Prophylactic antibiotic use for variceal bleeding in Child Class A cirrhosis
Scope for risk adaptive strategy
DOI:
https://doi.org/10.59736/IJP.23.03.993Keywords:
Prophylactic antibiotic, Acute variceal bleed, Child Class A cirrhosis, Risk adaptive strategy.Abstract
Background: Acute variceal bleeding is one of the serious complications in patients with liver cirrhosis, significantly contributing to morbidity in this population. The current recommendations encourage universal antibiotic prophylaxis. However, its benefit in low-risk patients, especially those in early stage of cirrhosis, is still not well understood. The aim of this study was to evaluate the necessity of antibiotic prophylaxis in patients with compensated, Child-Pugh Class A cirrhosis.
Methods: A study with a quasi-experimental design was carried out in Medical Unit 1 of Jinnah Hospital Lahore. This study involved 120 patients with early-stage cirrhosis (Child-Pugh A) who experienced acute variceal bleed. Patients with ascites, WBC >12×10³/µL, Child-Pugh B/C, hepatic encephalopathy, SBP, or hepatorenal syndrome were excluded. Two groups were formed from the study participants. Group A received intravenous ceftriaxone 1 gram daily, while Group B received a placebo. Outcomes included infection, hepatic encephalopathy, and mortality. Infection Probability Score (IPS) was calculated and predictive accuracy was evaluated using ROC curve analysis. Data analysis was carried out using SPSS v20.
Results: Mean age was 57.4 ± 12.1 years; 58.3% were male. Baseline characteristics did not differ significantly between the groups. No significant difference was found in encephalopathy (2.5%), ascites (5%), transfusion (16.7%), fever (6.7%), or mortality (4.2%) between groups (p > 0.05). IPS was substantially elevated in patients who died (12.6 ± 3.4) versus survivors (8.2 ± 1.1), p < 0.001. IPS showed strong predictive value for mortality (AUC = 0.877). IPS >10 predicted mortality with 80% sensitivity, 93.9% specificity, and 99.1% NPV.
Conclusion: Antibiotics for primary prophylaxis in Child Class A cirrhosis experiencing variceal bleed is not necessary and a risk adaptive strategy should be adopted. IPS may serve as a valuable tool in evaluating mortality risk associated with variceal bleeding.
References
Munir T, Safdar MN, Azhar S, Khan RR, Siddique S, Aaraj S, et al. Causes of upper GI bleed: variceal or non-variceal. Prof Med J. 2020 Apr 10; 27(4):820–4. https://doi.org/10.29309/TPMJ/2020.27.04.3920
Gao Y, Qian B, Zhang X, Liu H, Han T. Prophylactic antibiotics on patients with cirrhosis and upper gastrointestinal bleeding: a meta-analysis. PLoS One. 2022 Dec 22; 17(12):e0279496. https://doi.org/10.1371/journal.pone.0279496
Edelson J, Basso JE, Rockey DC. Updated strategies in the management of acute variceal haemorrhage. Curr Opin Gastroenterol. 2021 May 1; 37(3):167–72. https://doi.org/10.1097/MOG.0000000000000723
Mallet M, Rudler M, Thabut D. Variceal bleeding in cirrhotic patients. Gastroenterol Rep (Oxf). 2017 Aug; 5(3):185–92. https://doi.org/10.1093/gastro/gox024
Sarwar S, Khan AA, Alam A, Butt AK, Shafqat F, Malik K, et al. Non-endoscopic prediction of presence of esophageal varices in cirrhosis. J Coll Physicians Surg Pak. 2005 Sep 1; 15(9):528–31. https://doi.org/09.2005/jcpsp.528531
Ichita C, Shimizu S, Goto T, Haruki U, Itoh N, Iwagami M, et al. Effectiveness of antibiotic prophylaxis for acute esophageal variceal bleeding in patients with band ligation: a large observational study. World J Gastroenterol. 2024 Jan 21; 30(3):238–48. https://doi.org/10.3748/wjg.v30.i3.238
De Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C, Abraldes JG, et al. Baveno VII—renewing consensus in portal hypertension. J Hepatol. 2022 Apr 1; 76(4):959–74. https://doi.org/10.1016/j.jhep.2021.12.022
Carbonell N, Pauwels A, Serfaty L, Fourdan O, Lévy VG, Poupon R. Improved survival after variceal bleeding in patients with cirrhosis over the past two decades. Hepatology. 2004 Sep; 40(3):652–9. https://doi.org/10.1002/hep.20339
Gan M, Zong L, Yu X, Xu J. The effect of prophylactic antibiotics in acute upper gastrointestinal bleeding patients in the emergency department. World J Emerg Med. 2023; 14(6):442–8. https://doi.org/10.5847/wjem.j.1920-8642.2023.062
Martínez J, Hernández-Gea V, Rodríguez-de-Santiago E, Téllez L, Procopet B, Giráldez Á, et al. Bacterial infections in patients with acute variceal bleeding in the era of antibiotic prophylaxis. J Hepatol. 2021 Aug 1; 75(2):342–50. https://doi.org/10.1016/j.jhep.2021.03.026
Lee YY, Tee HP, Mahadeva S. Role of prophylactic antibiotics in cirrhotic patients with variceal bleeding. World J Gastroenterol. 2014 Feb 21; 20(7):1790–6. https://doi.org/10.3748/wjg.v20.i7.1790
Lee S, Saxinger L, Ma M, Prado V, Fernández J, Kumar D, et al. Bacterial infections in acute variceal hemorrhage despite antibiotics—a multicenter study of predictors and clinical impact. United Eur Gastroenterol J. 2017 Dec; 5(8):1090–9. https://doi.org/10.1177/2050640617704564
Taneja SK, Dhiman RK. Prevention and management of bacterial infections in cirrhosis. Int J Hepatol. 2011; 2011:784540. https://doi.org/10.4061/2011/784540
Thalheimer U, Triantos CK, Samonakis DN, Patch D, Burroughs AK. Infection, coagulation, and variceal bleeding in cirrhosis. Gut. 2005 Apr 1; 54(4):556–63. https://doi.org/10.1136/gut.2004.048181
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 Nov 14; 16(42):5317–23. https://doi.org/10.3748/wjg.v16.i42.5317
Zanetto A, Garcia-Tsao G. Management of acute variceal hemorrhage. F1000Res. 2019 Jun 25; 8:F1000Faculty. https://doi.org/10.12688/f1000research.18807.1
Voicu MN, Popescu F, Florescu DN, Rogoveanu I, Turcu-Stiolica A, Gheonea DI, et al. Clostridioides difficile infection among cirrhotic patients with variceal bleeding. Antibiotics (Basel). 2021 Jun 17; 10(6):731. https://doi.org/10.3390/antibiotics10060731
Ferrarese A, Passigato N, Cusumano C, Gemini S, Tonon A, Dajti E, et al. Antibiotic prophylaxis in patients with cirrhosis: current evidence for clinical practice. World J Hepatol. 2021 Aug 27; 13(8):840–54. https://doi.org/10.4254/wjh.v13.i8.840
Chang TS, Tsai YH, Lin YH, Chen CH, Lu CK, Huang WS, et al. Limited effects of antibiotic prophylaxis in patients with Child–Pugh class A/B cirrhosis and upper gastrointestinal bleeding. PLoS One. 2020 Feb 21; 15(2):e0229101. https://doi.org/10.1371/journal.pone.0229101
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 Mar 1; 39(3):746–53. https://doi.org/10.1002/hep.20126
Tevethia HV, Pande A, Vijayaraghavan R, Kumar G, Sarin SK. Combination of carvedilol with variceal band ligation in prevention of first variceal bleed in Child–Turcotte–Pugh B and C cirrhosis with high-risk oesophageal varices: the ‘CAVARLY TRIAL’. Gut. 2024 Nov 1; 73(11):1844–53. https://doi.org/10.1136/gutjnl-2023-331181
Tandon P, Abraldes JG, Keough A, Bastiampillai R, Jayakumar S, Carbonneau M, et al. Risk of bacterial infection in patients with cirrhosis and acute variceal hemorrhage, based on Child–Pugh class, and effects of antibiotics. Clin Gastroenterol Hepatol. 2015 Jun 1; 13(6):1189–96. https://doi.org/10.1016/j.cgh.2014.11.019
Bernard B, Cadranel JF, Valla D, Escolano S, Jarlier V, Opolon P. Prognostic significance of bacterial infection in bleeding cirrhotic patients: a prospective study. Gastroenterology. 1995 Jun 1; 108(6):1828–34. https://doi.org/10.1016/0016-5085(95)90146-9
Schiff S, Casa M, Di Caro V, Aprile D, Spinelli G, De Rui M, et al. A low-cost, user-friendly electroencephalographic recording system for the assessment of hepatic encephalopathy. Hepatology. 2016 May; 63(5):1651–9. https://doi.org/10.1002/hep.28477
Aguirre-Villarreal D, García-Juárez I. Navigating the controversy regarding antibiotic prophylaxis in acute variceal bleeding. World J Gastroenterol. 2024 May 14; 30(18):2485–94. https://doi.org/10.3748/wjg.v30.i18.2485
Bota DP, Mélot C, Ferreira FL, Vincent JL. Infection Probability Score (IPS): a method to help assess the probability of infection in critically ill patients. Crit Care Med. 2003 Nov 1; 31(11):2579–84. https://doi.org/10.1097/01.CCM.0000094223.92746.56
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