Universal antibiotic prophylaxis may no longer be necessary for patients with acute variceal bleeding

Abstract

A few decades ago, antibiotic prophylaxis for patients with acute variceal bleeding was reported beneficial. However, endoscopic and systemic therapy for variceal bleeding has dramatically improved since then, so the necessity of prophylactic antibiotics can be questioned. In this study, we reevaluated the efficacy of antibiotic prophylaxis in acute variceal bleeding, using the most recent data in our hospital. We retrospectively analyzed the medical records of 150 patients with acute variceal bleeding who were admitted to Kurashiki Central Hospital between January 2012 and December 2016. We compared the rates of bacterial infection, in-hospital mortality, 5-day rebleeding rate, and 30-day emergency readmission between patients treated or not treated with antibiotic prophylaxis. Forty-six patients (30.7%) received antibiotic prophylaxis; 104 (69.3%) did not. The rates of the outcomes in patients with antibiotic prophylaxis were 6.5% (bacterial infection), 4.3% (in-hospital mortality), 2.2% (5-day rebleeding), and 10.9% (30-day emergency readmission) and were not significantly different form the corresponding figures in those without antibiotic prophylaxis (1.9%, 7.7%, 1.9%, and 10.6%, respectively). Moreover, these rates in our patients, even without antibiotic prophylaxis, were much lower than rates reported in past years, perhaps because of improvements in care of patients with variceal hemorrhage. Antibiotic prophylaxis was not associated with significantly better outcomes of bacterial infection, mortality, rebleeding or readmission rate in patients with acute variceal bleeding. Universal antibiotic prophylaxis for patients with acute variceal bleeding should be reconsidered.

Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding: Is evidence adequate?

“…To reexamine the efficacy of antibiotic prophylaxis in cirrhotic patients, we performed a retrospective study and found that antibiotic prophylaxis was not significantly associated with lower rates of bacterial infection, rebleeding, readmission, or mortality. 6 Despite the low rate of antibiotics prescribing (30.7%), the frequency of bacterial infection (3.3%) was much lower than in previous reports. 6 In their study, Zullo et al did not mention anything about the association between antibiotic prophylaxis and clinical outcomes; however, sepsis occurred in only 2.4% of their patients, less than half of which resulted in mortality.…”

“…6 Despite the low rate of antibiotics prescribing (30.7%), the frequency of bacterial infection (3.3%) was much lower than in previous reports. 6 In their study, Zullo et al did not mention anything about the association between antibiotic prophylaxis and clinical outcomes; however, sepsis occurred in only 2.4% of their patients, less than half of which resulted in mortality. 1 We present here a summary of the results of all randomized controlled trials that were included in the systematic review 2 ; randomized controlled trials reported after that 7,8 ; the present study by Zullo et al 1 ; and our updated data 9 (Table 1).…”

Antibiotic prophylaxis in cirrhosis patients with upper gastrointestinal bleeding: An updated systematic review and meta‐analysis

“…A total of 15 studies (1933 subjects) reported outcome data on mortality risk among cirrhosis patients with UGIB. 8,9,13,14,16,[18][19][20][21][22]30,32,[34][35][36][37] The pooled risk of 6week mortality (CTP-A: 0%, CTP-B: 4.7%, CTP-C: 20.0%) increased proportionally with the underlying CTP class. Antibiotic prophylaxis reduces the risk of 6week mortality (RR = 0.72, 95% CI = 0.57-0.90, I 2 = 0%) (Figure 1).…”

“…A total of 9 studies (2235 subjects) reported outcome data on the risk of rebleeding among cirrhosis patients with UGIB. 8,13,14,16,21,[30][31][32]35,36 Antibiotic prophylaxis was associated with a significantly lower pooled risk of rebleeding within 7 days (RR = 0.45, 95% CI = 0.29-0.72, I 2 = 47%) (Figure 4A) and 6 weeks (RR = 0.57, 95% CI = 0.46-0.71, I 2 = 61%) (Figure 4B). The heterogeneity for rebleeding at 6 weeks was resolved when analysis was restricted to RCTs (RR = 0.59, 95% CI = 0.44-0.79, I 2 = 0%) (Supporting Information: Table 2).…”

“…A total of 16 studies (2230 subjects) reported outcomes on the risk of new infection among cirrhosis patients with UGIB. 9,13,14,16,[18][19][20][21][22][32][33][34][35]37 The pooled risk of infection increased proportionally with the underlying CTP class (CTP-A: 2.3%, CTP-B: 5.5%, CTP-C: 9.1%). 27,33,34 Antibiotic prophylaxis was associated with a lower risk of infection (RR = 0.39, 95% CI = 0.32-0.48, I 2 = 37%), with moderate heterogeneity observed (Supporting Information: Figure 4).…”