Prevention Of Spontaneous Bacterial Peritonitis Research Articles

Comparison of Rifaximin Alone and With Quinolones in the Primary Prevention of Spontaneous Bacterial Peritonitis in Patients With Decompensated Chronic Liver Disease.

Background In cirrhotic patients with ascites, primary prevention of spontaneous bacterial peritonitis (SBP) is a key strategy to lower morbidity and death. Rifaximin and fluoroquinolone used alternately as main prophylaxis are as effective as reported. This study aimed to compare the frequency of occurrence of SBP in patients with decompensated chronic liver disease treated with rifaximin alone and in combination with fluoroquinolone. Methodology A total of 76 patients with hepatitis C virus-related decompensated chronic liver disease and ascites were divided into two groups based on matching age, sex, and Child-Pugh class. Group A (38 patients) received rifaximin 1,100 mg/day in two divided doses with daily fluoroquinolone 400 mg/day, whereas group B (38 patients) received rifaximin 1,100 mg/day alone as a two dosage. The patients were monitored for up to three months. The study's endpoints were SBP, hepatocellular carcinoma, compliance failure, death, or liver transplantation. Results In this comparative study involving 76 patients, the demographic and clinical characteristics were assessed across two treatment groups: rifaximin alone (n = 38) and rifaximin with fluoroquinolone (n = 38). The combination therapy demonstrated a statistically significant reduction in SBP compared to rifaximin alone. Additionally, the overall survival rate was higher in the combination group. These findings suggest potential benefits of the combined approach in managing hepatic encephalopathy-related complications. Conclusions When compared to rifaximin alone for primary SBP prophylaxis, the combination of rifaximin with fluoroquinolone exhibited greater effectiveness with the same safety profile.

The role of prophylactic antibiotics in prevention of spontaneous bacterial peritonitis in compensated liver cirrhosis with upper gastrointestinal bleeding: randomized controlled, clinical trial

The role of prophylactic antibiotics in prevention of spontaneous bacterial peritonitis in compensated liver cirrhosis with upper gastrointestinal bleeding: randomized controlled, clinical trial

Antibiotic prophylaxis for prevention of spontaneous bacterial peritonitis in liver cirrhosis: systematic review.

Spontaneous bacterial peritonitis is a potentially life-threatening infection in patients with liver cirrhosis and ascites. Its prevention is vital to improve prognosis of cirrhotic patients. The main objective of this systematic review was to evaluate what is the most efficacious and safest antibiotic prophylactic strategy. Studies were located by searching PubMed and Cochrane Central Register of Controlled Trials in The Cochrane Library until February 2019. Randomized controlled trials evaluating primary or secondary spontaneous bacterial peritonitis prophylaxis in cirrhotic patients with ascites were included. The selection of studies was performed in two stages: screening of titles and abstracts, and assessment of the full papers identified as relevant, considering the inclusion criteria. Data were extracted in a standardized way and synthesized qualitatively. Fourteen studies were included. This systematic review demonstrated that daily norfloxacin is effective as a prophylactic antibiotic for the prevention of spontaneous bacterial peritonitis in patients with cirrhosis. Once weekly ciprofloxacin was not inferior to once daily norfloxacin, with good tolerance and no induced resistance. Trimethoprim-sulfamethoxazole and norfloxacin have similar efficacy for primary and secondary prophylaxis of spontaneous bacterial peritonitis, however, trimethoprim-sulfamethoxazole was associated with an increased risk of developing an adverse event. Rifaximin was more effective than norfloxacin in the secondary prophylaxis of spontaneous bacterial peritonitis, with a significant decrease in adverse events and mortality rate. Continuous long-term selective intestinal decontamination with norfloxacin is the most widely used prophylactic strategy in spontaneous bacterial peritonitis, yet other equally effective and safe options are available.

Pharmacotherapy of liver cirrhosis and its complications

This article provides information about the pharmacotherapy of liver cirrhosis (LC) and its complications, such as variceal hemorrhage, ascites, increased risk of bacterial infection, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome
 LC is a major healthcare problem and is associated with an increased mortality due to the development of complications. LC is currently the 11th most common cause of death globally. Prognosis of LC is highly variable and influenced by several variables, such as etiology, severity of liver disease, presence of complications and comorbidities. In advanced cirrhosis, survival decreases to one or two years.
 Pharmacotherapy for LC should be implemented in accordance with up-to-date guidelines and in conjunction with aetiology management, nutritional optimisation and patient education. The main treatment of uncomplicated ascites is diuretics such as spironolactone in combination with a loop diuretic. For treatment refractory ascites vasoconstrictors and albumin are recommended. Antibiotics play a well-established role in the treatment and prevention of spontaneous bacterial peritonitis. For hepatorenal syndrome, the administration of vasopressor terlipressin and albumin is recommended. Endoscopic treatment is used for variceal bleeding (for example, ligation for esophageal varices and tissue glue for gastric varices). A shunt (TIPS) is used to treat severe or repeat variceal hemorrhage or refractory ascites. Non-selective beta-blockers effectively reduce variceal re-bleeding risk in LC patients with moderate/large varices.
 Thus, the treatment of LC as one of the most formidable multiorgan pathologies involves a comprehensive approach aimed at the correction of the main pathology and the treatment and prevention of its complications.

Liver Cirrhosis: Modern Approach to the Problem

Liver Cirrhosis: Modern Approach to the Problem

Antibiotics for prophylaxis of spontaneous bacterial peritonitis: systematic review & Bayesian network meta-analysis.

Various antibiotic regimens are used for primary and secondary prevention of spontaneous bacterial peritonitis (SBP). A systematic review and network meta-analysis to compare various antibiotics regimens for primary and secondary prevention of SBP were done. We did a comprehensive literature search using various databases (i.e. MEDLINE via Ovid and PubMed, Embase, Cochrane Central Register of Controlled Trials and others) from inception to 26th October 2019 using various keywords. Only randomised studies which evaluated the role of antibiotics in adult cirrhotic patients with ascites for primary or secondary prophylaxis of SBP were included. The primary outcome was occurrence/recurrence of SBP episode and other outcomes assessed were extra-peritoneal infections and reduction in mortality. We did random-effects network meta-analysis using a Bayesian approach, and calculated odds ratios (ORs) and 95% credible intervals (CrI); agents were ranked using rank probabilities. We found total 1701 records in our systematic database search and out of these 17 randomised trials were found eligible for network meta-analysis. For primary prevention of SBP, the odds ratio (95% CrI) for norfloxacin daily was 0.061 (0.0060, 0.33) and for rifaximin daily was 0.037 (0.00085, 0.87) and norfloxacin and rifaximin alternate month was 0.027 (0.00061, 0.61) when compared to placebo or no comparator. For the secondary prevention of SBP, rifaximin daily had odds of 0.022 (0.00011, 0.73). Rifaximin is useful for both primary and secondary prevention of SBP whereas norfloxacin daily and alternate norfloxacin and rifaximin are useful for primary prophylaxis.

Doxycycline for the Prevention of Spontaneous Bacterial Peritonitis

Doxycycline for the Prevention of Spontaneous Bacterial Peritonitis

Norfloxacin, ciprofloxacin, trimethoprim-sulfamethoxazole, and rifaximin for the prevention of spontaneous bacterial peritonitis: a network meta-analysis.

For the prevention of spontaneous bacterial peritonitis (SBP) in cirrhotic patients with ascites, prophylactic antibiotics are recommended as a standard regimen. This study aimed to assess the efficacy of norfloxacin (N), ciprofloxacin (C), trimethoprim-sulfamethoxazole (T-S), and rifaximin (R) in the prevention of SBP. We searched the electronic databases including PubMed, Cochrane Library, Embase, and Web of Science from inception till 1 August 2018. The randomized-controlled trials that compared N, C, T-S, R, and placebo (P) were identified. A network meta-analysis (NMA) was carried out using the software STATA 14.0 and Revman 5.3. We included 16 studies involving 1984 participants in the NMA for SBP prevention. The NMA results showed that, compared with those treated with P (reference), patients treated with C, N, or R had a lower incidence of SBP and mortality. Similarly, the incidences of SBP and mortality for R were lower than those for N. The probabilities of ranking results showed that R ranked first with respect to the outcomes of the incidence of SBP and mortality. According to our results, R seemed to be the optimal regimen for protecting against SBP in patients with cirrhosis and ascites. However, considering the limitations of our study, additional high-quality studies are required in this respect.

Current and future pharmacological therapies for managing cirrhosis and its complications.

Due to the restrictions of liver transplantation, complication-guided pharmacological therapy has become the mainstay of long-term management of cirrhosis. This article aims to provide a complete overview of pharmacotherapy options that may be commenced in the outpatient setting which are available for managing cirrhosis and its complications, together with discussion of current controversies and potential future directions. PubMed/Medline/Cochrane Library were electronically searched up to December 2018 to identify studies evaluating safety, efficacy and therapeutic mechanisms of pharmacological agents in cirrhotic adults and animal models of cirrhosis. Non-selective beta-blockers effectively reduce variceal re-bleeding risk in cirrhotic patients with moderate/large varices, but appear ineffective for primary prevention of variceal development and may compromise renal function and haemodynamic stability in advanced decompensation. Recent observational studies suggest protective, haemodynamically-independent effects of beta-blockers relating to reduced bacterial translocation. The gut-selective antibiotic rifaximin is effective for secondary prophylaxis of hepatic encephalopathy; recent small trials also indicate its potential superiority to norfloxacin for secondary prevention of spontaneous bacterial peritonitis. Diuretics remain the mainstay of uncomplicated ascites treatment, and early trials suggest alpha-adrenergic receptor agonists may improve diuretic response in refractory ascites. Vaptans have not demonstrated clinical effectiveness in treating refractory ascites and may cause detrimental complications. Despite initial hepatotoxicity concerns, safety of statin administration has been demonstrated in compensated cirrhosis. Furthermore, statins are suggested to have protective effects upon fibrosis progression, decompensation and mortality. Evidence as to whether proton pump inhibitors cause gut-liver-brain axis dysfunction is conflicting. Emerging evidence indicates that anticoagulation therapy reduces incidence and increases recanalisation rates of non-malignant portal vein thrombosis, and may impede hepatic fibrogenesis and decompensation. Pharmacotherapy for cirrhosis should be implemented in accordance with up-to-date guidelines and in conjunction with aetiology management, nutritional optimisation and patient education.

Role of Rifaximin in Spontaneous Bacterial Peritonitis Prevention.

Cirrhosis affects millions of people around the world and is associated with increased morbidity and mortality. Spontaneous bacterial peritonitis (SBP) is a common complication of liver disease with cirrhosis and accounts for up to 30% of infections in patients with cirrhosis. Patients with a history of SBP and those deemed to be at high risk often are prescribed antibiotics to reduce the incidence of SBP. Fluoroquinolones and sulfamethoxazole-trimethoprim are commonly used antibiotics for long-term prevention for these specified populations; however, these antibiotics are associated with several adverse effects and interactions that may be harmful to patients. In addition, resistance development may decrease the efficacy of SBP treatment and prophylaxis. Given these limitations, rifaximin, a nonabsorbable, broad-spectrum antibiotic that is used for hepatic encephalopathy, may serve as a prophylactic alternative to conventional therapy. This review discusses guideline-recommended therapy and the evidence for using rifaximin for SBP prophylaxis.

Daily Norfloxacin vs. Weekly Ciprofloxacin to Prevent Spontaneous Bacterial Peritonitis: A Randomized Controlled Trial.

For the prevention of spontaneous bacterial peritonitis (SBP) in cirrhotic patients with ascites, norfloxacin 400 mg per day is recommended as a standard regimen. This study aims to investigate whether ciprofloxacin once weekly administration is not inferior to norfloxacin once daily administration for the prevention of SBP. This is an investigator-initiated open-label randomized controlled trial conducted at seven tertiary hospitals in South Korea. Liver cirrhosis patients with ascites were screened, and enrolled in this randomized controlled trial if ascitic protein ≤1.5 g/dL or the presence of history of SBP. Ascitic polymorphonucleated cell count needed to be <250/mm3. Patients were randomly assigned into norfloxacin daily or ciprofloxacin weekly group, and followed-up for 12 months. Primary endpoint was the prevention of SBP. One hundred twenty-four patients met enrollment criteria and were assigned into each group by 1:1 ratio (62:62). Seven patients in the norfloxacin group and five patients in the ciprofloxacin group were lost to follow-up. SBP developed in four patients (4/55) and in three patients (3/57) in each group, respectively (7.3% vs. 5.3%, P = 0.712). The transplant-free survival rates at 1 year were comparable between the groups (72.7% vs. 73.7%, P = 0.970). Incidence of infectious complication, hepatorenal syndrome, hepatic encephalopathy, and variceal bleeding rates were not significantly different (all P = ns). The factors related to survival were models representing underlying liver function. Once weekly ciprofloxacin was as effective as daily norfloxacin for the prevention of SBP in cirrhotic patients with ascites.

Comparison of Efficacy of Rifaximin and Norfloxacin in Prevention of Spontaneous Bacterial Peritonitis

Comparison of Efficacy of Rifaximin and Norfloxacin in Prevention of Spontaneous Bacterial Peritonitis

Systematic review with meta-analysis: rifaximin for the prophylaxis of spontaneous bacterial peritonitis.

The primary and secondary prevention of spontaneous bacterial peritonitis (SBP) is recommended in high-risk patients with cirrhosis. Several studies evaluating the efficacy of rifaximin for SBP prophylaxis have yielded conflicting results. Rifaximin has the potential advantage of preventing bacterial overgrowth and translocation without the systemic side effects of broad-spectrum antibiotics. To evaluate the efficacy of rifaximin in the primary and secondary prevention of SBP. A literature search using five databases was performed to identify studies on the association between rifaximin and SBP. We performed two meta-analyses: (1) rifaximin compared to systemic antibiotics and (2) rifaximin compared to no antibiotics. Random-effect modelling was conducted to determine overall pooled estimates and 95% confidence intervals (CIs). Five studies with 555 patients (295 rifaximin, 260 systemic antibiotics) compared rifaximin with systemic antibiotics. The pooled odds ratio (OR) for SBP was 0.45 (95% CI 0.16-1.27; P = .13) in patients receiving rifaximin and strengthened on sensitivity analysis (OR 0.38, 95% CI 0.19-0.76, P = .01). In the analysis comparing rifaximin with no antibiotics, there were five studies with 784 patients (186 rifaximin, 598 no antibiotics). The OR for SBP was 0.34 (95% CI 0.11-0.99; P < .05) in patients receiving rifaximin. In subgroup analysis, rifaximin reduced the risk of SBP by 47% compared to no antibiotics for primary prophylaxis and by 74% compared to systemic antibiotics for secondary prophylaxis. Rifaximin may be effective in preventing SBP in patients with cirrhosis and ascites compared to systemically absorbed antibiotics and compared to placebo.

Rifaximin for the prevention of spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis: a systematic review and meta-analysis.

Prophylactic antibiotics have been recommended in patients with a previous history of spontaneous bacterial peritonitis (SBP). Recently, there has been interest in the use of rifaximin for the prevention of SBP and hepatorenal syndrome (HRS). We conducted a meta-analysis to evaluate this association of rifaximin. We searched several databases from inception through 24 January 2017, to identify comparative studies evaluating the effect of rifaximin on the occurrence of SBP and HRS. We performed predetermined subgroup analyses based on the type of control group, design of the study, and type of prophylaxis. Pooled odds ratios (ORs) were calculated using a random effects model. We included 13 studies with 1703 patients in the meta-analysis of SBP prevention. Pooled OR [95% confidence interval (CI)] was 0.40 (95% CI: 0.22-0.73) (I=58%). On sensitivity analysis, adjusted OR was 0.29 (95% CI: 0.20-0.44) (I=0%). The results of the subgroup analysis based on type of control was as follows: in the quinolone group, pooled OR was 0.42 (95% CI: 0.14-1.25) (I=55%), and in the no antibiotic group, pooled OR was 0.40 (95% CI: 0.18-0.86) (I=64%). However, with sensitivity analysis, benefit of rifaximin was demonstrable; pooled ORs were 0.32 (95% CI: 0.17-0.63) (I=0%) and 0.28 (95% CI: 0.17-0.45) (I=0%) for the comparison with quinolones and no antibiotics, respectively. Pooled OR based on randomized controlled trials was 0.41 (95% CI: 0.22-0.75) (I=13%). For the prevention of HRS, the pooled OR was 0.25 (95% CI: 0.13-0.50) (I=0%). Rifaximin has a protective effect against the development of SBP in cirrhosis. However, the quality of the evidence as per the GRADE framework was very low. Rifaximin appeared effective for the prevention of HRS.

Rifaximin versus norfloxacin for prevention of spontaneous bacterial peritonitis: a systematic review

AimThe aim of this systematic review is to evaluate the efficacy and safety of rifaximin in the prophylaxis of spontaneous bacterial peritonitis (SBP) as compared with norfloxacin.MethodsWe searched MEDLINE, CINAHL,...

Su1499 - Rifaximin for Prevention of Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome in Cirrhosis: A Systematic Review and Meta-Analysis

Su1499 - Rifaximin for Prevention of Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome in Cirrhosis: A Systematic Review and Meta-Analysis

Issue Highlights

Issue Highlights

PS017 - Comparison of Daily Norfloxacin versus Weekly Ciprofloxacin for the Prevention of Spontaneous Bacterial Peritonitis in Cirrhotic Patients: A Randomized Controlled Trial

PS017 - Comparison of Daily Norfloxacin versus Weekly Ciprofloxacin for the Prevention of Spontaneous Bacterial Peritonitis in Cirrhotic Patients: A Randomized Controlled Trial

Efficacy and safety of alternating norfloxacin and rifaximin as primary prophylaxis for spontaneous bacterial peritonitis in cirrhotic ascites: a prospective randomized open-label comparative multicenter study.

Primary prevention of spontaneous bacterial peritonitis (SBP) is an important strategy to reduce morbidity and mortality in cirrhotic patients with ascites. Efficacy and safety of alternating rifaximin and norfloxacin as primary prophylaxis is questionable. Three hundred thirty-four cirrhotic patients with high SAAG (≥1.1) ascites, protein level in ascitic fluid less than 1.5 g/dL with advanced liver disease (Child-Pugh score >9 points with serum bilirubin level >3 mg/dL) or renal impairment (serum creatinine level >1.2 mg/dL, blood urea nitrogen level >25 mg/dL, or serum sodium level <130 mEq/L) were included in an open-label, randomized study aimed at comparing alternating use of norfloxacin and rifaximin vs. norfloxacin or rifaximin alone as primary prophylaxis for SBP. Both intention-to-treat and per-protocol efficacy analyses were done after 6 months of treatment by assessment of ascitic fluid neutrophil count. Safety analysis was done for all intention-to-treat populations. Alternating norfloxacin and rifaximin showed superior prophylaxis by intention-to-treat (74.7 vs. 56.4% vs. 68.3%, p < 0.048). Pairwise analysis showed that alternating regimen had lower probability to develop SBP when compared to a norfloxacin-based regimen in intention-to-treat (p = 0.016) and per protocol analysis (p = 0.039). There was no difference among the studied groups regarding the incidence and severity of adverse events reported. Alternating norfloxacin- and rifaximin-based primary prophylaxis for SBP showed higher efficacy with the same safety profile when compared with monotherapy of norfloxacin.

Effect of β-Blockers in Prevention of Spontaneous Bacterial Peritonitis and Subsequent Survival in Cirrhosis: A Meta-analysis

Introduction: β-blockers have well established role in the prevention of variceal hemorrhage. In addition, several studies have indicated that β-blockers could be helpful in preventing spontaneous bacterial peritonitis (SBP) inpatients with cirrhosis. On the other hand, some authors have suggested that use of β-blockers could be associated with higher mortality in patients with advanced cirrhosis. Our aim was to evaluate the role of β-blockers in prevention of SBP and subsequent survival in patients with liver cirrhosis. Methods: We performed a systematic search of published articles and abstracts from major gastroenterology meetings for studies comparing the risk of SBP with and without β-blockers in patients with liver cirrhosis. We calculated Odds ratio (OR) of studies with dichotomous outcomes of the event. Then we used Mantel-Haenszel method to pool the OR with generic inverse analysis of incidence of SBP into fixed or random effect model meta-analyses. In addition, we pooled data of mortality with and without beta-blockers, where provided, among the studies included in the meta-analysis. Results: A total of 4644 patients in eleven studies were included in the meta-analysis. Our analysis showed significant heterogeneity between the studies which was adjusted using ‘Random-effect' model. Our analysis did not show a significant difference in the use of β-blockers and the incidence of SBP (OR= 0.93; Confidence Interval (CI) 0.78, 1.10) (Fig. 1). In addition, there was no significant difference in the mortality with the use of β-blockers (OR= 1.27; CI 0.41, 3.96) (Fig. 2).Figure 1Figure 2Conclusion: Conclusions: Our analysis did not show any benefit of β-blockers in prevention of SBP in liver cirrhosis. Additionally, use of β-blockers was not associated with an increased mortality in cirrhosis.