الفهرس 
BACTERIAL INFECTIONS IN LIVER CIRRHOSIS
Mechanism of increased susceptibility to bacterial infection in patients with liver cirrhosisOnly 14 pages are availabe for public view
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Abstract
Bacterial infection is common and represents major cause of Morbidity and mortality in cirrhosise specially in the decompensated phase. Patients with cirrhosis are immuno-compromised and have an increased susceptibility to develop spontaneous bacterial infections, hospital-acquired infections, and a variety of infections from uncommon pathogens.
Moreover, bacterial infections have been acknowledged as a potential trigger factor in many complications of cirrhosis, including variceal bleeding, hepatic encephalopathy, renal failure and impairment in clotting factors.
Early identification of bacterial infections in patients with chronic liver disease is sometimes challenging. The clinical presentation is usually vague and atypical and the value of SIRS criteria for detection of sepsis is decreased Additionally the bacterial cultures require at least 24-48 hours for providing any results, thus delaying diagnosis and treatment Therefore the identification of other clinical and laboratory parameters would be of special interest in those patients.
Lately, inflammatory biomarkers such as CRP and PCT have been investigated as a tool for early diagnosis of bacterial infections in several clinical settings. Some studies have shown that CRP and PCT are reliable markers for diagnosis of bacterial infections in patients with chronic liver disease. However, their diagnostic accuracy and the cutoff values were highly variable.
The aim of this study was to evaluate the performance of CRP and PCT as markers for early diagnosis of bacterial infections in patients with end-stage liver disease and/or potential candidates for liver transplantation. To reach this aim, this case- control study has included 75 patients with dcompensated end stage liver disease, who were selected from ASCOT as well as from the Tropical medicine department Ain shams university.
The patients were then classified into three groups group A: was formed of 25 patients who were diagnosed as having chronic liver disease without confirmed bacterial infection (this group was designed to identify the effect of decompensated liver disease on the CRP value without the presence of bacterial infection), group B: (the control group): was formed of 25 patients, who were diagnosed as having end stage liver disease without confirmed bacterial infection (potential candidates for liver transplantation) and group C (the case group): was formed of 25 patients who were diagnosed as having end stage liver disease with confirmed bacterial infection).
The diagnosis of infection was established by assessment of clinical symptoms, appearance of fever and laboratory reports, including microbiological culture results (if available),compatible findings of imaging techniques, and the effect of antibiotic treatment.
Infections of skin and soft tissue, orocavital region, upper and lower respiratory tract (acute bronchitis, pneumonia), biliary tract (cholecystitis, cholangitis, liver abscess), intestinal tract (gastroenteritis), urinary tract (cystitis, pyelonephritis), osteomyelitis, and endocarditis were diagnosed on the basis of conventional criteria. The diagnosis of spontaneous bacterial peritonitis was made of the ascitic fluid polymorphonuclear cell (PMN) count was greater than 250/mm3, with or without positive culture, in the absence of an intra-abdominal source of infection. Bacteriemia was considered when clinical symptoms and signs of infection were present and confirmed by microbiological demonstration of the causative organism from blood culture in the absence of Site-specific infection.
In the current study and in the absence of confirmed infection the basal level of CRP was found to be elevated in cirrhotic patients.
In this study we found that the most frequent bacterial infection in the cirrhotic patients was UTI followed by SBP, Bacteraemia, pneumonia & Bacterascitis.
High levels of CRP and PCT were observed in infected cirrhotic patients and so, we can consider those markers as a marker for diagnosis of bacterial infections in cirrhotic patients.By using ROC analysis in determining the diagnostic accuracy of CRP and PCT in cirrhotic patients with infections we concluded]. The diagnostic accuracy of PCT [sensitivity (96%), specificity (92%) at cut off point (>0.5)] was higher than that of CRP [sensitivity (92%) and specificity (56%) at cut off point (>1.1)]. In the diagnosis of bacterial infection in cirrhotic patients. Also the positive predictive value (PPV) for PCT (92.3%) was higher than that for CRP (56%) and the negative predictive value (NPV) for PCT (95.8%) was higher than that for CRP (87.5%).
The current study showed No statistically significant relation between the severity of liver disease (assessed by Child-Pugh score) and noninvasive markers of bacterial infection (CRP & PCT).
And on the other hand both CRP and PCT had a statistically significant inverse relationship with MELD score in the infected cirrhotic patients.