Engelmann Cornelius, Berg Thomas
Section Hepatology, Department of Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany.
Visc Med. 2018 Aug;34(4):261-268. doi: 10.1159/000491107. Epub 2018 Jul 27.
Acute-on-chronic liver failure (ACLF) is associated with a high susceptibility to infections leading to complications and poor prognosis. The sensitized immune system overwhelmingly responds to invading bacteria leading to organ damage. After resolution of infection or prolonged disease duration, the phagocytic system becomes irresponsive with a reduced bacterial clearance capacity promoting secondary infection.
This review focuses on the best management strategies for patients with ACLF and infections. Using the following terms, an extensive literature research on the Medline database was performed: 'acute-on-chronic liver failure', 'infection', 'ACLF', 'bacteria', 'multi-resistance'.
Analysis of the literature confirmed that delayed diagnosis and treatment of infections in patients with ACLF results in a poor prognosis. Patients with ACLF should be considered as having a potential infection and should undergo a complete screening for sepsis. Once biochemical analysis indicates a potential infection, such as abnormal levels of C-reactive protein and procalcitonin, antibiotic treatment should be initiated immediately without microbiological culture results. For community-acquired infections third-generation cephalosporins are still the first choice, whereas in the nosocomial setting antibiotics with broader spectrum, such as piperacillin/combactam or carbapenems ± glycopeptides, are preferred. The patient should be re-assessed 48 h after treatment initiation in order to tailor the treatment. Non-response is suspicious, likely due to bacterial resistance or fungal infection, which should be considered when choosing further treatment strategies. Albumin substitution to prevent hepatorenal syndrome and to improve patients' outcome is mandatory in patients with spontaneous bacterial peritonitis. Prophylactic antibiotic therapy is suitable to prevent infections in high-risk patients.
The screening for infections and its treatment is an essential part of managing patients with ACLF. In order to improve patients' prognosis, antibiotic treatment should be initiated once an infection is suspected. However, preventive strategies are already established and should be applied according to the guidelines.
慢加急性肝衰竭（ACLF）患者极易发生感染，进而引发并发症，预后较差。致敏的免疫系统对入侵细菌产生强烈反应，导致器官损伤。感染得到控制或疾病持续时间延长后，吞噬系统反应迟钝，细菌清除能力下降，从而促进继发感染。
本综述聚焦于ACLF合并感染患者的最佳管理策略。使用以下检索词在Medline数据库中进行了广泛的文献研究：“慢加急性肝衰竭”、“感染”、“ACLF”、“细菌”、“多重耐药”。
文献分析证实，ACLF患者感染的延迟诊断和治疗会导致预后不良。ACLF患者应被视为有潜在感染风险，应进行全面的脓毒症筛查。一旦生化分析表明存在潜在感染，如C反应蛋白和降钙素原水平异常，即使没有微生物培养结果，也应立即开始抗生素治疗。对于社区获得性感染，第三代头孢菌素仍是首选，而在医院环境中，更倾向于使用广谱抗生素，如哌拉西林/舒巴坦或碳青霉烯类药物±糖肽类药物。治疗开始48小时后应对患者进行重新评估，以便调整治疗方案。治疗无反应令人怀疑，可能是由于细菌耐药或真菌感染，在选择进一步治疗策略时应予以考虑。对于自发性细菌性腹膜炎患者，必须进行白蛋白替代治疗以预防肝肾综合征并改善患者预后。预防性抗生素治疗适用于预防高危患者的感染。
感染筛查及其治疗是ACLF患者管理的重要组成部分。为改善患者预后，一旦怀疑感染应立即开始抗生素治疗。然而，预防性策略已经确立，应根据指南应用。
