Infections bactériennes et cirrhose alcoolique

Abstract

Bacterial infections are frequent and severe complications of alcoholic cirrhosis. Their in-hospital incidence rate fluctuates between 30 and 50%. Spontaneous bacterial peritonitis (SBP) with or without bacteremia, urinary tract infections and pneumonia are the most frequent. SBP and bacterial pneumonia prognosis are the most severe (30 to 40% of death). These bacterial infections are almost always seen in the setting of advanced liver disease. Organisms normally found in the gastrointestinal tract are the predominant causative agents of SBP. The pathogenesis of these infections involves bacterial translocation and ascitis is colonised from an episode of bacteremia. Severe cellular insufficiency and low ascitis protid are predictive factors of SBP. Gastrointestinal bleeding is another predisposing factor and furthermore, infection predisposes to portal hypertension-related bleeding recurrence. Treatment of active infection is an emergency and is based on non nephrotoxic antibiotics such as IV cefotaxime or oral fluoroquinolones in patients with no encephalopathy or renal insufficiency. Antibiotic prophylaxis is justified in patients recovering from a first spontaneous bacterial peritonitis episode or admitted for variceal bleeding. Bacteremia is due to the same bacteria as spontaneous bacterial peritonitis and their treatment is based on the same antibiotics. Urinary tract infections are mainly due to E Coli and are responsible for 5 to 15% of SBP and bacteremia cases. The causative germs of pneumonia and meningitis are pneumococcus but also gram-negative organisms. When the SBP outcome is unusual the diagnosis of tuberculosi must be ruled out. Finally, early diagnosis and treatment have improved severe bacterial infections prognosis in alcoholic cirrhotic patients but survivors of SBP should be considered for liver transplantation.