CC BY 4.0 · Semin Liver Dis 2020; 40(01): 011-019
DOI: 10.1055/s-0039-1693402
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Assessment and Management of Infection in Alcoholic Hepatitis

Nikhil Vergis
1   Department of Surgery & Cancer, Division of Digestive Diseases, Imperial College London, London, United Kingdom
,
Stephen R. Atkinson
1   Department of Surgery & Cancer, Division of Digestive Diseases, Imperial College London, London, United Kingdom
,
Mark R. Thursz
1   Department of Surgery & Cancer, Division of Digestive Diseases, Imperial College London, London, United Kingdom
› Author Affiliations
Further Information

Publication History

Publication Date:
01 August 2019 (online)

Abstract

Severe alcoholic hepatitis (SAH) is a condition characterized by jaundice and liver failure that develops after heavy and prolonged alcohol consumption. Infection frequently complicates the natural history of the disease and is independently associated with mortality. Objective recognition and recording of infection are therefore essential in the evaluation of therapeutic interventions and for antibiotic stewardship. This review will evaluate infections that complicate SAH at admission and beyond. Factors that associate with the development of infection will be identified and clinical and laboratory techniques available to identify infection will be discussed. Common pathogens and frequently used antibiotics will be reviewed and recommendations will be made for the management of infection for SAH patients. New techniques to assess infection earlier and more precisely may improve diagnosis and treatment of this important driver of mortality in SAH.

 
  • References

  • 1 Lucey MR, Mathurin P, Morgan TR. Alcoholic hepatitis. N Engl J Med 2009; 360 (26) 2758-2769
  • 2 Thursz MR, Richardson P, Allison M. , et al; STOPAH Trial. Prednisolone or pentoxifylline for alcoholic hepatitis. N Engl J Med 2015; 372 (17) 1619-1628
  • 3 Vergis N, Atkinson SR, Knapp S. , et al. In patients with severe alcoholic hepatitis, prednisolone increases susceptibility to infection and infection-related mortality, and is associated with high circulating levels of bacterial DNA. Gastroenterology 2017; 152 (05) 1068-1077.e4
  • 4 Dellinger RP, Carlet JM, Masur H. , et al. Surviving sepsis campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004; 32 (03) 858-873
  • 5 Dellinger RP, Levy MM, Carlet JM. , et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med 2008; 34 (01) 17-60
  • 6 Rhodes A, Evans LE, Alhazzani W. , et al. Surviving sepsis campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017; 43 (03) 304-377
  • 7 McPhail MJ, Shawcross DL, Abeles RD. , et al. Increased survival for patients with cirrhosis and organ failure in liver intensive care and validation of the chronic liver failure-sequential organ failure scoring system. Clin Gastroenterol Hepatol 2015; 13 (07) 1353-1360.e8
  • 8 Schmidt ML, Barritt AS, Orman ES, Hayashi PH. Decreasing mortality among patients hospitalized with cirrhosis in the United States from 2002 through 2010. Gastroenterology 2015; 148 (05) 967-977.e2
  • 9 Karakike E, Moreno C, Gustot T. Infections in severe alcoholic hepatitis. Ann Gastroenterol 2017; 30 (02) 152-160
  • 10 Louvet A, Wartel F, Castel H. , et al. Infection in patients with severe alcoholic hepatitis treated with steroids: early response to therapy is the key factor. Gastroenterology 2009; 137 (02) 541-548
  • 11 Arroyo V, Moreau R, Kamath PS. , et al. Acute-on-chronic liver failure in cirrhosis. Nat Rev Dis Prim 2016; 2: 16041
  • 12 Cabré E, Rodríguez-Iglesias P, Caballería J. , et al. Short- and long-term outcome of severe alcohol-induced hepatitis treated with steroids or enteral nutrition: a multicenter randomized trial. Hepatology 2000; 32 (01) 36-42
  • 13 Gustot T, Maillart E, Bocci M. , et al. Invasive aspergillosis in patients with severe alcoholic hepatitis. J Hepatol 2014; 60 (02) 267-274
  • 14 Forrest E, Storey N, Rohit S. , et al. Baseline neutrophil to lymphocyte ratio can identify favourable corticosteroid response in alcoholic hepatitis. J Hepatol 2017; 66 (01) S99
  • 15 Forrest EH, Atkinson SR, Richardson P. , et al; STOPAH trial Management Group. Application of prognostic scores in the STOPAH trial: discriminant function is no longer the optimal scoring system in alcoholic hepatitis. J Hepatol 2018; 68 (03) 511-518
  • 16 Sersté T, Moreno C, Gustot T. Reply to: “Prevalent acute-on-chronic liver failure and response to corticosteroids in alcoholic hepatitis”. J Hepatol 2018; 69 (05) 1201-1202
  • 17 Sersté T, Cornillie A, Njimi H. , et al. The prognostic value of acute-on-chronic liver failure during the course of severe alcoholic hepatitis. J Hepatol 2018; 69 (02) 318-324
  • 18 Michelena J, Altamirano J, Abraldes JG. , et al. Systemic inflammatory response and serum lipopolysaccharide levels predict multiple organ failure and death in alcoholic hepatitis. Hepatology 2015; 62 (03) 762-772
  • 19 Bennett JE, Dolin R, Blaser MJ. Mandell, Douglas, and Bennett’s Principles and Practice of Infectious Diseases. Vol. 1–2. Amsterdam, The Netherlands: Elsevier; 2004
  • 20 Kumar K, Mohindra S, Raj M, Choudhuri G. Procalcitonin as a marker of sepsis in alcoholic hepatitis. Hepatol Int 2014; 8 (03) 436-442
  • 21 Reinhart K, Meisner M. Biomarkers in the critically ill patient: procalcitonin. Crit Care Clin 2011; 27 (02) 253-263
  • 22 Atkinson SR, Maurice J, Vergis N, Forrest E, Thursz MR. Serum procalcitonin correlates with baseline renal function and predicts mortality in severe alcoholic hepatitis. J Hepatol 2017; 66 (01) S117
  • 23 Vergis N, Khamri W, Beale K. , et al. Defective monocyte oxidative burst predicts infection in alcoholic hepatitis and is associated with reduced expression of NADPH oxidase. Gut 2017; 66 (03) 519-529
  • 24 Ou C-Y, Vu T, Grunwald JT. , et al. An ultrasensitive test for profiling circulating tumor DNA using integrated comprehensive droplet digital detection. Lab Chip 2019; 19 (06) 993-1005
  • 25 MacVane SH, Nolte FS. Benefits of adding a rapid PCR-based blood culture identification panel to an established antimicrobial stewardship program. J Clin Microbiol 2016; 54 (10) 2455-2463
  • 26 Rosenstierne MW, Jensen CE, Fomsgaard A. Rapid, safe, and simple manual bedside nucleic acid extraction for the detection of virus in whole blood samples. J Vis Exp 2018 Doi: 10.3791/58001. (epub ahead of print)
  • 27 Magro L, Jacquelin B, Escadafal C. , et al. Paper-based RNA detection and multiplexed analysis for Ebola virus diagnostics. Sci Rep 2017; 7 (01) 1347
  • 28 Cuenca-Estrella M, Verweij PE, Arendrup MC. , et al; ESCMID Fungal Infection Study Group. ESCMID* guideline for the diagnosis and management of Candida diseases 2012: diagnostic procedures. Clin Microbiol Infect 2012; 18 (Suppl. 07) 9-18
  • 29 Iwanaga S. Biochemical principle of Limulus test for detecting bacterial endotoxins. Proc Jpn Acad, Ser B, Phys Biol Sci 2007; 83 (04) 110-119
  • 30 Sahin U, Toprak SK, Atilla PA, Atilla E, Demirer T. An overview of infectious complications after allogeneic hematopoietic stem cell transplantation. J Infect Chemother 2016; 22 (08) 505-514
  • 31 Marchetti O, Lamoth F, Mikulska M, Viscoli C, Verweij P, Bretagne S. ; European Conference on Infections in Leukemia (ECIL) Laboratory Working Groups. ECIL recommendations for the use of biological markers for the diagnosis of invasive fungal diseases in leukemic patients and hematopoietic SCT recipients. Bone Marrow Transplant 2012; 47 (06) 846-854
  • 32 Karageorgopoulos DE, Vouloumanou EK, Ntziora F, Michalopoulos A, Rafailidis PI, Falagas ME. β-D-glucan assay for the diagnosis of invasive fungal infections: a meta-analysis. Clin Infect Dis 2011; 52 (06) 750-770
  • 33 Senn L, Robinson JO, Schmidt S. , et al. 1,3-Beta-D-glucan antigenemia for early diagnosis of invasive fungal infections in neutropenic patients with acute leukemia. Clin Infect Dis 2008; 46 (06) 878-885
  • 34 Ellis M, Al-Ramadi B, Finkelman M. , et al. Assessment of the clinical utility of serial β-D-glucan concentrations in patients with persistent neutropenic fever. J Med Microbiol 2008; 57 (Pt 3): 287-295
  • 35 Lamoth F, Cruciani M, Mengoli C. , et al. β-glucan antigenemia assay for the diagnosis of invasive fungal infections in patients with hematological malignancies: A systematic review and meta-analysis of cohort studies from the third European Conference on Infections in Leukemia (ECIL-3). Clin Infect Dis 2012; 54 (05) 633-643
  • 36 Pfeiffer CD, Fine JP, Safdar N. Diagnosis of invasive aspergillosis using a galactomannan assay: a meta-analysis. Clin Infect Dis 2006; 42 (10) 1417-1427
  • 37 Shankar-Hari M, Datta D, Wilson J. , et al. Early PREdiction of sepsis using leukocyte surface biomarkers: the ExPRES-sepsis cohort study. Intensive Care Med 2018; 44 (11) 1836-1848
  • 38 Markwick LJ, Riva A, Ryan JM. , et al. Blockade of PD1 and TIM3 restores innate and adaptive immunity in patients with acute alcoholic hepatitis. Gastroenterology 2015; 148 (03) 590-602.e10
  • 39 Mookerjee RP, Stadlbauer V, Lidder S. , et al. Neutrophil dysfunction in alcoholic hepatitis superimposed on cirrhosis is reversible and predicts the outcome. Hepatology 2007; 46 (03) 831-840
  • 40 Riva A, Patel V, Kurioka A. , et al. Mucosa-associated invariant T cells link intestinal immunity with antibacterial immune defects in alcoholic liver disease. Gut 2018; 67 (05) 918-930
  • 41 Naveau S, Chollet-Martin S, Dharancy S. , et al; Foie-Alcool group of the Association Française pour l'Etude du Foie. A double-blind randomized controlled trial of infliximab associated with prednisolone in acute alcoholic hepatitis. Hepatology 2004; 39 (05) 1390-1397
  • 42 Boetticher NC, Peine CJ, Kwo P. , et al. A randomized, double-blinded, placebo-controlled multicenter trial of etanercept in the treatment of alcoholic hepatitis. Gastroenterology 2008; 135 (06) 1953-1960
  • 43 Nguyen-Khac E, Thevenot T, Piquet M-A. , et al; AAH-NAC Study Group. Glucocorticoids plus N-acetylcysteine in severe alcoholic hepatitis. N Engl J Med 2011; 365 (19) 1781-1789
  • 44 Fernández J, Prado V, Trebicka J. , et al; European Foundation for the Study of Chronic Liver Failure (EF-Clif). Multidrug-resistant bacterial infections in patients with decompensated cirrhosis and with acute-on-chronic liver failure in Europe. J Hepatol 2019; 70 (03) 398-411
  • 45 Jalan R, Fernandez J, Wiest R. , et al. Bacterial infections in cirrhosis: a position statement based on the EASL Special Conference 2013. J Hepatol 2014; 60 (06) 1310-1324
  • 46 Piano S, Singh V, Caraceni P. , et al. Epidemiology and effects of bacterial infections in patients with cirrhosis worldwide. Gastroenterology 2019; 156 (05) 1368-1380
  • 47 Bajaj JS, O'Leary JG, Reddy KR. , et al; NACSELD. Second infections independently increase mortality in hospitalized patients with cirrhosis: the North American consortium for the study of end-stage liver disease (NACSELD) experience. Hepatology 2012; 56 (06) 2328-2335
  • 48 Bajaj JS, Heuman DM, Sanyal AJ. , et al. Modulation of the metabiome by rifaximin in patients with cirrhosis and minimal hepatic encephalopathy. PLoS One 2013; 8 (04) e60042
  • 49 Achord JL. A prospective randomized clinical trial of peripheral amino acid-glucose supplementation in acute alcoholic hepatitis. Am J Gastroenterol 1987; 82 (09) 871-875
  • 50 Bonkovsky HL, Singh RH, Jafri IH. , et al. A randomized, controlled trial of treatment of alcoholic hepatitis with parenteral nutrition and oxandrolone. II. Short-term effects on nitrogen metabolism, metabolic balance, and nutrition. Am J Gastroenterol 1991; 86 (09) 1209-1218
  • 51 Simon D, Galambos JT. A randomized controlled study of peripheral parenteral nutrition in moderate and severe alcoholic hepatitis. J Hepatol 1988; 7 (02) 200-207
  • 52 Templeton A, Schlegel M, Fleisch F. , et al. Multilumen central venous catheters increase risk for catheter-related bloodstream infection: prospective surveillance study. Infection 2008; 36 (04) 322-327