Management of infection

Patients with acute liver failure are particularly susceptible to bacterial and fungal infections. In a prospective study of 50 patients, Rolando et al. found that 90% developed bacterial, and 32% fungal, infection. This usually arose within 3 days of admission, and the usual clinical signs of infection were often absent.

Prophylactic antimicrobial therapy does not appear to influence outcome and is not recommended (1) but empirical antimicrobials (e.g. rifaximin, neomycin/paromomycin/metronidazole, or vancomycin) are recommended if a patient develops positive surveillance cultures, refractory hypotension, progression to grade 3 to 4 hepatic encephalopathy, evidence of Systemic Inflammatory Response Syndrome, and in all patients who are listed for liver transplant. (2)

Liver transplantation is less likely to be feasible if antimicrobial therapy is delayed until the onset of clinical evidence of infection.

The choice of agents should be guided by the incidence, type and aetiology of infections in a given centre.

Rifaximin is recommended by the National Institute for Health and Care Excellence (NICE) as an option for reducing the recurrence of episodes of overt hepatic encephalopathy in people aged 18 years or older. (3)

Reference

1. Shingina A, Mukhtar N, Wakim-Fleming J, et al. Acute liver failure guidelines. Am J Gastroenterol. 2023 Jul 1;118(7):1128-53.
2. Stravitz RT, Kramer AH, Davern T, et al. Intensive care of patients with acute liver failure: recommendations of the U.S. Acute Liver Failure Study Group. Crit Care Med. 2007 Nov;35(11):2498-508.
3. NICE. Rifaximin for preventing episodes of overt hepatic encephalopathy. Technology appraisal guidance TA337, published March 2015