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World J Gastroenterol. Feb 21, 2014; 20(7): 1790-1796
Published online Feb 21, 2014. doi: 10.3748/wjg.v20.i7.1790
Role of prophylactic antibiotics in cirrhotic patients with variceal bleeding
Yeong Yeh Lee, Hoi-Poh Tee, Sanjiv Mahadeva
Yeong Yeh Lee, Department of Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia
Hoi-Poh Tee, Department of Internal Medicine, Hospital Tengku Ampuan Afzan, Kuantan 25100, Pahang, Malaysia
Sanjiv Mahadeva, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
Author contributions: All the authors were involved in the design, analysis and writing of manuscript.
Correspondence to: Yeong Yeh Lee, MD, PhD, FACP, FRCP, Department of Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Kelantan, Malaysia. justnleeyy@gmail.com
Telephone: +60-9-7676590 Fax: +60-9-7653370
Received: September 18, 2013
Revised: November 11, 2013
Accepted: January 6, 2014
Published online: February 21, 2014
Processing time: 175 Days and 0.2 Hours
Abstract

Bacterial infections are common in cirrhotic patients with acute variceal bleeding, occurring in 20% within 48 h. Outcomes including early rebleeding and failure to control bleeding are strongly associated with bacterial infection. However, mortality from variceal bleeding is largely determined by the severity of liver disease. Besides a higher Child-Pugh score, patients with hepatocellular carcinoma are particularly susceptible to infections. Despite several hypotheses that include increased use of instruments, greater risk of aspiration pneumonia and higher bacterial translocation, it remains debatable whether variceal bleeding results in infection or vice versa but studies suggest that antibiotic prophylaxis prior to endoscopy and up to 8 h is useful in reducing bacteremia and spontaneous bacterial peritonitis. Aerobic gram negative bacilli of enteric origin are most commonly isolated from cultures, but more recently, gram positives and quinolone-resistant organisms are increasingly seen, even though their clinical significance is unclear. Fluoroquinolones (including ciprofloxacin and norfloxacin) used for short term (7 d) have the most robust evidence and are recommended in most expert guidelines. Short term intravenous cephalosporin (especially ceftriaxone), given in a hospital setting with prevalent quinolone-resistant organisms, has been shown in studies to be beneficial, particularly in high risk patients with advanced cirrhosis.

Keywords: Antibiotics; Prophylaxis; Cirrhosis; Variceal bleeding; Infection

Core tip: Bacterial infections are common in cirrhotics with variceal bleeding and can influence its outcomes that include early rebleeding, failure to control bleeding and mortality. It remains unsure whether infection or bleeding is the initiating event but prophylactic antibiotics have been proven useful. Short term fluoroquinolones and cephalosporins are the most studied antibiotics, and they are recommended by guidelines in clinical situations that depend on the severity of liver disease and resistance profile.