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Variceal Hemorrhage pp 123–133Cite as

Antibiotic Prophylaxis in Acute Variceal Hemorrhage

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Abstract

Bacterial infection is a major problem in patients with cirrhosis and upper gastrointestinal hemorrhage. Incidence of infection ranges between 16 and 66 %. Clinical risk factors are poor liver function (Child-Pugh class C, ascites, jaundice, or hepatic encephalopathy), malnutrition, severity of the initial hemorrhage, and failure to control bleeding. Bacterial infection is independently associated to failure to control bleeding and rebleeding and increases hospital mortality. Antibiotic prophylaxis (oral norfloxacin in patients with preserved liver function and intravenous ceftriaxone in those with advanced cirrhosis) decreases the incidence of bacterial infection, improves bleeding control, prevents rebleeding, and reduces hospital mortality. Antibiotic prophylaxis is therefore an essential point in the management of patients with cirrhosis and acute variceal hemorrhage. The current chapter describes the pathogenesis, incidence, and clinical impact of bacterial infections in patients with cirrhosis and gastrointestinal bleeding and summarizes the prophylactic strategies currently recommended in this population.

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Abbreviations

ACLF:

Acute-on-chronic liver failure

GALT:

Gut-associated lymphoid tissue

IV:

Intravenous

SBP:

Spontaneous bacterial peritonitis

References

  1. Fernandez J, Gustot T. Management of bacterial infections in cirrhosis. J Hepatol. 2012;56 Suppl 1:S1–12.

    Article  CAS  PubMed  Google Scholar 

  2. Gustot T, Durand F, Lebrec D, Vincent JL, Moreau R. Severe sepsis in cirrhosis. Hepatology. 2009;50(6):2022–33.

    Article  CAS  PubMed  Google Scholar 

  3. Fernandez J, Navasa M, Gomez J, Colmenero J, Vila J, Arroyo V, et al. Bacterial infections in cirrhosis: epidemiological changes with invasive procedures and norfloxacin prophylaxis. Hepatology. 2002;35(1):140–8.

    Article  PubMed  Google Scholar 

  4. Fernández J, Acevedo J, Castro M, Garcia O, de Lope CR, Roca D, et al. Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study. Hepatology. 2012;55(5):1551–61.

    Article  PubMed  Google Scholar 

  5. Foreman MG, Mannino DM, Moss M. Cirrhosis as a risk factor for sepsis and death: analysis of the National Hospital Discharge Survey. Chest. 2003;124(3):1016–20.

    Article  PubMed  Google Scholar 

  6. Arvaniti V, D’Amico G, Fede G, Manousou P, Tsochatzis E, Pleguezuelo M, et al. Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis. Gastroenterology. 2010;139(4):1246–56.

    Article  PubMed  Google Scholar 

  7. Goulis J, Armonis A, Patch D, Sabin C, Greenslade L, Burroughs AK. Bacterial infection is independently associated with failure to control bleeding in cirrhotic patients with gastrointestinal hemorrhage. Hepatology. 1998;27(5):1207–12.

    Article  CAS  PubMed  Google Scholar 

  8. Ruiz-del-Arbol L, Urman J, Fernández J, González M, Navasa M, Monescillo A, et al. Systemic, renal, and hepatic hemodynamic derangement in cirrhotic patients with spontaneous bacterial peritonitis. Hepatology. 2003;38(5):1210–8.

    Article  PubMed  Google Scholar 

  9. Hou MC, Lin HC, Liu TT, Kuo BI, Lee FY, Chang FY, et al. Antibiotic prophylaxis after endoscopic therapy prevents rebleeding in acute variceal hemorrhage: a randomized trial. Hepatology. 2004;39(3):746–53.

    Article  CAS  PubMed  Google Scholar 

  10. Plessier A, Denninger MH, Consigny Y, Pessione F, Francoz C, Durand F, et al. Coagulation disorders in patients with cirrhosis and severe sepsis. Liver Int. 2003;23(6):440–8.

    Article  PubMed  Google Scholar 

  11. Thalheimer U, Triantos CK, Samonakis DN, Patch D, Burroughs AK. Infection, coagulation, and variceal bleeding in cirrhosis. Gut. 2005;54(4):556–63.

    Article  CAS  PubMed  Google Scholar 

  12. Merli M, Lucidi C, Pentassuglio I, Giannelli V, Giusto M, Di Gregorio V, et al. Increased risk of cognitive impairment in cirrhotic patients with bacterial infection. J Hepatol. 2013;59(2):243–50.

    Article  PubMed  Google Scholar 

  13. Moreau R, Jalan R, Gines P, Pavesi M, Angeli P, Cordoba J, et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology. 2013;144(7):1426–37.

    Article  PubMed  Google Scholar 

  14. Rimola A, García-Tsao G, Navasa M, Piddock LJ, Planas R, Bernard B, et al. Diagnosis, treatment and prophylaxis of spontaneous bacterial peritonitis: a consensus document. International Ascites Club. J Hepatol. 2000;32(1):142–53.

    Article  CAS  PubMed  Google Scholar 

  15. de Franchis R; Baveno V Faculty. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2010;53(4):762–8.

    Google Scholar 

  16. European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol. 2010;53(3):397–417.

    Article  Google Scholar 

  17. Runyon BA; AASLD Practice Guidelines Committee. Management of adult patients with ascites due to cirrhosis: an update. Hepatology. 2009;49(6):2087–107.

    Google Scholar 

  18. Llovet JM, Bartolí R, Planas R, Viñado B, Pérez J, Cabré E, et al. Selective intestinal decontamination with norfloxacin reduces bacterial translocation in ascitic cirrhotic rats exposed to hemorrhagic shock. Hepatology. 1996;23(4):781–7.

    Article  CAS  PubMed  Google Scholar 

  19. Wiest R, Lawson M, Geuking M. Pathological bacterial translocation in liver cirrhosis. J Hepatol. 2014;60(1):197–209.

    Google Scholar 

  20. Bolognesi M, Merkel C, Bianco S, Angeli P, Sacerdoti D, Amodio P, et al. Clinical significance of the evaluation of hepatic reticuloendothelial removal capacity in patients with cirrhosis. Hepatology. 1994;19(3):628–34.

    Article  CAS  PubMed  Google Scholar 

  21. Altura BM, Hershey SG. Sequential changes in reticuloendothelial system function after acute hemorrhage. Proc Soc Exp Biol Med. 1972;139(3):935–9.

    Article  CAS  PubMed  Google Scholar 

  22. Kim BI, Kim HJ, Park JH, Park DI, Cho YK, Sohn CI, et al. Increased intestinal permeability as a predictor of bacterial infections in patients with decompensated liver cirrhosis and hemorrhage. J Gastroenterol Hepatol. 2011;26(3):550–7.

    Article  PubMed  Google Scholar 

  23. Reiberger T, Ferlitsch A, Payer BA, Mandorfer M, Heinisch BB, Hayden H, et al. Non-selective betablocker therapy decreases intestinal permeability and serum levels of LBP and IL-6 in patients with cirrhosis. J Hepatol. 2013;58(5):911–21.

    Article  CAS  PubMed  Google Scholar 

  24. Wiest R, Garcia-Tsao G. Bacterial translocation (BT) in cirrhosis. Hepatology. 2005;41(3):422–33.

    Article  CAS  PubMed  Google Scholar 

  25. Shorvon PJ, Eykyn S, Cotton P. Gastrointestinal instrumentation, bacteremia and endocarditis. Gut. 1983;24(11):1078–93.

    Article  CAS  PubMed  Google Scholar 

  26. Fernandez J, Ruiz del Arbol L, Gomez C, Durandez R, Serradilla R, Guarner C, et al. Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroenterology. 2006;131(4):1049–56.

    Article  CAS  PubMed  Google Scholar 

  27. Soriano G, Guarner C, Tomás A, Villanueva C, Torras X, González D, et al. Predictive factors of bacterial infections in cirrhotic patients submitted to prophylactic selective intestinal decontamination. Gastroenterology. 1993;104:A998 (abstract).

    Google Scholar 

  28. Pauwels A, Mostefa-Kara N, Debenes B, Degoutte E, Lévy VG. Systemic antibiotic prophylaxis after gastrointestinal hemorrhage in cirrhotic patients with a high risk of infection. Hepatology. 1996;24(4):802–6.

    CAS  PubMed  Google Scholar 

  29. Rimola A, Bory F, Teres J, Perez-Ayuso RM, Arroyo V, Rodes J. Oral, nonabsorbable antibiotics prevent infection in cirrhotics with gastrointestinal hemorrhage. Hepatology. 1985;5(3):463–7.

    Article  CAS  PubMed  Google Scholar 

  30. Soriano G, Guarner C, Tomás A, Villanueva C, Torras X, González D, et al. Norfloxacin prevents bacterial infection in cirrhotics with gastrointestinal haemorrhage. Gastroenterology. 1992;103(4):1267–72.

    CAS  PubMed  Google Scholar 

  31. Rolando N, Gimson A, Philpott-Howard J, Sahathevan M, Casewell M, Fagan E, et al. Infectious sequelae after endoscopic sclerotherapy of esophageal varices: role of antibiotic prophylaxis. J Hepatol. 1993;18(3):290–4.

    Article  CAS  PubMed  Google Scholar 

  32. Blaise M, Pateron D, Trinchet JC, Levacher S, Beaugrand M, Pourriat JL. Systemic antibiotic therapy prevents bacterial infection in cirrhotic patients with gastrointestinal haemorrhage. Hepatology. 1994;20(1):34–8.

    Article  CAS  PubMed  Google Scholar 

  33. Hsieh WJ, Lin HC, Hwang SJ, Hou MC, Lee FY, Chang FY, et al. The effect of ciprofloxacin in the prevention of bacterial infection in patients with cirrhosis after upper gastrointestinal bleeding. Am J Gastroenterol. 1998;93(6):962–6.

    Article  CAS  PubMed  Google Scholar 

  34. Hong SN, Kim BJ, Lee SY, Lee CY, Ryu MK, Choi MS, et al. Prospective randomized trial of intravenous ciprofloxacin for prevention of bacterial infection in cirrhotic patients with esophageal variceal bleeding. Taehan Kan Hakhoe Chi. 2002;8(3):288–96.

    PubMed  Google Scholar 

  35. Lin YT, Lo GH, Lai KH, Chen TA, Lin WJ. Prophylactic antibiotics in cirrhotics with upper gastrointestinal hemorrhage: a prospective, controlled trial. Zhonghua Yi Xue Za Zhi. 2002;65(8):365–71.

    PubMed  Google Scholar 

  36. Xu HW, Wang JH, Tsai MS, Wu KL, Chiou SS, Changchien CS, et al. The effects of cefazolin on cirrhotic patients with acute variceal hemorrhage after endoscopic interventions. Surg Endosc. 2011;25(9):2911–8.

    Article  PubMed  Google Scholar 

  37. Sàbat M, Kolle L, Soriano G, Ortiz J, Pamplona J, Novella MT, et al. Parenteral antibiotic prophylaxis of bacterial infections does not improve cost-efficacy of oral norfloxacin in cirrhotic patients with gastrointestinal bleeding. Am J Gastroenterol. 1998;93(12):2457–62.

    PubMed  Google Scholar 

  38. Díaz Ferrer J, Román R, Bustíos C, Davalos M, Zumaeta E. Ciprofloxacin vs cefazolin in the prevention of infection in cirrhotic patients with gastrointestinal bleeding. Rev Gastroenterol Peru. 2011;31(4):319–23.

    PubMed  Google Scholar 

  39. Wu CK, Wang JH, Lee CH, Wu KL, Tai WC, Lu SN, et al. The outcome of prophylactic intravenous cefazolin and ceftriaxone in cirrhotic patients at different clinical stages of disease after endoscopic interventions for acute variceal hemorrhage. PLoS One. 2013;8(4):e61666.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  40. Bernard B, Grangé JD, Khac EN, Amiot X, Opolon P, Poynard T. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology. 1999;29(6):1655–61.

    Article  CAS  PubMed  Google Scholar 

  41. Bernard B, Cadranel J, Valla D, Escolano S, Jarlier V, Opolon P. Prognostic significance of bacterial infection in bleeding cirrhotic patients: a prospective study. Gastroenterology. 1995;108(6):1828–34.

    Article  CAS  PubMed  Google Scholar 

  42. Brown MR, Jones G, Nash KL, Wright M, Guha IN. Antibiotic prophylaxis in variceal hemorrhage: timing, effectiveness and Clostridium difficile rates. World J Gastroenterol. 2010;16(42):5317–23.

    Article  PubMed  Google Scholar 

  43. Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila F, Soares-Weiser K, Mendez-Sanchez N, Gluud C, et al. Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding—an updated Cochrane review. Aliment Pharmacol Ther. 2011;34(5):509–18.

    Article  CAS  PubMed  Google Scholar 

  44. Acevedo J, Silva A, Prado V, Fernandez J. The new epidemiology of nosocomial bacterial infections in cirrhosis: therapeutical implications. Hepatol Int. 2013;7:72–9.

    Article  Google Scholar 

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Author information

Authors and Affiliations

  1. Liver Intensive Care Unit, Hospital Clinic, University of Barcelona, Villarroel 170, Barcelona, 08026, Spain

    Javier Fernández M.D., Ph.D.

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  1. Javier Fernández M.D., Ph.D.
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Correspondence to Javier Fernández M.D., Ph.D. .

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Editors and Affiliations

  1. Luigi Sacco University Hospital, University of Milan, Milan, Italy

    Roberto de Franchis

  2. Ospedale Universitario Luigi Sacco, Universitá degli Studi di Milano, UOC Gastroenterologia, Milano, Italy

    Alessandra Dell’Era

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Fernández, J. (2014). Antibiotic Prophylaxis in Acute Variceal Hemorrhage. In: de Franchis, R., Dell’Era, A. (eds) Variceal Hemorrhage. Springer, New York, NY. https://doi.org/10.1007/978-1-4939-0002-2_10

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  • DOI: https://doi.org/10.1007/978-1-4939-0002-2_10

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