Antibiotic Prophylaxis for Cirrhotic Patients with Upper GI Bleeding
“Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding – an updated Cochrane review.” N. C. Chavez-Tapia et. al. Alimentary Pharmacology and Therapeutics. 2011; 34: 509–518
To compare all-cause mortality and infection mortality between cirrhotic patients with UGIB (upper gastrointestinal bleeding) receiving antibiotic prophylaxis vs. those that did not and to compare the frequency of bacterial infections in patients with UGIB who received antibiotic prophylaxis those that did not. This aim would be accomplished by performing a systematic review of randomized trials.
Randomized clinical trials comparing different types of antibiotic prophylaxis against no therapy, placebo or another type of antibiotic regimen were identified using the Cochrane Hepato-Biliary Controlled Trials Register.
Overall, 12 trials (1241 patients) were included in this meta-analysis evaluating antibiotic prophylaxis against placebo or no antibiotic prophylaxis.
Strongest evidence was shown for reduced rate of bacterial infections (bacteremia, UTIs, pneumonia) in cirrhotic patients with UGIB receiving antibiotic prophylaxis.
There was decrease in all cause mortality with the usage of antibiotic prophylaxis and antibiotic prophylaxis was associated with a significant decrease in mortality from bacterial infections, although few trials powered for these outcomes.
All antibiotics provided a beneficial effect although the protective effect was stronger with cephalosporins and quinolones although there is no difference in outcomes in using cephalosporin or quinolones.
There was reduction in bleeding episodes among patients with antibiotic prophylaxis and patients had shorter hospital stays but not ICU length of stay.
The Overall Weaknesses:
Randomized control trials included in this systematic review did not include antibiotic resistance patterns as well as harms and adverse effects of providing antibiotic prophylaxis.
Stronger evidence was shown for preventing infection vs. reduction in mortality. The reason for this was that many of the trials included in this meta-analysis were powered to determine infection prevention rather than the mortality benefit of receiving antibiotic prophylaxis.
A significant reduction in bacterial infections was observed in patients receiving antibiotic prophylaxis. Also, although still not yet overwhelming, antibiotic prophylaxis was associated with reduced all-cause mortality, bacterial infection mortality, and incidence of re-bleeding events and length of hospitalization.
No specific antibiotic regimen can be recommended but should take into account local hospital resistance patterns, adverse side effects and treatment costs (overall cephalosporin’s seemed to be the best antibiotics used for prophylaxis).
We still do not have enough studies to determine risks of antibiotic prophylaxis in cirrhotic patients with UGIB. However, given the significantly reduced rate of infection in these patients and the strong evidence showing a reduction in mortality antibiotics should be given to all cirrhotic patients with UGIB.