Evaluation of the current guidelines for antibacterial therapy strategies in patients with cirrhosis or liver failure

Abstract

Background Bacterial infections are common complications in patients with cirrhosis or liver failure and are correlated with high mortality. Clinical practice guideline (CPG) is a reference used to help clinicians make decisions. This systematic appraisal aimed to evaluate the methodological quality and summarize the recommendations of reported CPGs in these patients. Methods We systematically searched CPGs published from 2008 to 2019. The methodological quality of the included CPGs was assessed using the AGREE II instrument. We extracted and compared recommendations for prophylactic and empirical treatment strategies. Results Fourteen CPGs with a median overall score of 56.3% were included. The highest domain score was Clarity of Presentation (domain 4, 85.4%), and the lowest was for Stakeholder Involvement (domain 2, 31.3%). Three CPGs had an overall score above 80%, and 6 CPGs had a score above 90% in domain 4. Prophylaxis should be strictly limited to patients with varicose bleeding, low ascites protein levels and a history of spontaneous bacterial peritonitis. Fluoroquinolones (norfloxacin and ciprofloxacin), third-generation cephalosporins (G3) (ceftriaxone and cefotaxime) and trimethoprim–sulfamethoxazole (SXT) are recommended for preventing infections in patients with cirrhosis or liver failure. G3, β-lactam/β-lactamase inhibitor combinations (BLBLIs) and carbapenems are recommended as the first choice in empirical treatment according to local epidemiology of bacterial resistance. Conclusions The methodological quality of CPGs focused on patients with cirrhosis or liver failure evaluated by the AGREE II instrument is generally poor. Three CPGs that were considered applicable without modification and 6 CPGs that scored above 90% in domain 4 should also be paid more attention to by healthcare practitioners. Regarding recommendations, norfloxacin, ciprofloxacin, ceftriaxone, cefotaxime, and SXT are recommended for prophylactic treatment appropriately. G3, BLBLIs, and carbapenems are recommended for use in empirical treatment strategies.

Bacterial Infections in Acute-on-chronic Liver Failure: Epidemiology, Diagnosis, Pathogenesis, and Management

“…52 Trimethoprim-sulfamethoxazole was also an alternative for the prevention of infection in cirrhosis or liver failure, although its efficacy remained ambiguous. [52][53][54] Rifaximin has also been found to be useful for the primary and secondary prophylaxis of SBP. 52,53,[55][56][57] Rifaximin suppresses the translocation of certain bacteria and promotes gut barrier repair, thus preventing the translocation of bacteria from the intestinal lumen to the circulatory system.…”

Potential Therapeutic Strategies in the Treatment of Metabolic-Associated Fatty Liver Disease

“…Antibiotics can eliminate unfavorable microbiota, and their efficacy has been confirmed in several liver diseases [165]. For treating cirrhosis and encephalopathy, as well as spontaneous bacterial peritonitis, fluoroquinolones (norfloxacin and ciprofloxacin), third-generation cephalosporins (ceftriaxone and cefotaxime), and trimethoprim-sulfamethoxazole are recommended; and neomycin, metronidazole, polymyxin B, and rifaximin have been used.…”

Challenges and recommendations when selecting empirical antibiotics in patients with cirrhosis

“…Antibiotic prophylaxis in patients with acute gastrointestinal bleeding: There is broad consensus regarding prescribing antibiotic prophylaxis in acute gastrointestinal bleeding in patients with cirrhosis. This is mainly based on their high rate of bacterial infections without antibiotic use (up to 50% during the first days of hospitalization) and on the efficacy of prophylaxis in preventing infections, re-bleeding, and death[ 27 ]. Furthermore, the proposed duration of treatment is of only seven days.…”

“…Notably, no significant difference between quinolones and cephalosporins was observed[ 28 ]. However, due to the emergence of quinolone-resistant organisms, most international guidelines recommend ceftriaxone as the antibiotic of choice[ 27 , 29 - 31 ]. In countries such as the United States, where norfloxacin has been discontinued, ceftriaxone is the only recommended option[ 32 ].…”