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Published on: June 18, 2020
Role of prophylactic antibiotics in cirrhotic patients with variceal bleeding
Yeong Yeh Lee1, Hoi-Poh Tee1, Sanjiv Mahadeva1
1Yeong Yeh Lee, Department of Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia.
Insights
Bacterial infections are common in cirrhotic patients with acute variceal bleeding, impacting outcomes. Antibiotic prophylaxis, particularly short-term fluoroquinolones or intravenous cephalosporins, is recommended to reduce infection risk and improve patient prognosis.
Area of Science:
- Gastroenterology
- Hepatology
- Infectious Diseases
Background:
- Bacterial infections are prevalent in cirrhotic patients experiencing acute variceal bleeding (AVB), affecting approximately 20% within 48 hours.
- Infection is linked to adverse outcomes in AVB, including early rebleeding and failure to control bleeding.
- Liver disease severity, indicated by a higher Child-Pugh score, and hepatocellular carcinoma increase susceptibility to infections.
Purpose of the Study:
- To review the role of bacterial infections in acute variceal bleeding.
- To evaluate the efficacy of antibiotic prophylaxis in preventing infections and improving outcomes.
- To discuss current recommendations for antibiotic therapy in this patient population.
Main Methods:
- Literature review and synthesis of existing studies on bacterial infections in AVB.
- Analysis of data regarding the incidence, causative organisms, and impact of infections.
- Evaluation of evidence supporting antibiotic prophylaxis strategies.
Main Results:
- Bacterial infections are associated with increased rebleeding and mortality in AVB patients.
- Antibiotic prophylaxis, especially short-term (7 days) fluoroquinolones, is effective in reducing bacteremia and spontaneous bacterial peritonitis.
- Intravenous cephalosporins (e.g., ceftriaxone) may be beneficial in high-risk patients with advanced cirrhosis and quinolone-resistant organisms.
Conclusions:
- Antibiotic prophylaxis is crucial for managing cirrhotic patients with acute variceal bleeding.
- Short-term antibiotic therapy with fluoroquinolones or cephalosporins is recommended based on current evidence and guidelines.
- Further research may clarify the role of emerging resistant organisms and optimize treatment strategies.
Abstract:
Bacterial infections are common in cirrhotic patients with acute variceal bleeding, occurring in 20% within 48 h. Outcomes including early rebleeding and failure to control bleeding are strongly associated with bacterial infection. However, mortality from variceal bleeding is largely determined by the severity of liver disease. Besides a higher Child-Pugh score, patients with hepatocellular carcinoma are particularly susceptible to infections. Despite several hypotheses that include increased use of instruments, greater risk of aspiration pneumonia and higher bacterial translocation, it remains debatable whether variceal bleeding results in infection or vice versa but studies suggest that antibiotic prophylaxis prior to endoscopy and up to 8 h is useful in reducing bacteremia and spontaneous bacterial peritonitis. Aerobic gram negative bacilli of enteric origin are most commonly isolated from cultures, but more recently, gram positives and quinolone-resistant organisms are increasingly seen, even though their clinical significance is unclear. Fluoroquinolones (including ciprofloxacin and norfloxacin) used for short term (7 d) have the most robust evidence and are recommended in most expert guidelines. Short term intravenous cephalosporin (especially ceftriaxone), given in a hospital setting with prevalent quinolone-resistant organisms, has been shown in studies to be beneficial, particularly in high risk patients with advanced cirrhosis.
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