Prevention of infection in patients with cirrhosis and upper gastrointestinal bleeding
In children, cirrhosis with associated upper gastrointestinal bleeding is rare – seek expert advice from the relevant medical teams involved in care of these childrenBiggins 2021Shneider 2012.
In adults who have cirrhosis with acute upper gastrointestinal bleeding (variceal or nonvariceal), antibiotic prophylaxis is recommended because it reduces the risk of infection, recurrent haemorrhage and mortalityBiggins 2021Chavez-Tapia 2010European Association for the Study of the Liver 2018Garcia-Tsao 2017Kuo 2015Moon 2016.
The benefit of antibiotic prophylaxis in adults with cirrhosis categorised as Child–Pugh class A is likely to be small because the rate of infection and mortality in this group of patients is low. However, in these guidelines, antibiotic prophylaxis is recommended for all adults with cirrhosis and upper gastrointestinal bleeding because further research is required before antibiotic prophylaxis can be targeted by Child–Pugh classFortune 2014Tandon 2015.
Antibiotic prophylaxis should be started at presentation to hospital and before endoscopyFortune 2014Jia 2015. The optimal antibiotic prophylaxis regimen has not been determined. Intravenous prophylaxis may be appropriate when the patient is actively bleeding, with a switch to oral antibiotic prophylaxis once oral intake has resumed.
For antibiotic prophylaxis in adults with cirrhosis and acute upper gastrointestinal bleeding, useBiggins 2021Chavez-Tapia 2010European Association for the Study of the Liver 2018Garcia-Tsao 2017:
1ceftriaxone 1 g intravenously, daily. See below for intravenous to oral switch and duration of therapy ceftriaxone ceftriaxone ceftriaxone
OR
1ciprofloxacin 400 mg intravenously, 12-hourly1. For dosage adjustment in adults with kidney impairment, see ciprofloxacin intravenous dosage adjustment. See below for intravenous to oral switch and duration of therapy. ciprofloxacin ciprofloxacin ciprofloxacin
Once the patient is haemodynamically stable and able to tolerate oral medication, switch to oral prophylaxis; in adults, use:
norfloxacin 400 mg orally, 12-hourly2. For dosage adjustment in adults with kidney impairment, see norfloxacin dosage adjustment. See below for duration of therapy. norfloxacin norfloxacin norfloxacin
The optimal duration of prophylaxis is uncertainChavez-Tapia 2010Fortune 2014Lee 2016. Although most randomised controlled trials were for 7 days and many guidelines recommend prophylaxis for a maximum of 7 days, there is evidence to support a duration of 3 daysBiggins 2021Chavez-Tapia 2010European Association for the Study of the Liver 2018Fortune 2014Garcia-Tsao 2017Lee 2016Runyon 2012.
To reduce the emergence of antibiotic resistance, use the shortest possible duration of prophylaxis – 3 to 7 days (intravenous + oral) is recommended.
Consider stopping antibiotic prophylaxis once bleeding has resolved and vasoactive drugs (eg octreotide) have been stopped. At this stage, switching to oral prophylaxis is not required if prophylaxis has already been given for the minimum duration (ie 3 days).
Patients with cirrhosis may also require antibiotic prophylaxis to prevent spontaneous bacterial peritonitis.