To give you a brief outline of this CME session I'm going to touch upon a little bit upon

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "To give you a brief outline of this CME session I'm going to touch upon a little bit upon"

Transcription

1 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 1 Today we are going to talk about an important topic in chronic liver disease, cirrhosis of the liver. This CME activity is titled Infection Challenges in the Patient with Cirrhotic Cirrhosis of the liver. To give you a brief outline of this CME session I'm going to touch upon a little bit upon complications of cirrhosis of the liver and its natural history. We'll see how extensive is the problem or the scope of the problem. We'll talk a little bit about clinical management and when to use bacterial prophylaxis and how to treat infections in cirrhosis. and then we'll try and address this controversial area potential preventive approaches. Now cirrhosis is the 12th leading cause of the mortality among U.S. adults. And if you look at the other chronic disease such as diabetes this is responsible for as many fatalities as diabetes. On the other hand, if you look at a select age group, i.e. 45 to 54 years of age this becomes even a more important cause of death and clearly this accounts for a large fraction of healthcare costs today in the United States. It's humbling to admit that even today 10% of patients who are actually admitted to the hospital will actually not make it during that hospital stay. Now if you look at the "conventional complications of cirrhosis" these are the ones listed there: portal hypertension / variceal bleeding; ascites? spontaneous bacterial peritonitis; hepatorenal syndrome; hepatic encephalopathy; coagulopathy; hepatocellular carcinoma. They are aware of complications such as the hepatopulmonary syndrome and portal primary hypertension. But you can see infections are nowhere in this list, and clearly I think this list of "complications of cirrhosis" will need to be revised in the years to come.

2 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 2 Now looking at the natural history of cirrhosis I think this is the best way to do it, and I use this slide to talk to my patients because clearly compensated cirrhosis has a very different outlook as compared to decompensated cirrhosis. So if a patient has compensated cirrhosis the overall survival exceeds 10 years, on the other hand once a patient develops decompensated cirrhosis you can see the overall survival will drop and the 2 year survival is roughly less than 50%. And how do we define decompensated cirrhosis? This is again a very useful slide to talk to my patients. You can see this the cumulative risk of development of each of these complications in a patient with established cirrhosis of the liver. The first thing that will come up is esophageal varices, over time the next complication is ascites and then hepatic encephalopathy and hepatocellular carcinoma. As you can see, the graphs for hepatic encephalopathy and HEC are pretty much parallel to each other and this is the teaching, whenever we see a patient with new onset of encephalopathy we always screen for early or established hepatocellular carcinoma. Now moving on to the topic of infections. It's fair to summarize that cirrhosis is considered as an immunocompromised state, and ultimately this will lead to a variety of infections which account for a much higher mortality as compared to the patient without infection. Based on data approximately 1 out of 3 patients who will develop an infection ultimately will not survive. I think apart from early recognition and better treatment of spontaneous bacterial peritonitis leading to better survival there's been little improvement in the overall survival rates in recent decades. And hence again a humbling statistic cirrhosis with infection still accounts for a 4-fold increase in mortality among patients with

3 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 3 cirrhosis. But clearly the patient who is hospitalized is at the highest risk of developing infection, especially in those with GI bleeding. Bacterial infections occur anywhere from 30% of admitted patients with cirrhosis and clearly up to 45% in patients with GI hemorrhage. And if you look at these infection rates as compared to other infection rates in hospitalized patients these are clearly higher because the usual infection rate is somewhere between 5 and 7% in a patient who is hospitalized. Now which are the most common infections? In order of frequency, spontaneous bacterial peritonitis accounts for 1/4 of infections, another 1/5 are accounted for by urinary tract infection and then comes community acquired pneumonia. Now these are rare infections that I've listed over here, pathogens such as Microbacterium tuberculosis, C-difficile, cryptococcus, vibrio vulnificus, yersinia enterocolitica and listeria are more common and virulent in the patient with cirrhosis as compared to the general population. Again because of the high morbidity and mortality of infections in cirrhosis this would be the key message, prevention, early diagnosis and proper management of these infections are necessary to improve patient survival. Now another new entity that is being talked about these days is acute-on-chronic liver failure. I'm not going to spend much time defining this entity but it's fair to say that bacterial infections are the leading cause of mortality in patients with acute and chronic liver failure in end stage liver disease. And we all know what are the consequences of an infection. This is what I've listed here, clearly once a patient with cirrhosis is infected with prolonged hospitalization this can lead to acute kidney

4 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 4 injury and its consequences. Clearly we talked about mortality. And then for those of you who work at a transplant center these patients will now be removed or be de-listed from the liver transplant wait list. And there is also data that once a patient with cirrhosis gets infected this patient is now more susceptible to future further infections. Now diagnosis of infections in cirrhosis is clearly very difficult as compared to the non-cirrhotic patient population. And why? Cirrhosis as we all know has a background of what we would call a partial systemic inflammatory response, also known as SIRS. Hence it is very difficult to use the conventional definitions of infection in this patient population. Another kind of confounding factor is our usual modes or methods of infection diagnosis such as cultures could be negative in up to 50% of this patient population. And lastly, the lack of multicenter studies limits how we generalize what we have available for us at this time. So just to summarize, up to 1/3 of all hospitalized patients with cirrhosis are infected. With sepsis mortality increases to more than 50% and it's associated with significant costs. There is a 4-fold increase of death in infected cirrhosis patients and ICU mortality of patients with cirrhosis has remained unchanged over the last 50 years unlike other illnesses like cardiac failure where mortality has clearly decreased. We clearly have a lot of room for improvement in this area. Hence it's fair to say that the prevention, diagnosis and management of infections of infections in patients with end stage liver disease form the large unmet need.

5 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 5 What is the scope of this problem? And again as I outlined data is not easily available. Now the magnitude of the problem in cirrhosis is not quantifiable for many reasons. I already touched upon this, infections are difficult to recognize because 30 to 50% of patients with infection such as SBP can remain culture negative. Also conventional risk scoring strategies such as the SIRS criteria cannot reliably differentiate the SIRS plus infection from the noninfectious SIRS. There are also difficulties in diagnosing the presence o infections especially in hospitalized patients with cirrhosis, hence time appropriate strategies are needed to suspect infections and send cultures early so as to initiate appropriate antimicrobial therapy. A heightened suspicion of potentially resistant organisms is required in order to change therapy as needed. Now based on data in the U.S. from 20% of acute care hospitals this is the data available. This looked at approximately 65,000 patients in 2006 who had a discharge diagnosis of cirrhosis. Clearly you can see the costs out there, approximately $14 billion U.S. per year, and approximately 26,000 patients had presumed infection and required ICU support as identified by mechanical ventilation and invasive cardiovascular monitoring. The in-house mortality in this patient population who was hospitalized was 53%. The mean length of hospitalization was about 14 days. And once again I've highlighted the costs as listed over there. This is basically a U.S. nationwide inpatient sample study called the NIS study. In this study C- difficile infection in patients with cirrhosis was associated with a significantly higher mortality, length of stay and total cost compared with patients admitted with cirrhosis without C-difficile and

6 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 6 patients with C-difficile without cirrhosis. This data can be replicated almost anywhere in the world. Looking at a Korean national database patients with cirrhosis and bacteremia were more significantly likely to die than those without cirrhosis. Also bacteremia in patients with cirrhosis was more likely to occur due to intraabdominal infections and klebsiella pneumoniae was less likely to be due to coag-negative staph. Overall multivariate analysis confirmed that cirrhosis is an independent risk factor for mortality with an odds ratio of almost 2. This is another U.S. based study, the North American Consortium for the study of end stage liver disease. This includes about 12 centers from North America which are prospectively collecting data on infections in patients with cirrhosis. To date about 176 patients have been analyzed from these 9 sites. Once again the same there, common infections include SBP, UTI, spontaneous bacteremia, skin infections, respiratory tract infections and C-difficile. This is the spectrum of infections. grampositive and gram-negative infections account for 1/3 of overall infections, fungal infections are rare but you need to keep a very high index of suspicion because in this patient population 4% of infections were fungal in etiology. And once again another common these, 30% of infections had no identifier organisms. Clearly the mortality rate is different for different infections. Respiratory infections account for the highest mortality rate up to 44%, bacteremia approximately 40%, C- difficile 40%. The other infections have a slightly lower mortality rate averaging about 20 to 30% such as UTI, skin infections and SBP.

7 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 7 Overall the index infection was healthcare associated in more than half our patients in this patient population or nosocomial in about 20%. One thing that I alluded to earlier, 30% of patients will develop a second infection during the period of hospitalization. And the overall mortality in this group was about 25%. Clearly patients who ultimately died were much sicker, meaning they had a higher model for end stage liver disease score at admission, 25 versus 20, and they were more likely to have hepatic encephalopathy, hepatorenal syndrome or more likely to be ventilated and have an ICU stay during the hospitalization. We talked about this earlier, there was a higher incidence of second infections during hospitalization in patients who died as compared to those who survived. Patients who developed a second infection were more likely to have a gram-negative first infection, an ICU stay, a lower serum albumin, a greater length of hospitalization and a higher MELD score. Multivariate analysis showed that only second infection and MELD score were associated with death. I think I hope I've been able to convince you that there is a need to develop early diagnostic and prognostic markers including biomarkers for a better understanding of infections so that we can improve the outcomes in this patient population. Let us now look at some clinical scenarios of infections in cirrhosis. We'll talk a little bit more about the two entities listed there, GI bleeding, associated infections and prophylaxis. And then spontaneous bacterial peritonitis. Some of the other infections which I would like to cover are listed above, UTI, pneumonia, soft tissue infections, endocarditis, tuberculosis, C-difficile and then

8 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 8 emerging infections such as drug resistant infections and fungal infections. And then we'll touch upon a few peculiar infections in certain specific liver diseases such as genetic hemochromatosis and primary sclerosing cholangitis. Let's talk a little bit about GI bleeding because this is fairly common in our patient population with decompensated cirrhosis. GI bleeding is associated with an increased incidence of infection, roughly anywhere from 17 to 45% will develop an incidence of SBP or bacteremia following a GI bleed. Conversely, the presence of infection has also been found to increase the risk of early bleeding. Now what we use here is short term antibiotic prophylaxis, meaning prophylaxis with antibiotics only during the episode of GI bleeding. Most infections are caused by gram-negative bacteria and are preventable with selective decontamination of the GI tract with Quinolones. This is a recommendation that's put forward by the AASLD in patients with advanced cirrhosis, 1 gram intravenous Ceftriaxone for 7 days after the bleeding episode would be effective in preventing the bacterial infection. Clearly these patients are not going to be taking anything orally and hence one cannot use the oral agent Norfloxacillin. Now it's been shown by using this approach antibiotic prophylaxis significantly reduces rates of infection, rebleeding as well as mortality. Now a slightly controversial area is the use of nonselective beta blockers. These are commonly used to lower portal hypertension and prevent the initial variceal bleeding. There is also evidence that nonselective beta blockers can decrease bacterial translocation during an episode of acute

9 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 9 hemorrhage. Beta blockers increase gut motility, reduce bacterial translocation thereby reducing the incidence of infection. There is good evidence that in the post-surgical setting a nonselective beta blocker such as Propranolol reduces infections from 40% to about 15%. However, a word of caution, the use of beta blockers in patients with refractory ascites may limit the compensatory increase in cardiac output and increase actually the vulnerability in complications such as septic shock and renal failure. And hence I'm not sure we can propose this to be advocated for this particular indication. Moving on to SBP. The prevalence of spontaneous bacterial peritonitis in patients with cirrhosis and ascites admitted to the hospital ranges anywhere from 10 to 30%. Half of cases are present at the time of hospitalization and another half were actually developed during the hospital stay. The inhouse mortality from SBP again 30%. This is the current recommendation, when to perform a diagnostic paracentesis in a patient with cirrhosis. All patients who have ascites must undergo a diagnostic paracentesis at the time of a hospital admission. Clearly those who manifest symptoms of peritoneal infection it's easy to justify a diagnostic paracentesis. Also patients who have systemic signs of infection, unexplained hepatic encephalopathy and rapid impairment in renal function when hospitalized should undergo a diagnostic paracentesis. This is the definition or the criteria for SBP. The diagnostic cutoff is a PMN count of 250 cells while the highest specificity is reached at 500 cells. Again to highlight up to 65% of patients with clinical evidence of SBP will have negative cultures. How can you increase the yield? A bedside

10 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 10 inoculation of 10 ml of ascites fluid has shown to improve the sensitivity of picking up a positive blood culture to approximately 80%. I would certainly advocate for this practice. Now one thing that always comes up is how to distinguish spontaneous bacterial peritonitis from secondary bacterial peritonitis. Clearly you have to use your clinical judgment over here, however when the ascites fluid in a patient with cirrhosis is found to have a PMN count greater than or equal to 250 cells and there is a high suspicion for secondary peritonitis, one should also test the ascites fluid for total protein, LDH, glucose, gram stain, a CEA, and alkaline phosphatase and this would potentially help in differentiating SBP from secondary peritonitis. Clearly common causes of secondary peritonitis are entities such as a perforated viscus, it could be appendicitis, acute diverticulitis, etc. One should keep a very low threshold for performing abdominal imaging such as a CT scan of the abdomen. Now sometimes the differentiation between SBP and secondary peritonitis such as bacterial peritonitis caused by perforation or an acute inflammation of an organ as highlighted earlier can be quite difficult. It's important to remember that you need to keep a very high index of suspicion for secondary peritonitis because if you miss secondary peritonitis that patient is not going to do well. Luckily secondary peritonitis accounts for only 4.5% of all patients with peritonitis in a patient with cirrhosis. And this should be suspected in the following situations. Clearly a patient who is not doing clinically well despite the use of antibiotics, the presence of a polymicrobial infection in the ascites fluid is a good clue. So two or more organisms which are isolated in the ascites fluid

11 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 11 particularly anaerobes or fungi may be a clue for secondary peritonitis. Or the presence of at least 2 of the following criteria in the ascites fluid, a low glucose content, a high protein content and LDH which is greater than serum LDH. Clearly one could check ascites fluid CEA or alkaline phosphatase and the criteria are listed above. And as outlined previously you must keep a very low threshold and get a radiologic study such as a CT scan or MRI immediately and possibly even an emergent surgical evaluation or intervention. These are the AASLD guidelines for the diagnosis of SBP. SBP is present in 12% of patients at the time of admission of a patient with cirrhosis and ascites to justify a diagnostic paracentesis. The incidence is lower nowadays because we use preventive approaches in high risk patients. I mentioned the definition of the PMN criteria, and there is new technology available but not easily used as the dip stick testing of the ascites fluid and an automated cell count which may improve early detection of the infection literally within 2 or 3 minutes of performing the paracentesis. Now there are culture, there are entities such as culture negative neutrocytic ascites. This is the treatment algorithm, SBP for all comers should be treated with Cefotaxime 2 gm every 8 yours for a period of 5 days. This is adequate. Clearly you can revise your antibiotic schedule once you get the ascites fluid analysis back. And alternative could be an oral Quinolone such as oral Ofloxacin 400 mg every 12 hours for a period of 8 days. You can adopt the oral approach in patients who are not vomiting, who do not have shock, without grade II encephalopathy or without features of renal failure.

12 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 12 Now it's important to realize that the most common morbidity in patients with SBP is renal failure. Renal impairment develops of approximately 1/3 of all SBP patients and is a strong predictor of mortality during the hospitalization stay. How can we decrease the incidence of renal impairment? This is the approach. Using IV albumen. There is a very elegant study done several - almost a decade ago which showed that using this approach on day 0 and day 3 would decrease the mortality from 30% to 10%. A more recent study has shown that albumen should be given when there is renal impairment, serum creatinine more than 1 mg per deciliter, an elevated BUN or the total protein exceeds 4. Now once a patient is diagnosed with SBP a follow-up paracentesis is usually recommended after 48 hours to assess a response by checking the PMN count and the cultures. Patients with ascites fluid PMN counts greater than or equal to 250 ml millimeters in a nosocomial setting or in the presence of a recent beta-lactam antibiotic exposure all who culture an atypical organism or have atypical clinical responses to treatment are likely to do poorly. This is the overall outcome in a patient with SBP. Recovery from SBP is seen in most patients, so 90% of patients will make a good recovery. The 30 days survival is approximately 80%, however if a patient fails treatment in hospital mortality is very high, about 50 to 80%. And basically in patients where the liver disease will worsen, so rapid deterioration in renal - in liver function in SBP patients carries a very poor prognosis. Now what's humbling here is the 1 year survival after an episode of

13 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 13 SBP which drops to approximately 30%. We used to use SBP as a criteria for putting people on the liver transplant wait list, we don't do that anymore. I think a new trend is there's a recent shift in the microbial etiology of SBP towards cefotaxime-resistant strains and this may complicate survival by delaying resolution of the infection. So to summarize, how do we prevent SBP? In a patient with GI hemorrhage, IV ceftriaxone for 7 days, or twice daily norfloxacin for 7 days. In patients with - this should be given to prevent bacterial infections in patients with cirrhosis and GI hemorrhage. Perhaps a parenteral antibiotic while the patient is still bleeding, and this can be changed to an oral antibiotic for a total of 7 days as a more practical approach. Patients who survive an episode of SBP should receive long term prophylaxis with one of the two approaches listed above. We in this institution prefer trimethoprim and sulfamethoxazole. Another criteria for SBP prevention is listed over there. In patients with cirrhosis and ascites the long term use of antibiotics can be justified if the ascites fluid protein is less than or equal to 1.5 along with impaired renal function defined as creatinine more than 1.2 or BUN more than 25, or a serum sodium less than 130 or liver failure, meaning a Child's score more than 9 or a bilirubin more than 3. Patients who recover from an episode of SBP should be given antibiotics prophylaxis indefinitely. In those without antibiotic prophylaxis the rate of recurrence of SBP is 43% at 6 months, and almost 70% at 1 year and 75% at 2 years after the initial episode. This is why you need to prophylax your

14 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 14 patient indefinitely. There is a study showed that the use of an oral quinolone reduced the recurrence of SBP from 70% to 20%. Now in this institution one could use ciprofloxacin as outlined above rather than 750 mg of ciprofloxacin once a week because we think daily ciprofloxacin is probably more effective. Now moving on to the other infections. Urinary tract infections occur in approximately 15 to 20% of hospitalized patients. This is twice as frequent in patients with cirrhosis compared with matched controls. Clearly women have a higher rate of bacteruria as compared to men. And the organisms that cause UTI are usually a gram negative bacilli such as e-coli and klebsiella. What's comforting here is bacteruria is not associated with an increased risk of sepsis, SBP or other infections which are often seen in patients with cirrhosis. And again treatment with quinolones is usually very effective in approximately 95% of patient population. Moving on to the next infection, pneumonia. Pneumonia is the third leading cause of infections in patients with cirrhosis. Community acquired pneumonia is most often caused by streptococcal pneumoniae and H. influenza. Other organisms which have been implicated include staph aureus, mycoplasma and klebsiella and legionella. Now as opposed to UTI the risk of bacteremia in community acquired pneumonia is increased in a patient who has cirrhosis. Now other procedures that we perform in these patients such as tracheal intubation and esophageal tamponade put these patients even at a higher risk for hospital acquired pneumonia. In the presence

15 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 15 of comorbidities such as cirrhosis treatment is ideal with an IV beta-lactam plus a macrolide or an IV antipneumococcal quinolone. I cannot stress that when you see a patient with cirrhosis in your office you must make sure that they receive their pneumonococcal vaccination and this is a health maintenance recommendation in a patient with cirrhosis of the liver. Soft tissue infections, cellulitis, are clearly more common. And why? Chronic edema, an increased bacterial translocation predispose patient with cirrhosis to soft tissue infections. This accounts for approximately 11% of infections, broad gram positive as well as gram negative bacteria are common causes. Cellulitis is the most frequently observed skin infection and has a recurrence rate of almost 20%. Broad spectrum antibiotics are necessary for proper management of soft tissue infections and sometimes you may need surgical debridement. Overall this sometimes accounts for a prolonged hospital stay or even morbidity and outcome in these populations. Endocarditis, luckily rare. Approximately 10% of patients with infectious endocarditis will have cirrhosis as a predisposing cause. Now why is infective endocarditis common? Because patients with cirrhosis who are hospitalized have a higher risk of bacteremia associated with certain invasive procedures such as the TIPS procedure, upper endoscopy, etc. Now 60% of patients with cirrhosis may have underlying valvular disease which predisposes to endocarditis. Common organisms once again gram-positive bacteria, beta hemolytic streptococci and enterococci are the most commonly isolated organisms. The management of endocarditis is like any other management of endocarditis.

16 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 16 Tuberculosis. You need to keep a very high index of suspicion. Why? The incidence of virulence of Microbacterium tuberculosis infections are increased in patients with cirrhosis. In a study from Denmark the 30 day case fatality rate in patients with TB and liver cirrhosis was almost 30% and the one year fatality rate 50%. Now as opposed to patients without cirrhosis TB patients with cirrhosis show extra pulmonary involvement such as TB peritonitis more frequently. Another problem is the anti-tb drugs have a much higher risk of hepatotoxicity when used in patients with cirrhosis. Other infections such as C-difficile, a recent study of over 80,000 patients with cirrhosis found that C-difficile associated disease has a much higher mortality and a longer length of stay as compared to patients without this infection. And this is very new data, but clearly very important, antibiotics and proton pump inhibitors were independently associated with C-difficile infection. Thus it is now recommended that antibiotic prophylaxis be limited to patients at the highest risk of developing SBP and PPIs should be used very selectively in this patient population. Another emerging problem, drug resistant infections. I think you and I are going to see more and more of this emerging entity. Up to 2/3 of bacterial infections either nosocomial or in the context of antibiotic intervention have been found to be multidrug resistant. Clearly gram negative isolated SBP such as E-coli, klebsiella pneumoniae are being encountered with increasing rates of resistance. Also gram positive pathogens are increasingly common in patients with cirrhosis.

17 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 17 In a recent study MRSA was noted to account for approximately 25% of patients with nosocomial SBP. Enterococcal infections such as E. faecalis, E. faecium are now isolated anywhere from 10 to 25% of patients in the setting of cirrhosis. And enterococcal infections are pretty bad, 25% mortality rate. Clearly 1/3 of these patients with enterococcal bacteremia will have vancomycin resistance and the mortality rate clearly goes up very steeply. I talked about fungal infections earlier. You need to keep a very high index of suspicion because you need to send the blood culture or the ascites fluid for special fungal cultures to pickup these infections. As mentioned earlier liver cirrhosis is an underlying condition in approximately a third of non-hiv cryptococcemia cases and is a stronger independent predictor of the 30 day mortality than in those in patients with AIDS. Cryptococcus neoformans may infect the ascites and cause SBP. Unlike SBP spontaneous cryptococcal peritonitis presents with an elevation in the lymphocyte count and because usually you and I do not detect these patients early this has a very high mortality rate, almost 70%. Other liver diseases that predispose to fungal infections are primary sclerosing cholangitis. We'll now address liver infections in certain specific liver diseases: iron overload or genetic hemochromatosis. Now iron overload impairs your cell mediated response and enhances the growth of various pathogens such as E-coli, vibrio and listeria. Patients with genetic hemochromatosis face a 30-fold higher risk of acquiring V. vulnificus bacteremia. Luckily this is rare. This bacterium is acquired through ingestion of contaminated raw oysters. Clearly this vibrio septicemia has a very

18 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 18 high mortality rate in patients with liver disease as well as people who develop localized wound infections. Another infection is yersinia in this patient population, once again if it leads to bacteremia it can cause hepatic abscesses with a very high mortality rate. Primary sclerosing cholangitis, this is a separate liver disease with it's own infection bag. PSC is a risk factor for ascending cholangitis which itself is associated with a 16% mortality rate. Generally ascending cholangitis is relatively uncommon unless there's been some kind of intervention, mechanical intervention in the biliary tree, a procedure such as an ERCP or PTC. The most common infections are ERCP are caused by gram-negative bacteria such as E-coli, klebsiella and Enterobacter. Clearly if cholangitis occurs without intervention in PSC one should suspect the presence of CBD stones, a common bile duct stricture or the development of cholangiole carcinoma. In a study of explanted livers with PSC bacteria were isolated almost in 60% of this patient population and the common bacteria are listed above, alpha-hemolytic streptococci, enterococci and staphylococci. Let's now move on to potential preventive approaches in this patient population. I'll highlight some of our challenges and then future directions in this patient population in prevention of bacterial infection. As highlighted earlier the studies currently are limited because of single center experiences, poly-pharmacy is a predictor of infections, we'll talk a little bit about the role of intensive care management of cirrhosis and sepsis, we'll touch a little bit upon the concept or the changing concept of acute kidney injury and its role in infections in cirrhosis. We clearly highlight

19 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 19 the healthcare associated issues and nosocomial infections, and then the problem of multidrug resistant organism. These are the proposed categories of nosocomial infections in patients with cirrhosis. Spontaneous bloodstream infection that is not related to intervention or infection at other sites, urinary tract infections, pulmonary infections and SBP. To complete this list we would add C-difficile and then of course infections related to interventions such as urinary catheterization, mechanical ventilation, central line placement, paracentesis, thoracentesis, renal replacement therapy, interventional radiology procedures and use of IV nutrition. Now what's proposed - what predisposes to bacterial infections in patients with cirrhosis would be bacterial translocation. Changes in gut bacteria in cirrhosis can lead to bacterial overgrowth and subsequent enhanced bacterial translocation from the gut to the systemic circulation and ascites. Hence it's fair to say that bacterial translocation is a major pathogenetic factor for infections. This process is also facilitated by acid suppression and increased intestinal permeability in patients with cirrhosis, especially with advanced disease. Sepsis as a result of bacterial translocation and small bowel bacterial overgrowth is a key component of the natural history of infections. As highlighted earlier one of the key modulators of outcomes of infections as the underlying immune status which is negatively affected at multiple levels in

20 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 20 cirrhosis. I've highlighted some of the other theories over here. There is clearly more work to be done in this area. Let me stress a little bit upon the use of PPIs in SBP. Single center studies have shown - associated the use of PPIs with SBP and C-difficile. An important observation is that PPIs are overprescribed in our patients with cirrhosis and it's been found that an appropriate indication for a PPI sometimes may exist in less than 50% of our patient population. As highlighted earlier PPIs predispose to bacterial overgrowth and adversely affect your immune function. The controversy about nonselective beta blockade. There is contradictive association on the effect of nonselective beta blockers on the negative outcomes in cirrhosis. While a metaanalysis showed a reduced development of SBP in previous studies there is data recently emerging in a nonrandomized study that patients who received nonselective beta blockers actually had a worse survival, especially in the patients with subsets of refractory ascites. Also nonselective beta blockers increased the risk for hepatorenal syndrome and death in patients with cirrhosis and SBP. Hence this new data has led to the window hypothesis on the effect of nonselective beta blockers. This is probably new evidence that suggests that nonselective beta blockers only improve outcomes in a narrow window of cirrhosis natural history between those who have medium to large varices before the development of end stage liver disease. Clearly we need more studies to elucidate the clinical role of nonselective beta blockers in cirrhosis.

21 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 21 I would like for you to read this editorial by Bruce Runyon in Gastroenterology which kind of highlights when should the beta blocker window in cirrhosis be closed? You can see on the left in early cirrhosis beta blockers are not indicated, in the middle the window opens so beta blockers are clearly indicated for the primary prophylaxis of variceal bleeding, secondary prophylaxis of variceal bleeding. On the other hand, the window once again closes and will not reopen and it's been said today that beta blockers are potentially contraindicated in refractory ascites, systolic pressures less than 100, mean arterial pressure less than 82, acute kidney injury, hepatorenal syndrome, SBP, sepsis, poor medical follow-up and patients with medical noncompliance. A little bit about prognosis and management in the ICU. As outlined previously there are several precipitating factors associated with worsening in cirrhosis leading to multisystem organ failure. These include infection, GI bleeding, acute alcoholic hepatitis, superimposed viral hepatitis, drug induced liver injury and surgery in a patient with cirrhosis. The response to infection in patients with cirrhosis is often exaggerated leading to admission to the ICU because of sepsis, severe sepsis and septic shock. The key areas that you should work with with your ICU team in the management of patients with cirrhosis is the following. Prevention of nosocomial and second infections, reduction of unnecessary instrumentation, the judicious use of antibiotics and antifungal agents and then more studies need to be done on the validation of prognostic scores that take into account the underlying liver disease severity.

22 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 22 And I put here today a list of additional areas need to be addressed. Should we be using albumen and is albumen the preferred volume expander? How should coagulopathy be corrected? Which is the optimal vasopressor support? The methodology for determining adrenal insufficiency, the situations in which steroids should be given and what dosage should be used, and finally the role of artificial and bioartificial liver support devices needs to be determined in this patient population. A few slides upon the prevention and treatment of acute kidney injury in this patient population. Clearly the definition of acute kidney injury in patients with cirrhosis is rapidly evolving. A critical need is required to prevent and adequately treat renal dysfunction in patients with infected cirrhosis. This is because renal disfunction with acute kidney injury has emerged as the major determinant of mortality in patients with cirrhosis. Acute kidney injury including hepatorenal syndrome is associated with a markedly shorter survival. In patients with decompensated cirrhosis admitted to the hospital an increased creatinine concentration within 24 hours is associated with poor survival. Even more profound is the requirement for renal replacement therapy which has almost a higher than 90% in-hospital mortality. Now you are all familiar with the definitions of the criteria for type 1 and type 2 hepatorenal syndrome. I've listed these on the slides above and these are the standard definitions for type 1 and type 2 hepatorenal syndrome. It's fair to say today that the most common precipitating factor for type 1 hepatorenal syndrome is a bacterial infection. This may occur despite the clearance of the bacterial infection. And why is that? The inflammatory response to bacterial infections increases

23 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 23 the systemic arterial vasodilatation with further reduction in the effective arterial blood volume and further renal vasoconstriction leading to the renal failure. Now I highlighted the association between SBP and renal failure. SBP was the first bacterial infection recognized to be associated with a high incidence of renal failure in cirrhosis. This occurs in approximately 1/3 of patients despite resolution of the infection and has an in-hospital mortality rate of up to 60%. Any bacterial infection can precipitate renal failure in cirrhosis. Patients who develop renal failure with bacterial infections clearly have a much higher MELD score and lower mean arterial pressure. Other infections associated with renal failure and cirrhosis are listed above. These include biliary and GI infections, we talked about SBP earlier, urinary tract infection, pneumonia and skin infections. Now look at the statistic over here, once renal failure sets in the probability of survival at 3 months is only 30% and clearly this will be even lower with a higher MELD score. Hence I hope I've been able to convince you that any measure that can prevent renal failure in cirrhosis will go a long way, especially in the setting of infection. And what can we do right now? Use IV albumen in a patient with SBP. The use of a vasopressor agent such as Terlipressin in SBP has been proposed. This agent is not FDA approved right now in the United States. The use of a vasoconstrictor should be investigated as a potential alternative or an additive to albumen in the prevention of renal failure in SBP.

24 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 24 I'm not going to spend too much time on the management of hepatorenal syndrome. Listed on this slide are the standard published management approaches to HRS type 1. One would use a vasoconstrictor and albumen infusion. The choice of vasoconstrictor depends on local availability. In North America we use midodrine in combinations with octreotide, in most other parts of the world terlipressin is used. Give the overall poor survival in patients with cirrhosis bacterial infections and established renal failure there is now a trend to treating renal impairment at a much earlier stage if you have type 1 HRS. One definition has been to define the early stage of renal dysfunction as we all know serum creatinine is an inaccurate measure of renal function in a patient with cirrhosis. So listed here are the proposed definitions of kidney disease and cirrhosis. Acute kidney disease and chronic kidney disease, acute kidney injury defined as a rise in serum creatinine to more than 50% of baseline or a rise in creatinine to greater than.3 mg in 48 hours. HRS type 1 would be a specific form of acute kidney injury. Chronic kidney disease is the standard definition, GFR less than 60 for more than 3 months and it's fair to say that HRS type 2 is a specific form of chronic kidney disease. Then of course you have another entity, acute-on-chronic kidney disease which is being considered as a rise in serum creatinine of more than 50% from baseline or a rise in creatinine of more than 0.3 in less than 48 hours in a patient with cirrhosis whose GFR is less than 60 for more than 3 months. Moving on to multiresistant organisms and nosocomial infections. I've already highlighted this problem earlier. Infection present in one set of patients who are hospitalized, healthcare associated 30%, nosocomial up to 45%. The common community-acquired infections are usually SBP,

25 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 25 cellulitis. On the other hand the common healthcare associated infections are usually SBP, UTI. Now nosocomial infections are dominated by UTIs and that makes sense. How common is the problem of multidrug resistant organisms? If you look at different patient populations clearly in community-acquired infections there is a much lower resistance of MDR, only about 4%. On the other hand, if you look at nosocomial infections it will go up to as high as 35%. This - the high risk of MDR organisms decreases the efficacy of standard antibiotic regimens and clearly will double the mortality in this patient population. As highlighted earlier, a disturbing trend is the increased isolation of MRSA and enterococcal infections in patients with cirrhosis which clearly accounts for a very high mortality rate. SBP is an important cause of both community-acquired and nosocomial infections in patients with cirrhosis. Whereas community-acquired SBP is more commonly caused by gram-negative rods, nosocomial SBP has an increased prevalence of gram-positive cocci. In addition, nosocomial acquisition increases the risk of resistance to cephalosporins and quinolones and clearly increase mortality. So thus to summarize this important topic. Early diagnosis and proper management of infection in patients with cirrhosis are necessary. Luckily generally speaking intravenous third generation cephalosporins are recommended and are effective as empiric antibiotic therapy for most cases of spontaneous bacterial peritonitis and bacteremia. However, the risk of resistant organisms and

26 KAPIL CHOPRA, MD, DM, FACP, FASSSLD, AGAF 26 unusual organ pathogens should be kept in mind especially in patients with cirrhosis who have been previously receiving quinolone prophylaxis or as specifically with diseases such as genetic hemochromatosis. Auxiliary therapy with intravenous albumen will significantly reduce the morbidity and mortality in patients with spontaneous bacterial peritonitis who are at the highest risk of developing renal failure. The importance of preventive strategies cannot be underscored. Patients with cirrhosis admitted with GI hemorrhage benefit from what I would call short term antibiotic prophylaxis, whereas long term oral antibiotic prophylaxis is recommended in those who have recovered from an episode of SBP. What could be the potential future? Despite recent advances in the understanding of the mechanisms of infection in patients with cirrhosis the outcome of these patients with severe infections still remains poor. Clearly we need further studies into the mechanisms, diagnostic approaches and potential preventive strategies are needed to improve the management of these infections in patients with cirrhosis of the liver. I thank you very much for your attention. Thank you very much.

Evaluation and Prognosis of Patients with Cirrhosis

Evaluation and Prognosis of Patients with Cirrhosis Evaluation and Prognosis of Patients with Cirrhosis Marion G. Peters, MD John V. Carbone, MD, Endowed Chair Professor of Medicine Chief of Hepatology Research University of California San Francisco Recorded

More information

Acute on Chronic Liver Failure: Current Concepts. Disclosures

Acute on Chronic Liver Failure: Current Concepts. Disclosures Acute on Chronic Liver Failure: Current Concepts Vandana Khungar, MD MSc Assistant Professor of Medicine University of Pennsylvania, Perelman School of Medicine September 20, 2015 None to declare Disclosures

More information

Nursing college, Second stage Microbiology Dr.Nada Khazal K. Hendi L14: Hospital acquired infection, nosocomial infection

Nursing college, Second stage Microbiology Dr.Nada Khazal K. Hendi L14: Hospital acquired infection, nosocomial infection L14: Hospital acquired infection, nosocomial infection Definition A hospital acquired infection, also called a nosocomial infection, is an infection that first appears between 48 hours and four days after

More information

HBV & HCV induced. Liver Cirrhosis Iradj Maleki MD Gut & Liver Research Center Mazandaran University of Medical Sciences

HBV & HCV induced. Liver Cirrhosis Iradj Maleki MD Gut & Liver Research Center Mazandaran University of Medical Sciences HBV & HCV induced Liver Cirrhosis Iradj Maleki MD Gut & Liver Research Center Mazandaran University of Medical Sciences Definition of Cirrhosis Final pathway for a wide variety of chronic liver diseases

More information

Omega-3 fatty acids improve the diagnosis-related clinical outcome. Critical Care Medicine April 2006;34(4):972-9

Omega-3 fatty acids improve the diagnosis-related clinical outcome. Critical Care Medicine April 2006;34(4):972-9 Omega-3 fatty acids improve the diagnosis-related clinical outcome 1 Critical Care Medicine April 2006;34(4):972-9 Volume 34(4), April 2006, pp 972-979 Heller, Axel R. MD, PhD; Rössler, Susann; Litz, Rainer

More information

LIVER TRANSPLANTATION Update on Allocation Living Donor Liver Tx.

LIVER TRANSPLANTATION Update on Allocation Living Donor Liver Tx. LIVER TRANSPLANTATION Update on Allocation Living Donor Liver Tx. Steven L. Flamm MD Associate Professor of Medicine Medical Director, Liver Transplantation Northwestern University Medical School 1958

More information

Information for patients (and their families) waiting for liver transplantation

Information for patients (and their families) waiting for liver transplantation Information for patients (and their families) waiting for liver transplantation Waiting list? What is liver transplant? Postoperative conditions? Ver.: 4/2016 1 What is a liver transplant? Liver transplantation

More information

Antibiotics in sepsis

Antibiotics in sepsis Antibiotics in sepsis Jennifer Curello, PharmD, BCPS Antimicrobial Stewardship Program Ronald Reagan UCLA Medical Center September 13, 2013 Outline Sepsis definitions The sepsis bundle Timing of antimicrobials

More information

June 11, 2015 Tim Halterman

June 11, 2015 Tim Halterman June 11, 2015 Tim Halterman Defini&on Histologic change + loss of liver function Derives from Greek word kirrhos meaning yellow, tawny First named by Rene Laennec in 1819 Laennec s cirrhosis=alcoholic

More information

After the Cure: Long-Term Management of HCV Liver Disease Norah A. Terrault, MD, MPH

After the Cure: Long-Term Management of HCV Liver Disease Norah A. Terrault, MD, MPH After the Cure: Long-Term Management of HCV Liver Disease Norah A. Terrault, MD, MPH Professor of Medicine Department of Gastroenterology Director, Viral Hepatitis Center University of California San Francisco

More information

EVALUATION OF PROGNOSTIC FACTORS IN DECOMPENSATED LIVER CIRRHOSIS WITH ASCITES AND SPONTANEOUS BACTERIAL PERITONITIS

EVALUATION OF PROGNOSTIC FACTORS IN DECOMPENSATED LIVER CIRRHOSIS WITH ASCITES AND SPONTANEOUS BACTERIAL PERITONITIS Rev. Med. Chir. Soc. Med. Nat., Iaşi 2015 vol. 119, no. 4 INTERNAL MEDICINE - PEDIATRICS ORIGINAL PAPERS EVALUATION OF PROGNOSTIC FACTORS IN DECOMPENSATED LIVER CIRRHOSIS WITH ASCITES AND SPONTANEOUS BACTERIAL

More information

MANAGEMENT OF LIVER CIRRHOSIS

MANAGEMENT OF LIVER CIRRHOSIS MANAGEMENT OF LIVER CIRRHOSIS Information Leaflet Your Health. Our Priority. Page 2 of 6 What is cirrhosis? Cirrhosis is a result of long-term, continuous damage to the liver and may be due to many different

More information

Sepsis: What You Should Know

Sepsis: What You Should Know Issues & Answers Sepsis: What You Should Know Answers to your questions about what it is and how it is treated in the ICU. 2003 SCCM Your doctor or the intensivist (a doctor with special expertise and

More information

Rifaximin Treatment in Hepatic Encephalopathy

Rifaximin Treatment in Hepatic Encephalopathy Rifaximin Treatment in Hepatic Encephalopathy Bass NM, Mullen KD, Sanyal A et al. NEJM 362;12:1071-1081 Hina Ahmed, Pharm.D, ACPR, BCPS Clinical Pharmacist Toronto General Hospital Rifaximin (Xifaxan )

More information

Approach to Abnormal Liver Tests

Approach to Abnormal Liver Tests Approach to Abnormal Liver Tests Naga P. Chalasani, MD, FACG Professor of Medicine and Cellular & Integrative Physiology Director, Division of Gastroenterology and Hepatology Indiana University School

More information

PNEUMONIA. Pneumonia 3/18/2013. Etiology. Conditions that Predispose Individuals to Pneumonia

PNEUMONIA. Pneumonia 3/18/2013. Etiology. Conditions that Predispose Individuals to Pneumonia Pneumonia PNEUMONIA Dennis R. Wissing, PhD, RRT, FAARC Professor of Cardiopulmonary Science & Medicine LSU Health Shreveport An acute inflammation of the lung tissue due to a microorganism Involves bronchial

More information

Sepsis Surveillance Definition Work Update

Sepsis Surveillance Definition Work Update Sepsis Surveillance Definition Work Update Anthony Fiore, MD, MPH Chief, Epidemiology Research and Innovations Branch Division of Healthcare Quality Promotion Centers for Disease Control and Prevention

More information

SULFONAMIDES SULFONAMIDES TREATMENT OF URINARY TRACT INFECTIONS TREATMENT OF URINARY TRACT INFECTIONS DRUGS USED TO TREAT UTI S

SULFONAMIDES SULFONAMIDES TREATMENT OF URINARY TRACT INFECTIONS TREATMENT OF URINARY TRACT INFECTIONS DRUGS USED TO TREAT UTI S TREATMENT OF URINARY TRACT INFECTIONS Most acute lower urinary tract infections (acute bacterial cystitis) are uncomplicated. E.coli causes 75-90% of episodes of acute uncomplicated cystitis. Staph saprophyticus

More information

How can we best use MELD and Child-Pugh scores to assess the liver at baseline and during treatment of CHC and NASH?

How can we best use MELD and Child-Pugh scores to assess the liver at baseline and during treatment of CHC and NASH? How can we best use MELD and Child-Pugh scores to assess the liver at baseline and during treatment of CHC and NASH? Patrick S. Kamath, MD Division of Gastroenterology and Hepatology Mayo Clinic, College

More information

End Stage Liver Disease: What is New? Marion Peters MD UCSF Berlin 2012

End Stage Liver Disease: What is New? Marion Peters MD UCSF Berlin 2012 End Stage Liver Disease: What is New? Marion Peters MD UCSF Berlin 2012 Natural History of ESLD Increasing liver fibrosis Development of HCC Chronic liver disease Compensated cirrhosis Decompensated cirrhosis

More information

Skin and Soft Tissue Infection Guideline, including Diabetic Foot Ulcer Infection

Skin and Soft Tissue Infection Guideline, including Diabetic Foot Ulcer Infection Skin and Soft Tissue Infection Guideline, including Diabetic Foot Ulcer Infection Written by: Dr Ken Agwuh, Consultant Microbiologist Date: March 2016 Approved by: Drugs & Therapeutics Committee Date:

More information

Nosocomial Infections in the ICU. Gonzalo Bearman MD,MPH Associate Hospital Epidemiologist

Nosocomial Infections in the ICU. Gonzalo Bearman MD,MPH Associate Hospital Epidemiologist Nosocomial Infections in the ICU Gonzalo Bearman MD,MPH Associate Hospital Epidemiologist Nosocomial Infections 5-10% of patients admitted to acute care hospitals acquire infections 2 million patients/year

More information

CHRONIC KIDNEY DISEASE PRACTICE GUIDELINES

CHRONIC KIDNEY DISEASE PRACTICE GUIDELINES CHRONIC KIDNEY DISEASE PRACTICE GUIDELINES Reviewed and approved 5/2014 Risk Chronic kidney disease is defined as either kidney damage or decreased kidney function (decreased GFR) for 3 or more months.

More information

Introduction to Infection Control

Introduction to Infection Control CHAPTER 3 Introduction to Infection Control George Byrns and Mary Elkins Learning Objectives 1 Define terms used in infection control. 2. Review significant risk factors for infection. 3. Identify the

More information

Why Do Some Antibiotics Fail?

Why Do Some Antibiotics Fail? Why Do Some Antibiotics Fail? Patty W. Wright, M.D. April 2010 Objective To outline common reasons why antibiotic therapy is not successful and how this can be avoided. And to teach you a little bit about

More information

Jaundice. Michael Ornes

Jaundice. Michael Ornes Jaundice Michael Ornes Definitions Jaundice: hyperbilirubinemia leading to yellow discoloration of the skin Icterus: hyperbilirubinemia leading to yellow discoloration of the sclera Usually undetectable

More information

Iatrogenesis. Suzanne Beyea,, RN, PhD, FAAN Associate Director: Centers for Health and Aging

Iatrogenesis. Suzanne Beyea,, RN, PhD, FAAN Associate Director: Centers for Health and Aging Iatrogenesis Suzanne Beyea,, RN, PhD, FAAN Associate Director: Centers for Health and Aging Iatrogenesis Definition from the Greek word, iatros,, meaning healer, iatrogenesis means brought forth by a healer

More information

DRG 416 Septicemia. ICD-9-CM Coding Guidelines

DRG 416 Septicemia. ICD-9-CM Coding Guidelines oding uidelines Septicemia ICD-9-CM Coding Guidelines The below listed septicemia guidelines are not inclusive. The coder should refer to the applicable Coding Clinic guidelines for additional information.

More information

Liver Failure. Nora Aziz. www.3bv.org. Bones, Brains & Blood Vessels

Liver Failure. Nora Aziz. www.3bv.org. Bones, Brains & Blood Vessels Liver Failure Nora Aziz www.3bv.org Bones, Brains & Blood Vessels Severe deterioration in liver function Looses ability to regenerate/repair decompensated Liver extensively damaged before it fails Equal

More information

{ Rifaximin versus Nonabsorbable Disaccharides for the Treatment of Hepatic Encephalopathy: A Meta Analysis}

{ Rifaximin versus Nonabsorbable Disaccharides for the Treatment of Hepatic Encephalopathy: A Meta Analysis} { Rifaximin versus Nonabsorbable Disaccharides for the Treatment of Hepatic Encephalopathy: A Meta Analysis} {Dong Wu, Shu-Mei Wu, Jie Lu, Ying-Qun Zhou, Ling Xu, and Chuan-Yong Guo} Noor Al-Hakami, Pharm

More information

Sepsis Awareness Month

Sepsis Awareness Month Aon Kenya Insurance Brokers Ltd Aon Hewitt Healthcare Division Sepsis Awareness Month Issue 11 September 2015 In this Issue 2 Getting to understand Sepsis 3 Stages in Sepsis Advancement 4 Diagnosis & Treatment

More information

Liver Diseases. An Essential Guide for Nurses and Health Care Professionals

Liver Diseases. An Essential Guide for Nurses and Health Care Professionals Brochure More information from http://www.researchandmarkets.com/reports/1047385/ Liver Diseases. An Essential Guide for Nurses and Health Care Professionals Description: Liver disease is a rapidly growing

More information

State of Kuwait Ministry of Health Infection Control Directorate. Guidelines for Prevention of Surgical Site Infection (SSI)

State of Kuwait Ministry of Health Infection Control Directorate. Guidelines for Prevention of Surgical Site Infection (SSI) State of Kuwait Ministry of Health Infection Control Directorate Guidelines for Prevention of Surgical Site Infection (SSI) September 1999 Updated 2007 Surgical Wound: According to 1998 Kuwait National

More information

NP/PA Clinical Hepatology Fellowship Summary of Year-Long Curriculum

NP/PA Clinical Hepatology Fellowship Summary of Year-Long Curriculum OVERVIEW OF THE FELLOWSHIP The goal of the AASLD NP/PA Fellowship is to provide a 1-year postgraduate hepatology training program for nurse practitioners and physician assistants in a clinical outpatient

More information

Preoperative Laboratory and Diagnostic Studies

Preoperative Laboratory and Diagnostic Studies Preoperative Laboratory and Diagnostic Studies Preoperative Labratorey and Diagnostic Studies The concept of standardized testing in all presurgical patients regardless of age or medical condition is no

More information

Bacterial Classification and Disease

Bacterial Classification and Disease Bacterial Classification and Disease Purpose To provide an overview of how physicians think when confronted with a bacterial infection To alert you to the importance of bacterial classification in treatment

More information

Bile Duct Diseases and Problems

Bile Duct Diseases and Problems Bile Duct Diseases and Problems Introduction A bile duct is a tube that carries bile between the liver and gallbladder and the intestine. Bile is a substance made by the liver that helps with digestion.

More information

The most serious symptoms of this stage are:

The most serious symptoms of this stage are: The Natural Progression of Hepatitis C The natural history of hepatitis C looks at the likely outcomes for people infected with the virus if there is no medical intervention. However, the process of trying

More information

Solid Organ Transplantation

Solid Organ Transplantation Solid Organ Transplantation Infection Prevention And Control Transplant Atlantic 2011 October 13/2011 Kathy Hart Introduction In the past several years, the drugs that we use, the surgeries themselves,

More information

Painful Micturition and Increased Frequency of Micturition

Painful Micturition and Increased Frequency of Micturition C H A P T E R Painful Micturition and Increased Frequency of Micturition 1 1 Patients may complain of a painful or burning sensation when they pass urine or may tell you that the number of times that they

More information

SE5h, Sepsis Education.pdf. Surviving Sepsis

SE5h, Sepsis Education.pdf. Surviving Sepsis Surviving Sepsis 1 Scope and Impact of the Problem: Severe sepsis is a major healthcare problem that affects millions of people around the world each year with an extremely high mortality rate of 30 to

More information

National Digestive Diseases Information Clearinghouse

National Digestive Diseases Information Clearinghouse Cirrhosis National Digestive Diseases Information Clearinghouse U.S. Department of Health and Human Services NATIONAL INSTITUTES OF HEALTH What is cirrhosis? Cirrhosis is a condition in which the liver

More information

X-Plain Pneumonia Reference Summary

X-Plain Pneumonia Reference Summary X-Plain Pneumonia Reference Summary Introduction Pneumonia is an inflammation and infection of the lungs. Every year, more than 60,000 Americans die of pneumonia. It can affect anybody, but is more dangerous

More information

Risk stratification tool for children aged under 5 years with suspected sepsis

Risk stratification tool for children aged under 5 years with suspected sepsis Risk stratification tool for children aged under 5 years with suspected sepsis Category Age Behaviour No response to social cues Appears ill to a healthcare professional Does not wake, or if roused does

More information

CHAPTER 11 DISEASES OF THE DIGESTIVE SYSTEM (K00-K95) April MVP Health Care, Inc.

CHAPTER 11 DISEASES OF THE DIGESTIVE SYSTEM (K00-K95) April MVP Health Care, Inc. DISEASES OF THE DIGESTIVE SYSTEM (K00-K95) April 2014 2014 MVP Health Care, Inc. CHAPTER SPECIFIC CATEGORY CODE BLOCKS K00-K14 Diseases of oral cavity and salivary glands K20-K31 Diseases of esophagus,

More information

PREGNANCY AND THE LIVER

PREGNANCY AND THE LIVER Imtiaz Alam, M.D. Phone: [512] 719-4370 Mandy Mishra, CNS Fax: [512] 719-4371 Austin Hepatitis Center 12201, Renfert Way Suite 235 Austin, TX 78758 PREGNANCY AND THE LIVER How does pregnancy affect the

More information

Inhibit terminal acid secretion from parietal cells by blocking H + /K + - ATPase pump

Inhibit terminal acid secretion from parietal cells by blocking H + /K + - ATPase pump Chris J. Taylor, Pharm.D., BCPS Clinical Pharmacist Phoenix VA Health Care System Review pharmacology of PPIs Discuss possible association between PPI use and development of the following: Pneumonia (community-acquired

More information

Ansh. Liver Clinic. Prevention to Cure. Dr. Jayshri A. Shah. Dr. Ankur J. Shah. For Appointments : l

Ansh. Liver Clinic. Prevention to Cure. Dr. Jayshri A. Shah. Dr. Ankur J. Shah. For Appointments : l (Division of ANSH MEDICARE SOLUTIONS PVT. LTD.) CIN : U74999MH2016PTC284829 Dr. Jayshri A. Shah MD, DNB, MNAMS, MRCP (UK), CCST (UK) Consultant Hepatologist, Gastroenterologist, Endoscopist Dr. Ankur J.

More information

Cardiac Cirrhosis. Presented by 高 毓 佳 2003.6.16

Cardiac Cirrhosis. Presented by 高 毓 佳 2003.6.16 Cardiac Cirrhosis Presented by 高 毓 佳 2003.6.16 Associated Cardiac and Hepatic Disorders Heart disease affecting the liver Mild alterations of liver function test in heart failure Cardiogenic ischemic hepatitis

More information

10 ml of the ascitic fluid were aspirated from each patient and they were divided as the following:

10 ml of the ascitic fluid were aspirated from each patient and they were divided as the following: Summary The objective of the present work was to study the utility of serum procalcitonin for rapid and early diagnosis of bacterial infection in chronic liver diseases and to compare between serum PCT

More information

Guideline for the Diagnosis and Management of Community Acquired Pneumonia: Adult

Guideline for the Diagnosis and Management of Community Acquired Pneumonia: Adult Guideline for the Diagnosis and Management of Community Acquired Pneumonia: Adult Etiology Outpatients No comorbid factors Comorbid factors Hospitalized Moderate/Severe Patients Usual Pathogens S. pneumoniae

More information

CELLULITIS. Cellulitis is a common presentation to the Emergency Department.

CELLULITIS. Cellulitis is a common presentation to the Emergency Department. CELLULITIS Introduction Cellulitis is a common presentation to the Emergency Department. The term cellulitis refers to an uncomplicated non-necrotizing acute infection of the skin that involves the mid

More information

Study of Effects of Probiotic Lactobacilli in Preventing Major Complications in Patients of Liver Cirrhosis

Study of Effects of Probiotic Lactobacilli in Preventing Major Complications in Patients of Liver Cirrhosis Research Article Study of Effects of Probiotic Lactobacilli in Preventing Major Complications in Patients of Liver Cirrhosis RR. Pawar*, ML. Pardeshi and BB. Ghongane Department of Pharmacology, B.J. Medical

More information

HOW MANY PATIENTS SUFFER FROM POST-OPERATIVE SEPSIS? WHAT IS SEPSIS?

HOW MANY PATIENTS SUFFER FROM POST-OPERATIVE SEPSIS? WHAT IS SEPSIS? SEPSIS: Information About Post-Operative Sepsis for Patients and Relatives WHAT IS SEPSIS? Sepsis is a life threatening condition that arises when the body s response to an infection injures its own tissues

More information

LIVER TRANSPLANTATION IN ALAGILLE SYNDROME

LIVER TRANSPLANTATION IN ALAGILLE SYNDROME LIVER TRANSPLANTATION IN ALAGILLE SYNDROME Ronald J. Sokol, MD Children s Hospital Colorado University of Colorado School of Medicine Treatment of Liver Disease in Improve bile flow ALGS Ursodeoxycholic

More information

HEPATOLOGY CLERKSHIP

HEPATOLOGY CLERKSHIP College of Osteopathic Medicine HEPATOLOGY CLERKSHIP Office for Clinical Affairs 515-271-1629 FAX 515-271-1727 Elective Rotation General Description This elective rotation is a four (4) week introductory,

More information

Sepsis: Identification and Treatment

Sepsis: Identification and Treatment Sepsis: Identification and Treatment Daniel Z. Uslan, MD Associate Clinical Professor Division of Infectious Diseases Medical Director, UCLA Sepsis Task Force Severe Sepsis: A Significant Healthcare Challenge

More information

PREDICTING PROGNOSIS AMONG CIRRHOTIC PATIENTS: CHILD-PUGH VERSUS APACHE III VERSUS MELD SCORING SYSTEMS

PREDICTING PROGNOSIS AMONG CIRRHOTIC PATIENTS: CHILD-PUGH VERSUS APACHE III VERSUS MELD SCORING SYSTEMS Phil J Gastroenterol 2006; 2: 19-24 PREDICTING PROGNOSIS AMONG CIRRHOTIC PATIENTS: CHILD-PUGH VERSUS APACHE III VERSUS MELD SCORING SYSTEMS Ira I Yu, Luis Abola Section of Gastroenterology, Department

More information

Vanderbilt University Medical Center Emergency General Surgery Service Surgical Residency Rotation and Curriculum

Vanderbilt University Medical Center Emergency General Surgery Service Surgical Residency Rotation and Curriculum UNIT 15 INTERNAL MEDICINE UNIT OBJECTIVES: 1. Summarize the principles of effective surgical consultation on medical patients. 2. Explain the risks of surgery in geriatric patients with respect to age

More information

Mohamed Akoad, MD, FACS Chair, Department of Transplantation Alicia Parrott, RN Living Donor Nurse Coordinator

Mohamed Akoad, MD, FACS Chair, Department of Transplantation Alicia Parrott, RN Living Donor Nurse Coordinator Mohamed Akoad, MD, FACS Chair, Department of Transplantation Alicia Parrott, RN Living Donor Nurse Coordinator Living Donor Liver Transplantation is a surgical innovation that has been developed to address

More information

Certified Clinical Documentation Specialist Examination Content Outline - 2016

Certified Clinical Documentation Specialist Examination Content Outline - 2016 Certified Clinical Documentation Specialist Examination Content Outline - 2016 1. Healthcare Regulations, Reimbursement, and Documentation Requirements Related to the Inpatient Prospective Payment System

More information

The Initial and 24 h (After the Patient Rehabilitation) Deficit of Arterial Blood Gases as Predictors of Patients Outcome

The Initial and 24 h (After the Patient Rehabilitation) Deficit of Arterial Blood Gases as Predictors of Patients Outcome Biomedical & Pharmacology Journal Vol. 6(2), 259-264 (2013) The Initial and 24 h (After the Patient Rehabilitation) Deficit of Arterial Blood Gases as Predictors of Patients Outcome Vadod Norouzi 1, Ali

More information

Sepsis and the Clinical Laboratory

Sepsis and the Clinical Laboratory Sepsis and the Clinical Laboratory Alison Woodworth, PhD Department of Pathology, Microbiology, and Immunology Vanderbilt University Medical Center Nashville, TN Learning Objectives Outline the Pathogenesis

More information

Infective Endocarditis:

Infective Endocarditis: Infective Endocarditis: definition and epidemiology Vandecasteele S.J., MD, PhD Dept. Nephrology and Infectious Diseases AZ Sint-Jan AV, Brugge, Belgium AZ Sint-Jan AV Ruddershove 10 8000 Brugge Definition

More information

Bloodstream infections less common than respiratory or urinary tract infections, but severe and lifethreatening Types of bloodstream infections: 1) In

Bloodstream infections less common than respiratory or urinary tract infections, but severe and lifethreatening Types of bloodstream infections: 1) In Institute for Microbiology, Medical Faculty of Masaryk University and St. Anna Faculty Hospital in Brno Agents of bloodstream infections Bloodstream infections less common than respiratory or urinary tract

More information

Emergency Care CHAPTER. Hematologic and Renal Emergencies THIRTEENTH EDITION. Emergency Care, 13e Daniel Limmer Michael F. O'Keefe

Emergency Care CHAPTER. Hematologic and Renal Emergencies THIRTEENTH EDITION. Emergency Care, 13e Daniel Limmer Michael F. O'Keefe Emergency Care THIRTEENTH EDITION CHAPTER 24 Hematologic and Renal Emergencies Multimedia Directory Slide 15 Slide 40 Sickle Cell Anemia Video Information About Renal Failure Video Topics The Hematologic

More information

Cytomegalovirus in the immunocompent: Prevent, Treat, or Ignore?

Cytomegalovirus in the immunocompent: Prevent, Treat, or Ignore? Cytomegalovirus in the immunocompent: Prevent, Treat, or Ignore? Gordon D. Rubenfeld, MD MSc Professor of Medicine, University of Toronto Chief, Program in Trauma, Emergency, and Critical Care Sunnybrook

More information

Cirrhosis and HCV. Jonathan Israel M.D.

Cirrhosis and HCV. Jonathan Israel M.D. Cirrhosis and HCV Jonathan Israel M.D. Outline Relationship of fibrosis and cirrhosisprevalence and epidemiology. Sequelae of cirrhosis Diagnosis of cirrhosis Effect of cirrhosis on efficacy of treatment

More information

Alcohol Liaison Service. Liver Disease. Information

Alcohol Liaison Service. Liver Disease. Information Alcohol Liaison Service Liver Disease Information Introduction Most liver diseases do not show symptoms and when they do, the symptoms are often vague. There are hundreds of liver disorders and some are

More information

Liver Cancer And Tumours

Liver Cancer And Tumours Liver Cancer And Tumours What causes liver cancer? Many factors may play a role in the development of cancer. Because the liver filters blood from all parts of the body, cancer cells from elsewhere can

More information

Diagnostics: Page 2 of 5

Diagnostics: Page 2 of 5 Proteinuria Proteinuria is a condition in which there are increased amounts of protein in the urine. There are a number of different diseases which can result in proteinuria. In the early stages of the

More information

+Severe Sepsis EMS Spearheads the Attack against a Devastating Syndrome

+Severe Sepsis EMS Spearheads the Attack against a Devastating Syndrome + +Severe Sepsis EMS Spearheads the Attack against a Devastating Syndrome By Andrew Garlisi MD MPH MBA VAQSF CASE PRESENTATION You are called to the residence of a 74 year-old female who has experienced

More information

LIVER FUNCTION ABNORMALITIES FALL INTO 2 MAIN GROUPS: 1) HEPATIC INJURY 2) CHOLESTATIC

LIVER FUNCTION ABNORMALITIES FALL INTO 2 MAIN GROUPS: 1) HEPATIC INJURY 2) CHOLESTATIC HEPATIC DISEASE LIVER FUNCTION ABNORMALITIES FALL INTO 2 MAIN GROUPS: 1) HEPATIC INJURY 2) CHOLESTATIC LFT s HEPATIC INJURY: ALT (5-40) AST (5-40) CHOLESTASIS: ALP (30-120) & GGT (5-65) (together) NONSPECIFIC

More information

so good that so many people want a liver transplant. And if you look at what that means across the

so good that so many people want a liver transplant. And if you look at what that means across the LIVING DONOR LIVER TRANSPLANT, ABHI HUMAR, MD 1 The topic today is live donor liver transplant and I d start this by saying that liver transplantation is really a victim of its own success. We ve gotten

More information

POAC CLINICAL GUIDELINE

POAC CLINICAL GUIDELINE POAC CLINICAL GUIDELINE Acute Pylonephritis DIAGNOSIS COMPLICATED PYELONEPHRITIS EXCLUSION CRITERIA: Male Known or suspected renal impairment (egfr < 60) Abnormality of renal tract Known or suspected renal

More information

Intra-abdominal. abdominal Infections. Marnie Peterson, Pharm.D., BCPS Dept. of Pediatric Infectious Diseases Medical School University of Minnesota

Intra-abdominal. abdominal Infections. Marnie Peterson, Pharm.D., BCPS Dept. of Pediatric Infectious Diseases Medical School University of Minnesota Intra-abdominal abdominal Infections Marnie Peterson, Pharm.D., BCPS Dept. of Pediatric Infectious Diseases Medical School University of Minnesota Intra-abdominal abdominal Infections! Peritonitis! Intra-abdominal

More information

ANTIBIOTICS IN SEPSIS

ANTIBIOTICS IN SEPSIS ANTIBIOTICS IN SEPSIS Jennifer Curello, PharmD, BCPS Clinical Pharmacist, Infectious Diseases Antimicrobial Stewardship Program Ronald Reagan UCLA Medical Center October 27, 2014 The power of antibiotics

More information

Adverse Outcomes after Major Surgery in Patients with Pressure Ulcer: A Nationwide Population- Based Retrospective Cohort Study

Adverse Outcomes after Major Surgery in Patients with Pressure Ulcer: A Nationwide Population- Based Retrospective Cohort Study P2054 Adverse Outcomes after Major Surgery in Patients with Pressure Ulcer: A Nationwide Population- Based Retrospective Cohort Study Chia-Lun Chou 1, Woan-Ruoh Lee 1,2, Chun-Chieh Yeh 3,4, Chun-Chuan

More information

Urinary Tract Infections

Urinary Tract Infections Urinary Tract Infections Overview A urine culture must ALWAYS be interpreted in the context of the urinalysis and patient symptoms. If a patient has no signs of infection on urinalysis, no symptoms of

More information

Diagnosis and management of community acquired pneumonia in children

Diagnosis and management of community acquired pneumonia in children Diagnosis and management of community acquired pneumonia in children an Robinson Relationships with commercial interests: Grants/Research Support: NIH, Pfizer Speakers Bureau/Honoraria: None Consulting

More information

Methicillin-Resistant Staphylococcus aureus (MRSA) A new challenge for a new century Laura L. Radke,, MD March 5 th, 2008

Methicillin-Resistant Staphylococcus aureus (MRSA) A new challenge for a new century Laura L. Radke,, MD March 5 th, 2008 Methicillin-Resistant Staphylococcus aureus (MRSA) A new challenge for a new century Laura L. Radke,, MD March 5 th, 2008 History Initially appeared in hospitals in the 1960 s Healthcare associated (HA

More information

James T. Dwyer DO, FACOI

James T. Dwyer DO, FACOI Antibiotics in the Surgical Patient James T. Dwyer DO, FACOI Objectives Define current prophylactic recommendations for the use of antibiotics in the surgical patient List current antibiotics available

More information

Alcoholic Hepatitis (Teacher s Guide)

Alcoholic Hepatitis (Teacher s Guide) Thomas Ormiston, M.D. Updated 5/5/15 2007-2015, SCVMC Alcoholic Hepatitis (Teacher s Guide) (30 minutes) I. Objectives Recognize the signs and symptoms of alcoholic hepatitis Understand the treatment options

More information

PACKAGE LEAFLET. CLINDAMYCIN capsules Clidamycin. One capsule of 75 mg contains 75 mg Clindamycin (as hydrochloride).

PACKAGE LEAFLET. CLINDAMYCIN capsules Clidamycin. One capsule of 75 mg contains 75 mg Clindamycin (as hydrochloride). PACKAGE LEAFLET CLINDAMYCIN capsules Clidamycin COMPOSITION One capsule of 75 mg contains 75 mg Clindamycin (as hydrochloride). One capsule of 150 mg contains 150 mg Clindamycin (as hydrochloride). PROPERTIES

More information

Three triggers that suggest that patients could benefit from a hospice palliative care approach

Three triggers that suggest that patients could benefit from a hospice palliative care approach Why is it important to identify people nearing the end of life? About 1% of the population dies each year. Although some deaths are unexpected, many more in fact can be predicted. This is inherently difficult,

More information

COMPLICATIONS OF CIRRHOSIS COMPLICATIONS OF CIRRHOSIS OBSERVATIONS OF AN AGING HEPATOLOGIST. Philip C. Delich, M.D.

COMPLICATIONS OF CIRRHOSIS COMPLICATIONS OF CIRRHOSIS OBSERVATIONS OF AN AGING HEPATOLOGIST. Philip C. Delich, M.D. 1 COMPLICATIONS OF CIRRHOSIS OBSERVATIONS OF AN AGING HEPATOLOGIST COMPLICATIONS OF CIRRHOSIS Philip C. Delich, M.D. Faculty Disclosure Dr. Delich has indicated that he does not have any relevant financial

More information

Decreasing Sepsis Mortality at the University of Colorado Hospital

Decreasing Sepsis Mortality at the University of Colorado Hospital Decreasing Sepsis Mortality at the University of Colorado Hospital Maureen Dzialo, RN, BSN - Nurse Manager, Cardiac Intensive Care Unit Olivia Kerveillant, RN Clinical Nurse III, Medical Intensive Care

More information

Heart transplantation

Heart transplantation Heart transplantation A patient s guide 1 Heart transplantation Heart transplantation has the potential to significantly improve the length and quality of life for patients with severe heart failure.

More information

Course Outline and Syllabus for Students

Course Outline and Syllabus for Students Course Outline and Syllabus for Students Name: Ian Crandall Course Number: PHM242H1 Course Title: Microbiology of Infectious Diseases Course Description: The course provides a brief introduction to the

More information

Liver Cancer What is the liver? What is liver cancer?

Liver Cancer What is the liver? What is liver cancer? Liver Cancer What is the liver? The liver is the largest internal organ in the body and is important in digesting food. The liver performs many other functions, including collecting and filtering blood

More information

Open the Flood Gates Urinary Obstruction and Kidney Stones. Dr. Jeffrey Rosenberg Dr. Emilio Lastarria Dr. Richard Kasulke

Open the Flood Gates Urinary Obstruction and Kidney Stones. Dr. Jeffrey Rosenberg Dr. Emilio Lastarria Dr. Richard Kasulke Open the Flood Gates Urinary Obstruction and Kidney Stones Dr. Jeffrey Rosenberg Dr. Emilio Lastarria Dr. Richard Kasulke Nephrology vs. Urology Nephrologist a physician who has been trained in the diagnosis

More information

Acute abdominal conditions Key Points

Acute abdominal conditions Key Points 7 Acute abdominal conditions Key Points 7.1 ASSESSMENT AND DIAGNOSIS Referred abdominal pain Fore gut pain (stomach, duodenum, gall bladder) is referred to the upper abdomen Mid gut pain (small intestine,

More information

Section 1: Clinical Microbiology Laboratory handbook Trauma and Orthopaedics

Section 1: Clinical Microbiology Laboratory handbook Trauma and Orthopaedics Section 1: Clinical Microbiology Laboratory handbook Trauma and Orthopaedics Guidance for use of the microbiology laboratory / specimen taking in patients with suspected infection related to T+O Approved

More information

ENTEROCOCCUS MODULE 17.1 INTRODUCTION OBJECTIVES 17.2 ENTEROCOCCI. Notes

ENTEROCOCCUS MODULE 17.1 INTRODUCTION OBJECTIVES 17.2 ENTEROCOCCI. Notes 17 ENTEROCOCCUS 17.1 INTRODUCTION is a genus of lactic acid bacteria. Enterococci are catalase negative Gram-positive cocci that often occur in pairs (diplococci) or short chains, and are difficult to

More information

Lamivudine for Patients with hronic Hepatitis B and Advanced Liver Disease. From : New England Journal of Medicine

Lamivudine for Patients with hronic Hepatitis B and Advanced Liver Disease. From : New England Journal of Medicine Lamivudine for Patients with hronic Hepatitis B and Advanced Liver Disease From : New England Journal of Medicine Volume 351:1521-1531, Number 15, Oct 7, 2004 馬 偕 紀 念 醫 院 一 般 內 科, 肝 膽 腸 胃 科 新 竹 分 院 陳 重

More information

Role of Adult-to-adult Living Liver Transplantation in PSC

Role of Adult-to-adult Living Liver Transplantation in PSC Role of Adult-to-adult Living Liver Transplantation in PSC Michael Abecassis, MD, MBA J. Roscoe Miller Distinguished Professor Departments of Surgery and Microbiology-Immunology Chief, Division of Organ

More information

Give Your Pet a Longer, Healthier Life

Give Your Pet a Longer, Healthier Life Give Your Pet a Longer, Healthier Life Wellness Exam A wellness exam starts with a comprehensive physical examination by your pet s veterinarian. Once the exam has been completed, further services such

More information

Nurse Practitioner Outcomes: The Integration & Future Directions of The Liver Transplant NP. Amanda Tinning MN NP October 13, 2011

Nurse Practitioner Outcomes: The Integration & Future Directions of The Liver Transplant NP. Amanda Tinning MN NP October 13, 2011 Nurse Practitioner Outcomes: The Integration & Future Directions of The Liver Transplant NP Amanda Tinning MN NP October 13, 2011 Overview Define clinical outcomes Discuss the contributions of the NP role

More information

Probiotics for the Treatment of Adult Gastrointestinal Disorders

Probiotics for the Treatment of Adult Gastrointestinal Disorders Probiotics for the Treatment of Adult Gastrointestinal Disorders Darren M. Brenner, M.D. Division of Gastroenterology Northwestern University, Feinberg School of Medicine Chicago, Illinois What are Probiotics?

More information

Clostridium Difficile Colitis: Treatments, Guidelines, and Challenges

Clostridium Difficile Colitis: Treatments, Guidelines, and Challenges Clostridium Difficile Colitis: Treatments, Guidelines, and Challenges Brian S. Zuckerbraun, MD, FACS Henry T. Bahnson Professor of Surgery University of Pittsburgh Chief, Trauma and Acute Care Surgery

More information