroenterology, 5, 528-532.
[42] Baijal, R., Praveenkumar, H.R., Amarapurkar, D.N., Nagaraj, K. and Jain, M. (2010) Prevalence of Tuberculosis in Patients with Cirrhosis of Liver in Western India. Tropical Doctor, 40, 163-164.
[43] Yoo, C.G., Kim, Y.W., Han, S.K., Shim, Y.S. and Yim, J.J. (2007) Characteristics of Tuberculosis in Patients with Liver Cirrhosis. Respirology, 12, 401-405.
[44] Thulstrup, A.M., Mølle, I., Svendsen, N. and Sørensen, H.T. (2000) Incidence and Prognosis of Tuberculosis in Patients with Cirrhosis of the Liver. A Danish Nationwide Population Based Study. Epidemiology and Infection, 124, 221-225.
[45] Liu, B.M., Chung, K.J., Chen, C.H., Kung, C.T., Ko, S.F., Liu, P.P. and Chang, H.W. (2008) Risk Factors for the Outcome of Cirrhotic Patients with Soft Tissue Infections. Journal of Clinical Gastroenterology, 42, 312-316.
[46] Rongey, C., Lim, N.H. and Runyon, B.A. (2008) Cellulitis in Patients with Cirrhosis and Edema: An Under-Recognized Complication Currently More Common than Spontaneous Bacterial Peritonitis. The Open Gastroenterology Journal, 2, 24-27.
[47] Horowitz, Y., Sperber, A.D. and Almong, Y. (2004) Gram Negative Cellulites Complication Cirrhosis. Mayo Clinic Proceedings, 79, 247-250.
[48] Mohan, P., Ramu, B., Bashkar, E. and Venkataraman, J. (2011) Prevalence and Risk Factors for Bacterial Skin Infections and Mortality in Cirrhosis. Annals of Hepatology, 10, 15-20.
[49] Kuo, C.M., Kuo, C.H. and Changchien, C.S. (2001) Liver Abscess in Patients with Cirrhosis of the Liver: A 12-Year Experience. Journal of Gastroenterology, 36, 552-556.
[50] Chang, W.N., Lu, C.H., Chang, C.S. and Huang, C.R. (2003) Community Acquired Spontaneous Bacterial Meningitis in Patients with Alcoholic Liver Disease. Journal of the Formosan Medical Association, 102, 653-655.
[51] Su, C.M., Chang, W.N., Tsai, N.W., Huang, C.R., Wang, H.C. and Lu, C.H. (2010) Clinical Features and Outcome of Community-Acquired Bacterial Meningitis in Adult Patients with Liver Cirrhosis. American Journal of the Medical Sciences, 340, 452-456.
[52] Bajaj, J.S., Zadvornova, Y., Heuman, D.M., Hafeezullah, M., Hoffmann, R.G., Sanyal, A.J. and Saeian, K. (2009) Associations of Proton Pump Inhibitor Therapy with Spontaneous Bacterial Peritonitis in Cirrhotic Patients with Ascites. American Journal of Gastroenterology, 104, 1130-1134.
[53] Choi, E.J., Lee, H.J., Kim, K.O., Lee, S.H., Eun, J.R., Jang, B.I. and Kim, T.N. (2011) Association between Acid Suppressive Therapy and Spontaneous Bacterial Peritonitis in Cirrhotic Patients with Ascites. Scandinavian Journal of Gastroenterology, 46, 616-620.
[54] Kondrup, J. (2006) Nutrition in End Stage Liver Disease. Best Practice & Research Clinical Gastroenterology, 20, 547-560.
[55] Campillo, B., Richardet, J.P. and Bories, P.N. (2006) Validation of Body Mass Index for the Diagnosis of Malnutrition in Patients with Liver Cirrhosis. Gastroentérologie Clinique et Biologique, 30, 1137-1143.
[56] Gunsar, F., Riamondo, M.L., Jones, S., Terreni, N., Wong, C., Patch, D., Sabin, C. and Burroughs, A.K. (2006) Nutritional Status and Prognosis in Cirrhotic Patients. Alimentary Pharmacology & Therapeutics, 24, 563-572.
[57] Merli, M., Lucidi, C., Giannelli, V., Giusto, M., Riggio, O., Falcone, M., Ridola, L., Attili, A.F. and Venditti, M. (2010) Cirrhotic Patients Are at Risk for Health Care-Associated Bacterial Infections. Clinical Gastroenterology and Hepatology, 8, 979-985.

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