Editorial
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Dec 27, 2018; 10(12): 892-897
Published online Dec 27, 2018. doi: 10.4254/wjh.v10.i12.892
Unresolved issues in the prophylaxis of bacterial infections in patients with cirrhosis
Melisa Dirchwolf, Sebastián Marciano, José Martínez, Andrés Eduardo Ruf
Melisa Dirchwolf, José Martínez, Andrés Eduardo Ruf, Unidad de Hígado, Hospital Privado de Rosario, Rosario 2000, Argentina
Sebastián Marciano, Unidad de Hígado, and Departamento de Investigación del Hospital Italiano de Buenos Aires, Buenos Aires 1424, Argentina
Author contributions: Dirchwolf M, Marciano S, Martínez J and Ruf AE conceived the study and drafted the manuscript; all authors approved the final version of the article.
Conflict-of-interest statement: The authors have no conflict of interest to declare.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Melisa Dirchwolf, MD, Attending Doctor, Unidad de Higado, Hospital Privado de Rosario, Presidente Roca 2440, Rosario 2000, Santa Fe, Argentina. unidaddehigado.hpr@grupogamma.com.ar
Telephone: +54-341-4893545
Received: August 6, 2018
Peer-review started: August 7, 2018
First decision: August 24, 2018
Revised: September 4, 2018
Accepted: October 11, 2018
Article in press: October 11, 2018
Published online: December 27, 2018
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.

Keywords: Cirrhosis, Antibiotic Prophylaxis, Multi-drug resistant bacteria, Spontaneous bacterial peritonitis, Bacterial infections

Core tip: Antibiotic prophylaxis in patients with cirrhosis has proven to be effective in preventing new episodes of bacterial infections and reducing mortality. However, the broad and fixed indication of long-term antibiotic therapy in these patients has led to an increase in the emergence of multi-drug resistant bacteria. The development of new strategies for bacterial infection prevention is currently under debate, thus reflecting the need for randomized controlled trials and local epidemiological studies to improve prophylactic antibiotic choice in patients with cirrhosis.