Papp Mária, Farkas Anikó, Udvardy Miklós, Tornai István
Debreceni Egyetem, Orvos- és Egészségtudományi Centrum, Altalános Orvostudományi Kar Belgyógyászati Intézet, Gasztroenterológiai Tanszék Debrecen Nagyerdei krt. 98. 4012, Hungary.
Orv Hetil. 2007 Mar 4;148(9):387-95. doi: 10.1556/OH.2007.27882.
Bacterial infections are well described complications of cirrhosis that greatly increase mortality rates. Two factors play important roles in the development of bacterial infections in these patients: the severity of liver disease and gastrointestinal haemorrhage. The most common infections are spontaneous bacterial peritonitis, urinary tract infections, pneumonia and sepsis. Gram-negative and gram-positive bacteria are equal causative organisms. For primary prophylaxis, short-term antibiotic treatment (oral norfloxacin or ciprofloxacin) is indicated in cirrhotic patients (with or without ascites) admitted with gastrointestinal haemorrhage (variceal or non-variceal). Administration of norfloxacin is advisable for hospitalized patients with low ascitic protein even without gastrointestinal haemorrhage. The first choice in empirical treatment of spontaneous bacterial peritonitis is the iv. III. generation cephalosporin; which can be switched for a targeted antibiotic regime based on the result of the culture. The duration of therapy is 5-8 days. Amoxicillin/clavulanic acid and fluoroquinolones--patients not on prior quinolone prophylaxis--were shown to be as effective and safe as cefotaxime. In patients with evidence of improvement, iv. antibiotics can be switched safely to oral antibiotics after 2 days. In case of renal dysfunction, iv albumin should also be administered. Long-term antibiotic prophylaxis is recommended in patients who have recovered from an episode of spontaneous bacterial peritonitis (secondary prevention). For "selective intestinal decontamination", poorly absorbed oral norfloxacin is the preferred schedule. Oral ciprofloxacin or levofloxacin (added gram positive spectrum) all the more are reasonable alternatives. Trimethoprim/sulfamethoxazole is only for patients who are intolerant to quinolones. Prophylaxis is indefinite until disappearance of ascites, transplant or death. Long-term prophylaxis is currently not recommended for patients without previous spontaneous bacterial peritonitis episode, not even when refractory ascites or low ascites protein content is present.
细菌感染是肝硬化常见的并发症，会显著增加死亡率。在这些患者发生细菌感染的过程中，有两个因素起着重要作用：肝病的严重程度和胃肠道出血。最常见的感染是自发性细菌性腹膜炎、尿路感染、肺炎和败血症。革兰氏阴性菌和革兰氏阳性菌是同等的致病微生物。对于一级预防，对于因胃肠道出血（静脉曲张或非静脉曲张）入院的肝硬化患者（无论有无腹水），建议进行短期抗生素治疗（口服诺氟沙星或环丙沙星）。对于腹水蛋白含量低的住院患者，即使没有胃肠道出血，服用诺氟沙星也是可取的。自发性细菌性腹膜炎经验性治疗的首选是静脉注射第三代头孢菌素；可根据培养结果改为针对性的抗生素治疗方案。治疗持续时间为5 - 8天。阿莫西林/克拉维酸和氟喹诺酮类药物（未接受过喹诺酮类药物预防的患者）被证明与头孢噻肟一样有效和安全。在病情有改善迹象的患者中，静脉注射抗生素2天后可安全地改为口服抗生素。如果出现肾功能不全，也应静脉注射白蛋白。对于从自发性细菌性腹膜炎发作中康复的患者，建议进行长期抗生素预防（二级预防）。对于“选择性肠道去污”，口服吸收差的诺氟沙星是首选方案。口服环丙沙星或左氧氟沙星（增加革兰氏阳性菌谱）更是合理的替代方案。复方新诺明仅适用于对喹诺酮类药物不耐受的患者。预防措施一直持续到腹水消失、移植或死亡。目前不建议对既往无自发性细菌性腹膜炎发作的患者进行长期预防，即使存在顽固性腹水或腹水蛋白含量低的情况。
