Rifaximin Treatment in Hepatic Encephalopathy

Abstract

To the Editor: Bass et al. (March 25 issue)1 conducted a randomized, double-blind, placebo-controlled trial comparing 6-month rifaximin therapy with placebo in patients with chronic liver disease who were in remission from recurrent hepatic encephalopathy. They found that rifaximin not only maintained remission more effectively than placebo but also significantly reduced the risk of hospitalization for hepatic encephalopathy. Nevertheless, several issues deserve discussion. First, since infection or gastrointestinal bleeding is known to precipitate an episode of hepatic encephalopathy,2 the authors should provide data on the frequency of breakthrough episodes without precipitating factors to reduce the confounding effects. Second, patients with cirrhosis usually have complications associated with infections caused by enteric bacteria. Because of the antimicrobial effect of rifaximin against enteric bacteria, patients who received this drug appeared to have fewer episodes of bacteremia, sepsis, or bacterial peritonitis than did those receiving placebo (3 of 140 patients in the rifaximin group vs. 8 of 159 patients in the placebo group). However, whether the frequency of recurrence of spontaneous bacterial peritonitis could be reduced or prevented by the prophylactic use of rifaximin deserves further investigation.3 Chia-Chi Wang, M.D.