Acute on Chronic Liver Failure: Role of the Bacterial Infections

Acute-on-chronic liver failure (ACLF) refers to a syndrome characterized by acute deterioration of liver function of a pre-existing chronic liver disease with increased short-term mortality at 3 months due to multiorgan failure. Definition of ACLF has been refined, but differences between western and eastern areas still exist. Diagnosis of ACLF as recommended by the EASL-CLIF consortium is based on the assessment of organ dysfunction. The pathogenesis of this syndrome is attributable to an exaggerated host response to inflammation, responsible for the severe haemodynamic derangement leading to multiorgan failure. ACLF is triggered by precipitating events like acute hepatitis either viral, drug-induced, toxic, or alcoholic, variceal bleeding and sepsis. Bacterial infection is currently considered the most frequent trigger of ACLF in Western countries. Cirrhotic patients, particularly if decompensated are prone to develop bacterial infection because loss of integrity of the intestinal mucosal barrier and translocation of pathogen-associated molecular patterns (PAMPs). Bacterial translocation may develop into overt infection at different sites, along with sepsis and septic shock that may lead to ACLF. Epidemiology of bacterial infection in cirrhosis has been changing and this accounts for new antibiotic regimens as empirical therapy in critically ill cirrhotic patients with bacterial infection. In this chapter, we will discuss on definition, pathogenesis, clinical aspects and therapy of bacterial infection-related ACLF.