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

Table 1 Current recommendations and uncertainties regarding antibiotic prophylaxis in patients with cirrhosis

Procedure/clinical setting	Antibiotic prophylaxis	Areas of uncertainties
Spontaneous bacterial peritonitis	Primary prophylaxis recommended in decompensated patients with low ascitic fluid proteins. Secondary prophylaxis recommended	Second-line antibiotics. Quinolone resistance. Rifaximin. Secondary prophylaxis after MDR infection
Variceal bleeding	Prophylaxis recommended in acute bleeding from esophageal/gastric variceal bleeding	Prophylaxis in compensated (e.g., Child-Pugh A) patients having acute variceal bleeding. Prophylaxis in elective endoscopic therapy of gastric/esophageal varices
Endoscopic retrograde cholangiopancreatography	Routine prophylaxis not recommended. Prophylaxis is recommended in patients with incomplete drainage and in those with primary sclerosing cholangitis
Transjugular intrahepatic portosystemic shunt	Prophylaxis should be considered in difficult procedures	Prophylaxis in patients with thrombosed transjugular intrahepatic portosystemic shunt undergoing invasive procedures
Radiofrequency ablation. Trans-arterial chemoembolization. Radioembolization	Routine prophylaxis not recommended. Advisable in patients with prior interventions on biliary tree	Intra-procedural antibiotic instillation
Liver transplantation	Routine prophylaxis is recommended	Length of prophylaxis
Severe alcoholic hepatitis receiving steroids	Prophylaxis would be preferable	Length of prophylaxis, antibiotic class
Acute liver failure	Prophylaxis is advisable in high-risk patients, or those waiting for liver transplant	Antibiotic class