What is the relationship between Urinary Tract Infection (UTI) and elevated liver function tests (LFTs) in a patient?

From the Guidelines

For a patient with a urinary tract infection (UTI) who is admitted with elevated liver function tests, initial empiric therapy should include ceftriaxone 1-2g IV daily or ciprofloxacin 400mg IV twice daily, adjusting based on culture results, as recommended by the European Association of Urology guidelines on urological infections 1. When managing a UTI in a patient with elevated liver function tests, it is crucial to consider the potential impact of hepatic metabolism on antibiotic selection.

• The choice of antibiotic should be guided by the severity of the infection, local resistance patterns, and specific host factors such as allergies.
• Ceftriaxone is preferred in patients with severe hepatic impairment due to its minimal dose adjustment requirements.
• Treatment duration should be 7-14 days, depending on the severity of the infection, as outlined in the European Association of Urology guidelines 1.
• Regular monitoring of both liver function tests and clinical response is essential to ensure effective treatment and minimize potential liver toxicity.
• Antibiotics with significant hepatic metabolism, such as erythromycin or high-dose fluconazole, should be avoided.
• Adequate hydration should be maintained, and antipyretics should be used cautiously, preferring acetaminophen at reduced doses (maximum 2g/day) over NSAIDs.
• The underlying cause of elevated liver enzymes should be investigated concurrently, as it may be related to sepsis from the UTI or represent a separate condition requiring specific management, as discussed in the ACR Appropriateness Criteria for abnormal liver function tests 1.
• Once the patient improves clinically, transition to oral antibiotics can be considered based on susceptibility results and liver function status.

From the Research

UTI and Liver Function Test

• A patient admitted for high liver function test may have underlying conditions that need to be evaluated, as stated in the study 2.
• The evaluation of abnormal liver function tests in hospitalized patients should be organized into four steps: determining the association with the illness, determining the etiology of the underlying liver disease, evaluating the severity of the liver dysfunction, and looking for associated complications 2.

UTI as a Risk Factor for Autoimmune Liver Disease

• Urinary tract infections (UTI) have been associated with autoimmune liver diseases, such as primary biliary cirrhosis (PBC) and primary sclerosing cholangitis 3.
• Recurrent UTI has been strongly associated with PBC, and to a lesser extent with autoimmune hepatitis (AIH) 3.
• The link between UTI and PBC may be explained by molecular mimicry between microbial and human PDC-E2 epitopes 3.

Antibiotics and Liver Injury

• Antibiotics are a common cause of drug-induced liver injury (DILI), with some antibiotics having a delayed onset of liver injury 4.
• The clinical phenotype of DILI associated with different types of antibiotics is highly variable, and some antibiotics can lead to severe consequences, such as acute liver failure (ALF) or autoimmune-like reactions 4.
• Commonly used antibiotics, such as azithromycin, ciprofloxacin, and amoxicillin-clavulanate, have been associated with DILI, as reported in the study 5.

Treatment and Management

• Daily ciprofloxacin treatment has been shown to reduce hospitalizations in patients with advanced liver disease awaiting liver transplantation 6.
• The treatment of UTI with nitrofurantoin can induce AIH, highlighting the importance of careful antibiotic selection and monitoring for liver injury 3.