What antibiotics are used in liver cirrhosis?

From the Guidelines

The primary antibiotic used for patients with cirrhosis is ceftriaxone, typically prescribed at a dose of 1 g IV every 24 hours for up to seven days, especially in patients with advanced cirrhosis or in hospital settings with high prevalence of quinolone-resistant bacterial infections. For patients with cirrhosis and gastrointestinal hemorrhage, the use of antibiotics is crucial to prevent bacterial infections, which are associated with early recurrence of variceal hemorrhage and increased mortality 1. Key considerations for antibiotic use in cirrhosis patients include:

• The risk of spontaneous bacterial peritonitis (SBP) and other infections, which is highest in patients with more severe liver disease (i.e., Child B and C) 1
• The need to use antibiotics judiciously due to the patient's compromised liver function and increased risk of adverse effects
• The importance of considering local resistance patterns when selecting an antibiotic, as the prevalence of quinolone-resistant bacterial infections can vary by region 1
• The potential for antibiotic resistance, especially in patients who have received multiple courses of antibiotics For SBP prophylaxis in high-risk patients:

• Norfloxacin 400 mg orally twice daily
• Alternative: Ciprofloxacin 500 mg orally twice daily For active SBP treatment:
• Cefotaxime 2 g IV every 8 hours for 5-7 days
• Alternative: Ceftriaxone 1-2 g IV once daily for 5-7 days It's essential to adjust antibiotic dosages according to the patient's renal function, as many cirrhosis patients have concurrent kidney issues 1. Additionally, being aware of the potential for antibiotic resistance is crucial, especially in patients who have received multiple courses of antibiotics 1.

From the FDA Drug Label

The half-life of piperacillin and of tazobactam increases by approximately 25% and 18%, respectively, in patients with hepatic cirrhosis compared to healthy subjects However, this difference does not warrant dosage adjustment of piperacillin and tazobactam due to hepatic cirrhosis. In preliminary studies in patients with stable chronic liver cirrhosis, no significant changes in ciprofloxacin pharmacokinetics have been observed.

Antibiotics used in liver cirrhosis:

• Piperacillin-tazobactam: no dosage adjustment is required in patients with hepatic cirrhosis 2
• Ciprofloxacin: no significant changes in pharmacokinetics have been observed in patients with stable chronic liver cirrhosis 3

From the Research

Antibiotics Used in Liver Cirrhosis

• Quinolones, such as norfloxacin, are used for prophylaxis in patients with cirrhosis and variceal hemorrhage, as well as for long-term prophylaxis in patients who have recovered from an episode of spontaneous bacterial peritonitis (SBP) 4, 5.
• Third-generation cephalosporins are recommended for the treatment of SBP, but may not be effective against enterococcal infections, which can cause treatment failure 5, 6.
• Ampicillin plus gentamycin may be effective against enterococcal infections, but vancomycin-resistant enterococcus is a concern 6.
• Cephalosporins, such as third-generation cephalosporins, are used for the treatment of SBP, but the emergence of multidrug-resistant bacteria is a concern 4, 7.

Specific Infections and Antibiotic Use

• Spontaneous bacterial peritonitis (SBP): third-generation cephalosporins, quinolones 4, 5.
• Urinary tract infections: quinolones, cephalosporins 4, 5.
• Pneumonia: antibiotics should be chosen based on epidemiological data and the risk of multidrug-resistant bacteria 8.
• Cellulitis and skin infections: antibiotics should be chosen based on the severity of the infection and the risk of multidrug-resistant bacteria 8, 7.

Considerations for Antibiotic Use

• The risk of multidrug-resistant bacteria is high in healthcare-associated and hospital-acquired infections, and empiric antibiotic therapy should be chosen accordingly 8, 7.
• Albumin administration may improve survival in patients with SBP and advanced liver disease 5, 7.
• The choice of antibiotic should be based on the severity of the infection, the risk of multidrug-resistant bacteria, and the patient's underlying liver disease 4, 8, 7.