Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain.
Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Barcelona, Spain.
Hepatology. 2016 Jun;63(6):2019-31. doi: 10.1002/hep.28330. Epub 2016 Jan 11.
Patients with cirrhosis, particularly those with decompensated cirrhosis, are at increased risk of bacterial infections that may further precipitate other liver decompensations including acute-on-chronic liver failure. Infections constitute the main cause of death in patients with advanced cirrhosis, and strategies to prevent them are essential. The main current strategy is the use of prophylactic antibiotics targeted at specific subpopulations at high risk of infection: prior episode of spontaneous bacterial peritonitis, upper gastrointestinal bleeding, and low-protein ascites with associated poor liver function. Antibiotic prophylaxis effectively prevents not only the development of bacterial infections in all these indications but also further decompensation (variceal bleeding, hepatorenal syndrome) and improves survival. However, antibiotic prophylaxis is also associated with a clinically relevant and increasing drawback, the development of infections due to multidrug-resistant organisms. Several strategies have been suggested to balance the risks and benefits of antibiotic prophylaxis.
Antibiotic stewardship principles such as the restriction of antibiotic prophylaxis to subpopulations at a very high risk for infection, the avoidance of antibiotic overuse, and early deescalation policies are key to achieve this balance; nonantibiotic prophylactic measures such as probiotics, prokinetics, bile acids, statins, and hematopoietic growth factors could also contribute to ameliorate the development and spread of multidrug-resistant bacteria in cirrhosis. (Hepatology 2016;63:2019-2031).
目的：阐明肝硬化患者，尤其是失代偿期肝硬化患者，发生细菌感染的风险增加，这可能进一步导致其他肝失代偿，包括慢加急性肝衰竭。感染是肝硬化终末期患者死亡的主要原因，预防感染的策略至关重要。目前的主要策略是使用针对特定高危感染人群的预防性抗生素：自发性细菌性腹膜炎、上消化道出血和低蛋白性腹水伴肝功能不良。抗生素预防不仅能有效预防所有这些适应证中细菌感染的发生，还能预防进一步的失代偿（静脉曲张出血、肝肾综合征），并改善生存率。然而，抗生素预防也存在相关的临床缺陷，即发生多重耐药菌感染。已经提出了几种策略来平衡抗生素预防的风险和获益。
结论：抗生素管理原则，如将抗生素预防限于感染风险极高的亚群、避免抗生素过度使用以及早期降阶梯策略，是实现这种平衡的关键；非抗生素预防措施，如益生菌、促动力药、胆汁酸、他汀类药物和造血生长因子，也可能有助于改善肝硬化中多重耐药菌的发生和传播。
