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.