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Infektionen bei Leberzirrhose – von bakterieller Translokation über spontan-bakterielle Peritonitis und Pneumonie zum akut-auf-chronischen Leberversagen

Infections in patients with liver cirrhosis—from bacterial translocation to spontaneous bacterial peritonitis and pneumonia to acute-on-chronic liver failure

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Zusammenfassung

Patienten mit Leberzirrhose haben ein deutlich erhöhtes Risiko für Infektionen. Etwa 25–35 % der Patienten mit Leberzirrhose weisen bei Aufnahme in ein Krankenhaus eine Infektion auf oder entwickeln diese im Lauf der Hospitalisation. Grund hierfür ist eine Dysfunktion des Immunsystems, die „cirrhosis-associated immune dysfunction“ (CAID). Die häufigsten Primärinfektionen bei Patienten mit Leberzirrhose sind Harnwegsinfektionen (25 %), spontan-bakterielle Peritonitis (23 %), Bakteriämie (21 %) sowie Haut- und Weichteilinfektionen (13 %). Bei den nosokomialen Infektionen der Patienten mit Leberzirrhose spielen Aspiration und ventilatorassoziierte respiratorische Infektionen (28 %), Harnwegsinfektionen (26 %), Pilzinfektionen (14 %) sowie Clostridioides-difficile-Infektionen (12 %) eine entscheidende Rolle. Das akut-auf-chronische Leberversagen („acute-on-chronic liver failure“, ACLF) ist durch eine akute Dekompensation einer chronischen Lebererkrankung definiert, die mit mindestens einem Organversagen einhergeht und mit einer hohen Letalität assoziiert ist. In Europa sind bakterielle Infektionen Hauptauslöser für ein ACLF. Das Erregerspektrum, das ursprünglich durch gramnegative Bakterien charakterisiert war, verschiebt sich zunehmend in Richtung grampositiver und multiresistenter Bakterien sowie fungaler Infektionen. Dies führt zu einer Erhöhung des Risikos für schwere Verläufe mit hoher Letalität. Von klinisch höchster Relevanz und prognosedeterminierend ist daher eine schnelle antibiotische und antimykotische Infekttherapie. Bei ACLF sollte immer die Indikation zur Lebertransplantation berücksichtigt und im Transplantationsteam evaluiert werden.

Abstract

Patients with liver cirrhosis have an increased risk of developing infections and sepsis. Infection is present at admission or develops during hospitalization in about 25 to 35% of patients. The most common infections in patients with cirrhosis reported in the literature include urinary tract infections (25%), spontaneous bacterial peritonitis (23%), spontaneous bacteremia (21%) and skin and soft tissue infections (13%). Of clinical importance: 24% of patients develop a second infection during their hospitalization; these include: aspiration and ventilation-related respiratory infections (28%), urinary infections including catheter-related infections (26%), fungal infections (14%), and Clostridioides difficile infections (12%). Acute-on-chronic liver failure (ACLF) is characterized by acute decompensation of chronic liver disease, which is associated with organ failure and high mortality. In Europe, the main triggers for ACLF are bacterial infections. Thus, bacterial infections must be systemically sought in patients with liver cirrhosis, since they may appear as a precipitant or a consequence of ACLF. Deterioration of liver function and consequent increase in MELD (Model of End-state Liver Disease) score or encephalopathy may be the only signs of an ongoing infection in patients with chronic liver disease due to an underlying cirrhosis-associated immune dysfunction (CAID). An early diagnosis followed by an empirical antibiotic therapy is therefore crucial. Moreover, a fungal infection should always be discussed in these high-risk patients. Of clinical relevance, multidrug resistant (MDR) bacterial infections constitute a prevalent, growing healthcare problem in patients with decompensated liver cirrhosis and ACLF across Europe and negatively affect prognosis.

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  1. Klinik und Poliklinik für Innere Medizin 1, Universitätsklinikum Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland

    S. Schmid, S. Scherm, M. Haderer, K. Gülow & M. Müller-Schilling

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Schmid, S., Scherm, S., Haderer, M. et al. Infektionen bei Leberzirrhose – von bakterieller Translokation über spontan-bakterielle Peritonitis und Pneumonie zum akut-auf-chronischen Leberversagen. Gastroenterologe 15, 201–210 (2020). https://doi.org/10.1007/s11377-020-00439-6

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