Skip to main content

Advertisement

SpringerLink
Log in

Opportunistic infection in patients with acute liver failure

  • Original Article
  • Published:
Hepatology International Aims and scope Submit manuscript

Abstract

Background

Treatment with systemic corticosteroids is often used for acute liver failure (ALF), but this has increased the number of profoundly immunocompromised patients and cases of opportunistic infection.

Methods

Between January 2007 and December 2012, all patients (n = 51) referred to the Chiba University Hospital for treatment of ALF were studied. Patients with prothrombin activity of 40 % or less of the standardized values were defined as having ALF. Patient age, sex, cause of ALF, alanine aminotransferase and total bilirubin levels, prothrombin activity and total amount of corticosteroid were analyzed to determine the factors associated with the occurrence of opportunistic infection.

Results

Opportunistic infections occurred in 21.6 % (n = 11) of ALF patients. Thirty-five patients underwent systemic corticosteroid therapy, and 31.4 % of those patients showed opportunistic infections. Cytomegalovirus (n = 9, 81.8 %) and Pneumocystis jiroveci (n = 6, 54.5 %) were the microorganisms frequently suspected as the causes of opportunistic infection. In 7 (63.6 %) of the 11 cases of opportunistic infection, 2 or more species of microorganism were detected. Seven patients (63.6 %) with opportunistic infection were cured by treatment. Cox regression analysis for the patients who underwent systemic corticosteroid therapy steroid treatment revealed that age over 52 years (compared to younger patients: odds ratio = 9.62, 95 % confidence interval = 1.22–76.9) was only the predictive factor for the occurrence of opportunistic infection.

Conclusion

Opportunistic infections are not rare in ALF patients, and the appropriate diagnosis and treatment of these infections are critical during ALF treatment.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

Abbreviations

ALF:

Acute liver failure

PSL:

Prednisolone

ALT:

Alanine aminotransferase

T-Bil:

Total bilirubin

SD:

Standard deviation

OR:

Odds ratio

CI:

Confidence interval

IU:

International units

RA:

Rheumatoid arthritis

References

  1. Czaja AJ, Freese DK. Diagnosis and treatment of autoimmune hepatitis. Hepatology 2002;36:479–497

    Article  PubMed  Google Scholar 

  2. Fujiwara K, Yasui S, Yonemitsu Y, Fukai K, Arai M, Imazeki F, et al. Efficacy of combination therapy of antiviral and immunosuppressive drugs for the treatment of severe acute exacerbation of chronic hepatitis B. J Gastroenterol 2008;43:711–719

    Article  PubMed  CAS  Google Scholar 

  3. Fujiwara K, Yasui S, Yonemitsu Y, Mikata R, Arai M, Kanda T, et al. Efficacy of high-dose corticosteroid in the early stage of viral acute liver failure. Hepatol Res 2013; doi:10.1111/hepr.12148

    Google Scholar 

  4. Vaquero J, Polson J, Chung C, Helenowski I, Schiodt FV, Reisch J, et al. Infection and the progression of hepatic encephalopathy in acute liver failure. Gastroenterology 2003;125(3):755–764

    Article  PubMed  Google Scholar 

  5. Smith JA, Kauffman CA. Pulmonary fungal infections. Respirology 2012;17:913–926

    Article  PubMed  Google Scholar 

  6. Eizuru Y, Minematsu T, Minamishima Y, Ebihara K, Takahashi K, Tamura K, et al. Rapid diagnosis of cytomegalovirus infection by direct immunoperoxidase staining with human monoclonal antibody against an immediate early antigen. Microbiol Immunol 1991;35:1015–1022

    Article  PubMed  CAS  Google Scholar 

  7. Arai M, Imazeki F, Yonemitsu Y, Kanda T, Fujiwara K, Fukai K, et al. Opportunistic infection in the patients with acute liver failure: a report of three cases with one fatality. Clin J Gastroenterol 2009;2:420–424

    Article  Google Scholar 

  8. Trikudanathan S, McMahon GT. Optimum management of glucocorticoid-treated patients. Nat Clin Pract Endocrinol Metab 2008;4:262–271

    Article  PubMed  CAS  Google Scholar 

  9. Ford AC, Peyrin-Biroulet L. Opportunistic infections with anti-tumor necrosis factor-α therapy in inflammatory bowel disease: meta-analysis of randomized controlled trials. Am J Gastroenterol 2013;108(8):1268–1276

    Article  PubMed  CAS  Google Scholar 

  10. Hoyo I, Sanclemente G, Cervera C, Cofán F, Ricart MJ, Perez-Villa F, et al. Opportunistic pulmonary infections in solid organ transplant recipients. Transpl Proc 2012;44:2673–2675

    Article  CAS  Google Scholar 

  11. Rolando N, Harvey F, Brahm J, Philpott-Howard J, Alexander G, Gimson A, et al. Prospective study of bacterial infection in acute liver failure: an analysis of fifty patients. Hepatology 1990;11:49–53

    Article  PubMed  CAS  Google Scholar 

  12. Rolando N, Philpott-Howard J, Williams R. Bacterial and fungal infection in acute liver failure. Semin Liver Dis 1996;16:389–402

    Article  PubMed  CAS  Google Scholar 

  13. Ware AJ, Jones RE, Thorey JW, Combes B. A controlled trial of steroid therapy in massive hepatic necrosis. Am J Gastroenterol 1974;62:130–133

    PubMed  CAS  Google Scholar 

  14. Redeker AG, Schweitzer IL, Yamahiro HS. Randomization of corticosteroid therapy in fulminant hepatitis. N Engl J Med 1976;294:728–729 letter

    Article  PubMed  CAS  Google Scholar 

  15. Randomized trial of steroid therapy in acute liver failure: a report from the European Association for the Study of the Liver. Gut 1979;20:620–623

  16. Rakela J, Mosley JW, Edwards VM, Govindarajan S, Alpert E, The Acute Hepatic Failure Study Group. Double-blinded, randomized trial of hydrocortisone in acute hepatic failure. Dig Dis Sci 1991;36:1223–1228

    Article  PubMed  CAS  Google Scholar 

  17. Oketani M, Ido A, Nakayama N, Takikawa Y, Naiki T, Yamagishi Y, et al. Etiology and prognosis of fulminant hepatitis and late-onset hepatic failure in Japan: Summary of the annual nationwide survey between 2004 and 2009. Hepatol Res 2013;2:97–105

    Article  Google Scholar 

  18. Rolando N, Gimson A, Wade J, Philpott-Howard J, Casewell M, Williams R. Prospective controlled trial of selective parenteral and enteral antimicrobial regimen in fulminant liver failure. Hepatology 1993;17:196–201

    Article  PubMed  CAS  Google Scholar 

  19. Salmerón JM, Titó L, Rimola A, Mas A, Navasa MA, Llach J, et al. Selective intestinal decontamination in the prevention of bacterial infection in patients with acute liver failure. J Hepatol 1992;14:280–285

    Article  PubMed  Google Scholar 

  20. Hughes WT, Armstrong D, Bodey GP, Bow EJ, Brown AE, Calandra T, et al. 2002 guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clin Infect Dis 2002;34:730–751

    Article  PubMed  Google Scholar 

  21. Pizzo PA, Robichaud KJ, Gill FA, Witebsky FG. Empiric antibiotic and antifungal therapy for cancer patients with prolonged fever and granulocytopenia. Am J Med 1982;72:101–111

    Article  PubMed  CAS  Google Scholar 

  22. EORTC International Antimicrobial Therapy Cooperative Group. Empiric antifungal therapy in febrile granulocytopenic patients. Am J Med 1989;86(6 Pt 1):668–672

    Google Scholar 

  23. Iriyama N, Matsukawa Y, Miura K, Inomata H, Hirabayashi Y, Hatta Y, et al. Efficacy and safety of antifungal prophylaxis with oral itraconazole solution among patients receiving corticosteroids: who should be given prophylaxis? J Infect Chemother 2011;17:744–749

    Article  PubMed  CAS  Google Scholar 

  24. Thomas CF Jr, Limper AH. Pneumocystis pneumonia. N Engl J Med 2004;350:2487–2498

    Article  PubMed  CAS  Google Scholar 

  25. Alberti-Flor JJ, Hernandez ME, Ferrer JP, Howell S, Jeffers L. Fulminant liver failure and pancreatitis associated with the use of sulfamethoxazole-trimethoprim. Am J Gastroenterol 1989;84:1577–1579

    PubMed  CAS  Google Scholar 

  26. Zaman F, Ye G, Abreo KD, Latif S, Zibari GB. Successful orthotopic liver transplantation after trimethoprim-sulfamethoxazole associated fulminant liver failure. Clin Transpl 2003;17:461–464

    Article  Google Scholar 

  27. Sarkar D, Fisher PB. Molecular mechanisms of aging-associated inflammation. Cancer Lett 2006;236:13–23

    Article  PubMed  CAS  Google Scholar 

  28. Caruso C, Lio D, Cavallone L, Franceschi C. Aging, longevity, inflammation, and cancer. Ann N Y Acad Sci 2004;1028:1–13

    Article  PubMed  CAS  Google Scholar 

  29. Chung HY, Cesari M, Anton S, Marzetti E, Giovannini S, Seo AY, et al. Molecular inflammation: underpinnings of aging and age-related diseases. Ageing Res Rev 2009;8:18–30

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  30. Komano Y, Harigai M, Koike R, Sugiyama H, Ogawa J, Saito K, et al. Pneumocystis jiroveci pneumonia in patients with rheumatoid arthritis treated with infliximab: a retrospective review and case-control study of 21 patients. Arthr Rheum 2009;61:305–312

    Article  CAS  Google Scholar 

Download references

Compliance with ethical requirements and Conflict of interest

The study was reviewed and approved by the institutional review board of Chiba University School of Medicine. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008. Informed consent was obtained from all patients for being included in the study. The authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

  1. Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Inohana 1-8-1, Chiba, 260-8670, Japan

    Makoto Arai, Tatsuo Kanda, Shin Yasui, Keiichi Fujiwara, Fumio Imazeki & Osamu Yokosuka

  2. Division of Control and Treatment of Infectious Disease, Chiba University, Chiba, Japan

    Akira Watanabe & Takeyuki Sato

  3. Department of Emergency and Critical Care Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan

    Shigeto Oda

Authors
  1. Makoto Arai
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Tatsuo Kanda
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Shin Yasui
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Keiichi Fujiwara
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Fumio Imazeki
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Akira Watanabe
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Takeyuki Sato
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Shigeto Oda
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Osamu Yokosuka
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Makoto Arai.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Arai, M., Kanda, T., Yasui, S. et al. Opportunistic infection in patients with acute liver failure. Hepatol Int 8, 233–239 (2014). https://doi.org/10.1007/s12072-013-9514-4

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12072-013-9514-4

Keywords

Search

Navigation