Meta-Analysis
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. May 27, 2020; 12(5): 239-252
Published online May 27, 2020. doi: 10.4254/wjh.v12.i5.239
Systemic review and network meta-analysis: Prophylactic antibiotic therapy for spontaneous bacterial peritonitis
Nolan Faust, Akihiro Yamada, Haider Haider, Yuga Komaki, Fukiko Komaki, Dejan Micic, Atsushi Sakuraba
Nolan Faust, Department of Medicine, The University of Chicago, Chicago, IL 60637, United States
Akihiro Yamada, Haider Haider, Yuga Komaki, Fukiko Komaki, Dejan Micic, Atsushi Sakuraba, Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, The University of Chicago Medicine, Chicago, IL 60637, United States
Akihiro Yamada, Section of Gastroenterology, Department of Internal Medicine, Toho University Sakura Medical Center, Sakura 2850841, Japan
Yuga Komaki, Digestive and Lifestyle Diseases, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima 890-8544, Japan
Author contributions: Faust N and Yamada A analyzed the data and drafted the manuscript; Haider H, Komaki Y, Komaki F and Micic D critical reviewed and approved of manuscript; Sakuraba A made the study concept and design, analyzed the data and wrote the manuscript.
Conflict-of-interest statement: Sakuraba A is the speaker’s bureau for Takeda. The others have no conflict.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (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: Atsushi Sakuraba, MD, PhD, Assistant Professor, Section of Gastroenterology, Hepatology and Nutrition, Department of Medicine, The University of Chicago Medicine, 5841 S. Maryland Ave. MC 4076, Chicago, IL 60637, United States. asakurab@medicine.bsd.uchicago.edu
Received: December 9, 2019
Peer-review started: December 9, 2019
First decision: January 6, 2020
Revised: March 26, 2020
Accepted: April 23, 2020
Article in press: April 23, 2020
Published online: May 27, 2020
Processing time: 169 Days and 21.4 Hours
Abstract
BACKGROUND

Spontaneous bacterial peritonitis (SBP) is an important prognostic factor for outcomes in patients with cirrhosis. Antibiotic prophylaxis is recommended in patients at high risk for developing SBP, but the choice of antibiotics remains unclear.

AIM

To evaluate the efficacy of various antibiotics for prophylaxis of SBP based on randomized control trials (RCTs).

METHODS

Electronic databases were searched through November 2018 for RCTs evaluating the efficacy of therapies for primary or secondary prophylaxis of SBP. The primary outcome was the development of SBP. Sensitivity analyses limited to studies of primary or secondary prophylaxis and studies reported after 2010 were performed. The secondary outcome was the risk of all-cause mortality or transplant. The outcomes were assessed by rank of therapies based on network meta-analyses. Individual meta-analyses were also performed.

RESULTS

Thirteen RCTs (1742 patients) including norfloxacin, ciprofloxacin, rifaximin, trimethoprim-sulfamethoxazole (TMP-SMX), or placebo/no comparator were identified. Individual meta-analyses showed superiority of rifaximin over norfloxacin as well as norfloxacin and TMP-SMX over placebo. Network meta-analysis demonstrated the rank of efficacy in reducing the risk of SBP as: Rifaximin, ciprofloxacin, TMP-SMX, norfloxacin, and placebo/no comparator. Rifaximin ranked highest in sensitivity analyses limited to studies of primary or secondary prophylaxis and studies reported after 2010. Similarly, rifaximin ranked highest in reducing the risk of death/transplant.

CONCLUSION

The present comprehensive network meta-analysis provides RCT based evidence for superior efficacy of rifaximin compared to other antibiotics for the prophylaxis of SBP and reducing risk of death/transplant. Further RCTs are warranted to confirm our findings.

Keywords: Spontaneous bacterial peritonitis; Prophylaxis; Antibiotics; Network meta-analysis; Systemic review; Cirrhosis

Core tip: Spontaneous bacterial peritonitis (SBP) is an important prognostic factor for outcomes in patients with cirrhosis. We performed a systematic review and network meta-analysis of randomized control trials evaluating the efficacy of antibiotics for primary or secondary prophylaxis of SBP. Rifaximin ranked highest in reducing the risk of SBP as well as the risk of death/transplant. Our comprehensive network meta-analysis provides randomized control trials-based evidence for superior efficacy of rifaximin compared to other antibiotics for the prophylaxis of SBP and reducing the risk of death/transplant.