Rifaximin: A reasonable alternative for norfloxacin in the prevention of spontaneous bacterial peritonitis in patients with HCV-related liver cirrhosis

Abstract

Background: Norfloxacin is the most commonly used agent for the prophylaxis against spontaneous bacterial peritonitis (SBP) in patients with liver cirrhosis. Rifaximin, another broad spectrum antibiotic, is used for the treatment of traveler's diarrhea and hepatic encephalopathy. Objective: We aimed to test the efficacy of rifaximin versus norfloxacin for prevention of SBP in patients with hepatitis C virus (HCV)-related liver cirrhosis. Patients and methods: 86 patients with HCV-related liver cirrhosis and ascites were enrolled and divided into two groups of matching age, sex and Child-Pugh class. Group I was given norfloxacin 400 mg/day as single dose, and group II rifaximin 1200 mg/day in three divided doses. They were followed for up to one year. Study endpoints were SBP, hepatocellular carcinoma, compliance failure, death, or liver transplantation. Results: More than 70% of patients received the antimicrobial as primary prophylaxis and the rest were given secondary prophylaxis against SBP. The mean follow-up period was 10.16 ± 2.64 months for norfloxacin and 10.26 ± 2.32 months for rifaximin (p = 0.863). Although statistically insignificant (p = 0.265), patients on rifaximin developed fewer episodes of SBP than those on norfloxacin (4.7% vs. 14%). Also, the infection-free duration before SBP was longer (p = 0.129) with rifaximin than norfloxacin (9.5 vs. 5.0 months). Rifaximin significantly reduced the rate of new compared to past episodes of SBP by 20.9% (p = 0.007) vs. 13.9% for norfloxacin (p = 0.112). Overall survival was equal in both groups. Patients adhered to therapy regimen of norfloxacin for significantly longer time than rifaximin (p = 0.010). Conclusion: Rifaximin is -at least -as good as norfloxacin. It seems to be an appropriate alternative for long-term primary and secondary prophylaxis of SBP in cirrhotic patients with ascites. Modification of dose regimen should be considered to improve patient's compliance to rifaximin.

Systematic review with meta‐analysis: rifaximin for the prophylaxis of spontaneous bacterial peritonitis

“…Of those reviewed in detail, 63 were excluded because they were not original studies, 39 were excluded because they did not provide data related to rifaximin exposure, 15 were excluded because they did not report data on SBP outcomes and four were excluded due to inadequate clinical trial information. Overall, nine studies were included in the meta‐analysis: three randomised trials and 6 cohort studies as detailed in Figure …”

“…Five studies compared rifaximin to systemic antibiotics and five studies compared rifaximin to placebo in the prevention of SBP. Lutz et al included patients in all three treatment groups (rifaximin, systemic antibiotics and placebo) and this study was included in both meta‐analyses .…”

“…Five studies with a total of 555 patients were included in the analysis comparing rifaximin with systemic antibiotics for SBP prophylaxis; 295 patients received rifaximin and 260 received systemic antibiotics . Systemic antibiotics consisted primarily of oral quinolones including norfloxacin and ciprofloxacin.…”

“…Additional data were obtained by the authors of Shamseya 2016 study. Three studies compared rifaximin to systemic antibiotics for primary prophylaxis and four studies for secondary prophylaxis. The OR for primary prophylaxis was 0.59 (95% CI 0.32‐1.09; P = .10) (Figure S1).…”

“…Due to its high concentration in the enteric system, rifaximin has the potential advantage of preventing intestinal bacterial overgrowth and translocation without the systemic side effects of broad‐spectrum antibiotics . Several studies evaluating the effectiveness of rifaximin in preventing SBP in high risk patients have shown inconsistent results . We conducted a systematic review and meta‐analysis to evaluate the efficacy of rifaximin in the prevention of SBP.…”