Discussion:
This case presentation provokes multiple questions most importantly, but
not limited to, the timing of antibiotics used in the hospital setting.
Also, the consideration for empiric antibiotics for bacteremia and
possible fungal infections in the cirrhotic. Interestingly, the
connection between spontaneous bacterial peritonitis (SBP) and the
prophylactic use of ciprofloxacin is well established, although the
necessity to empirically cover for fungus in the cirrhotic septic
patient is not11. Of note, other immunosuppressive
conditions such as HIV are treated with prophylactic medications to
prevent serious infections, including fungal infections. A retrospective
study by Kumar et al. suggests that every hour of delay regarding
antibiotic coverage in a cirrhotic lead to decreased survival by
7.6%12. Cirrhosis alters normal physiology, often
masking indicators of severe sepsis such as hypotension, leukopenia, and
dysfunction of thermoregulation2,3,4. Thus, early
detection of severe sepsis and appropriate coverage can be delayed,
further leading to difficult detection
Plessier et al. established fungal infections are responsible for
up to 15% of cirrhotic infections13. The patient
presented in this case was not started on fungal coverage until multiple
days into the hospital admission. During the hospital course the patient
initially had decreasing pressor requirements attributed to appropriate
bacterial coverage for Acinetobacter Baumanii as well as other
unknown microbes with vancomycin and meropenem, but shortly after fungi
grew in the collected peritoneal fluid. Despite subsequent micafungin
coverage, the patient went into rapid hemodynamic decompensation,
multiorgan system failure and ultimately succumbed to his condition.
This raises the question: Do patients with cirrhosis requiring intensive
levels of critical care benefit from empiric antifungal coverage?
Hassan et al. highlights that delayed treatment and diagnosis can
become fatal and although fungal infections are rare, empirically
treating for fungal infections can improve the
outcome14. Retrospective analysis for the management
of this case, the suspected result of decompensation would be attributed
to a lack of fungal empiric coverage on arrival to the intensive care
unit. This case provokes multiple questions. Primarily, when is it
appropriate to provide antifungal coverage in a patient? Maertenset al. outlines the use for empiric antibiotic coverage for
antifungals who have persistent sepsis for 4-7 days after broad spectrum
antibiotics15. Based on these recommendations, the
patient was appropriately treated within those parameters. This study
specifically assesses antifungal requirements in a neutropenic and
cirrhotic patient. Antifungal coverage in the septic cirrhotic is not
well established. Do patients with refractory septic shock secondary to
broad spectrum or appropriate sensitive coverage warrant immediate
antifungal consideration? Furthermore, should cirrhosis be treated as an
immunosuppressive condition and warrant greater initial empiric
coverage? These questions are poorly understood but this case highlights
the importance and the necessity to explore these questions to improve
patients’ outcomes.
The other peculiar aspect of this case is the sheer fact that a patient
with no underlying exposure could present with Acinetobacter
baumanii bacteremia suspected from pneumonia. The patient had no
underlying past medical history except for newly diagnosed cirrhosis on
the admission. The patient was self-isolated due to the Covid-19
pandemic which makes this finding even more profound. Dijkshoornet al, outlines that Acinetobacter baumanii is a rare
infection often multi-drug resistant (MDR) and often associated with
ventilator associated pneumonia (VAP)16. This case
illustrates cirrhosis as the only underlying known immunosuppressive
condition in a patient with a rare typically nosocomial acquired
infection complicated by fungal peritonitis with no previous
hospitalization or exposure. Cirrhosis evidently may have a profound
impact on a patients’ immune system due to CAID. Therefore, this
transient level of natural immunosuppression in the cirrhotic population
should strongly be considered in the intensive care setting when
determining appropriate treatment.