A randomized controlled study of trimethoprim‐sulfamethoxazole <i>versus</i> norfloxacin for the prevention of infection in cirrhotic patients

Lontos, Steve; Shelton, Edward; Angus, Peter W; Vaughan, Rhys; Roberts, Stuart K.; Gordon, Adam; Gow, Paul J

doi:10.1111/1751-2980.12132

Cited by 33 publications

(45 citation statements)

References 20 publications

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“…Overall, these 10 trials included 910 patients. Out of 10 RCTs, four compared norfloxacin with placebo (included the study by Novella et al comparing continuous 1‐year norfloxacin treatment versus norfloxacin administered only during hospitalization), two compared ciprofloxacin with placebo, one norfloxacin with ciprofloxacin, one compared norfloxacin with rifaximin, and two compared norfloxacin with trimethoprim/sulfamethoxazole . SBP occurrence was reported in all the included trials, mortality rate was registered in eight RCTs, HRS occurrence in four RCTs …”

Section: Resultsmentioning

confidence: 99%

“…Quality assessment was performed in the context of the primary outcomes and overall, the studies were felt to be at low risk of bias. Overall, four RCTs were considered at higher risk of bias mainly because of selection and reporting bias. Study quality assessments are summarized in Figure .…”

Section: Resultsmentioning

confidence: 99%

“…Again, no evidence of heterogeneity was found. Of note, since the two RCTs testing trimethoprim/sulfamethoxazole did not report survival data, this antimicrobial agent could not be assessed in this analysis.…”

Section: Resultsmentioning

confidence: 99%

“…Oral quinolones have been used for long period with favourable results in this subset of patients, as confirmed in a recent meta‐analysis; however, several concerns on the cost and safety profile of long‐term quinolones therapy along with the increasing risk of antibiotic resistance pushed to test other antimicrobial agents such as rifaximin or trimethoprim/sulfamethoxazole …”

Section: Discussionmentioning

confidence: 99%

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Comparative efficacy of long‐term antibiotic treatments in the primary prophylaxis of spontaneous bacterial peritonitis

Facciorusso

Papagiouvanni

Cela

et al. 2019

Liver International

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Background & Aims: Several antibiotic treatments aiming to prevent spontaneous bacterial peritonitis (SBP) in cirrhotic patients with low-protein content in ascitic fluid have been tested; however, there are limited data on the comparative efficacy of these regimens. We assessed their comparative efficacy through a network metaanalysis and using GRADE criteria to appraise quality of evidence.Methods: Through literature review through October 2018, we identified 10 randomized controlled trials comparing antibiotic treatments (norfloxacin, ciprofloxacin, trimethoprim/sulfamethoxazole and rifaximin) with each other or placebo. Primary outcome was SBP occurrence, with mortality rate and rate of other infections as secondary outcomes. Results:In comparison with placebo, moderate quality evidence supports the use of norfloxacin and ciprofloxacin in primary prophylaxis of SBP (risk ratio 0.23; 95% CI, 0.09-0.56; P = 0.001 and 0.23; 0.07-0.79; P = 0.02 respectively) while only low quality evidence suggests superiority of rifaximin (risk ratio 0.15; 0.05-0.42). When antimicrobial agents were compared to each other, no significant difference was found.With regard to mortality, moderate quality supports the superiority of norfloxacin over placebo (risk ratio, 0.68; 95% CI, 0.47-0.99; P = 0.04), while ciprofloxacin and rifaximin showed only a non-significant benefit and no significant difference was found in the other comparisons. None of the tested antibiotics proved to significantly decrease the rate of other infections.Conclusions: Norfloxacin appears to have significant benefit both in terms of SBP prevention and mortality; ciprofloxacin represents a valuable option although without a clear survival benefit. Rifaximin shows interesting results but needs to be tested in further trials. K E Y W O R D S cirrhosis, GRADE, liver, norfloxacin | 1449 FACCIORUSSO et Al.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 2 more Smart Citations

Comparative efficacy of long‐term antibiotic treatments in the primary prophylaxis of spontaneous bacterial peritonitis

Facciorusso

Papagiouvanni

Cela

et al. 2019

Liver International

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“…The value of this strategy has been demonstrated by a few randomized controlled trials showing a significant reduction of new SBP episodes (from 70 to 20% after 1 year of follow-up) [7] but not a significantly longer survival. Besides norfloxacin, other antibiotics, such as ciprofloxacin and co-trimoxazole, have been tested [14], but norfloxacin remains the most used.…”

Section: Therapy and Prophylaxis Of Sbpmentioning

confidence: 99%

Treatment of Spontaneous Bacterial Peritonitis

Salerno

Mura

2015

Dig Dis

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Spontaneous bacterial peritonitis (SBP) is an infection of patients with cirrhosis and ascites. This peculiarity is due to the frequent intestinal translocation that allows bacteria to cross the intestinal barrier, colonizing the ascitic fluid. In cirrhosis, SBP is inferior only to urinary tract infections. It is prevalently sustained by Gram-negative bacteria such as Escherichia coli and Klebsiella. Risk factors for developing SBP are advanced age, refractory ascites, variceal bleeding, renal failure, low albumin levels (below 2.5 g/ml), bilirubin over 4 mg/dl, Child-Pugh class C and a previous diagnosis of SBP. Thus, this is an indication for a long-term antibiotic prophylaxis with norfloxacin. Renal failure - especially the hepatorenal syndrome - complicates SBP in about 20% of cases independently of the efficacy of the antibiotic therapy. The mortality of these patients is about 90%. Infusion of albumin significantly reduces the incidence of hepatorenal syndrome and consequently the risk of death. Long-term quinolonic prophylaxis as well as increased antibiotic therapies are causing the emergence of multidrug-resistant agents as frequent causes of SBP. In such cases, the antibiotic sensitivity to quinolones is low, and European recommendations suggest a second-line antibiotic therapy, including meropenem or piperacillin plus tazobactam. Collection of blood, urine and ascitic fluid for cultures is important for bacterial recognition, possibly before starting an empirical antibiotic therapy. Indeed, the probability of positive cultures rapidly vanishes when they are performed during already implemented antibiotic administration. It is important to know that a failure of the first-line therapy is associated with an increased probability of death.

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Antibiotic prophylaxis to prevent spontaneous bacterial peritonitis in people with liver cirrhosis: a network meta-analysis

Komolafe

Roberts

Freeman

et al. 2020

Cochrane Database of Systematic Reviews

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A randomized controlled study of trimethoprim‐sulfamethoxazole versus norfloxacin for the prevention of infection in cirrhotic patients

Abstract: This study failed to demonstrate a difference between N and T-S groups in their effects on preventing infection in patients with liver cirrhosis. T-S can be considered an alternative first-line therapy for infection prophylaxis.

Cited by 33 publications

References 20 publications

Comparative efficacy of long‐term antibiotic treatments in the primary prophylaxis of spontaneous bacterial peritonitis

Comparative efficacy of long‐term antibiotic treatments in the primary prophylaxis of spontaneous bacterial peritonitis

Treatment of Spontaneous Bacterial Peritonitis

Antibiotic prophylaxis to prevent spontaneous bacterial peritonitis in people with liver cirrhosis: a network meta-analysis

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