Unresolved issues in the prophylaxis of bacterial infections in cirrhosis patients

Abstract

Bacterial infections are highly prevalent and a frequent cause of hospitalization and short-term mortality in patients with cirrhosis. Due to their negative impact on survival, antibiotic prophylaxis for bacterial infections in high-risk subgroups of patients with cirrhosis has been the standard of care for decades. Patients with prophylaxis indications include those at risk for a first episode of spontaneous bacterial peritonitis (SBP) due to a low ascitic fluid protein count and impaired liver and kidney function, patients with a prior episode of SBP and those with an episode of gastrointestinal bleeding. Only prophylaxis due to gastrointestinal bleeding has a known and short-time duration. All other indications imply long-lasting exposure to antibiotics - once the threshold requirement for initiating prophylaxis is met - without standardized criteria for re-assessing antibiotic interruption. Despite the fact that the benefit of antibiotic prophylaxis in reducing bacterial infections episodes and mortality has been thoroughly reported, the extended use of antibiotics in patients with cirrhosis has also had negative consequences, including the emergence of multi-drug resistant bacteria. Currently, it is not clear whether restricting the use of broad and fixed antibiotic regimens, tailoring the choice of antibiotics to local bacterial epidemiology or selecting non-antibiotic strategies will be the preferred antibiotic prophylaxis strategy for patients with cirrhosis in the future.

Editorial: Terlipressin and MDRO colonisation in cirrhosis—Is there a causal link?

“…However, managing bacterial infections remains challenging, mainly due to the rise in multidrug-resistant organisms (MDRO), which contribute significantly to morbidity and short-term mortality. 1 Factors associated with MDRO infections in cirrhosis, such as MDRO colonisation, are of keen interest. 2 Yet, predicting MDRO colonisation is challenging, with few known associated variables beyond hospitalisation and antibiotic therapy.…”

“…In recent decades, there has been a notable progress in managing complications of cirrhosis, such as hepatorenal syndrome and variceal bleeding, leading to improvements in survival. However, managing bacterial infections remains challenging, mainly due to the rise in multidrug‐resistant organisms (MDRO), which contribute significantly to morbidity and short‐term mortality 1 . Factors associated with MDRO infections in cirrhosis, such as MDRO colonisation, are of keen interest 2 .…”

Korean Guidelines for Use of Antibiotics for Intra-abdominal Infections in Adults

“…On the other hand, Piano et al reported that antibiotics used prophylactically in patients with cirrhosis were not associated with the development of a resistance [ 18 ]. The issue of prophylactic antibiotic administration in patients with cirrhosis is unresolved [ 121 ]. In another study, MDRO infections in patients with SBP were associated with the use of antibiotics, including prophylactic antibiotics; hospital-acquired infections; recent history of MDRO infections; recent inpatient care; use of healthcare; and upper gastrointestinal bleeding in patients with liver cirrhosis [ 19 122 123 ].…”