Antibiotic prophylaxis in patients with cirrhosis: Current evidence for clinical practice

Abstract

Patients with cirrhosis show an increased susceptibility to infection due to disease-related immune-dysfunction. Bacterial infection therefore represents a common, often detrimental event in patients with advanced liver disease, since it can worsen portal hypertension and impair the function of hepatic and extra-hepatic organs. Among pharmacological strategies to prevent infection, antibiotic prophylaxis remains the first-choice, especially in high-risk groups, such as patients with acute variceal bleeding, low ascitic fluid proteins, and prior episodes of spontaneous bacterial peritonitis. Nevertheless, antibiotic prophylaxis has to deal with the changing bacterial epidemiology in cirrhosis, with increased rates of gram-positive bacteria and multidrug resistant rods, warnings about quinolones-related side effects, and low prescription adherence. Short-term antibiotic prophylaxis is applied in many other settings during hospitalization, such as before interventional or surgical procedures, but often without knowledge of local bacterial epidemiology and without strict adherence to antimicrobial stewardship. This paper offers a detailed overview on the application of antibiotic prophylaxis in cirrhosis, according to the current evidence.

Keywords: Cirrhosis; Quinolones; Spontaneous bacterial peritonitis; Liver transplantation; Trans-jugular intrahepatic portosystemic shunt; Variceal bleeding

Core Tip: Antibiotic prophylaxis represents a cornerstone for the management of several complications of decompensated cirrhosis, as spontaneous bacterial peritonitis and variceal bleeding. Short-term antibiotic prophylaxis is often applied in many other settings during hospitalization of patients with cirrhosis, such as before interventional or surgical procedures, but often without knowledge of local bacterial epidemiology and without strict adherence to antimicrobial stewardship.