Antibiotic prophylaxis during bleeding for portal hypertension: authors’ reply

Abstract

Sirs, We are grateful for the correction regarding the number of patients with bacterial infection in the norfloxacin group from the Fernandez et al. trial.1, 2 The corrected relative risk is 0.42 (95% CI 0.13, 1.15; P-value 0.069), which is not a major change from the one reported in our article.3 We concur with Garcia-Pagan that evidence must be sought, to understand if patients with advanced cirrhosis or poorer liver function benefit as much from antibiotic prophylaxis. Unfortunately, the trials included in our meta-analysis did not provide precise information on efficacy by disease stage or liver function. We attempted to contact authors to gather information from the individual trials, but few replied and we were forced to restrict our study to the available aggregated information. Relevant information regarding comparisons between antibiotics is available in the complete version of this meta-analysis on The Cochrane Library.4 Summarising, we conducted a test for interaction and failed to observe a differential effect by antibiotic group on overall mortality (cephalosporins vs. quinolones, P = 0.39; quinolones vs. quinolones plus beta-lactams, P = 0.17). Therefore, until new evidence points towards a specific antibiotic group offering more benefit, antibiotics must be selected considering specific setting conditions (i.e. availability, resistance, cost) and patient characteristics. Although the association of antibiotic prophylaxis and reduced rebleeding rate has been known to be biologically plausible,5 previous clinical evidence was conflicting.6, 7 Our meta-analysis presents consistent findings, showing the potential benefit of prophylaxis to reduce the number of rebleeding episodes, as well as early rebleeding (within 7 days). However, we recognise that given the limited number of trials (three) more research on this outcome is still needed. Despite extensive antibiotic use and abuse, current evidence provides increasing support of their efficacy for prophylaxis in old and new outcomes. Doubtless, further trials evaluating diverse antibiotic schemas in patients at different stages of cirrhosis must be conducted to assess the robustness of the benefits of antibiotic prophylaxis. Declaration of personal and funding interests: None.