From the Guidelines
Antibiotics are administered in esophageal variceal hemorrhages to reduce the risk of bacterial infections, recurrent bleeding, and bleeding-related death.
Rationale for Antibiotic Use
- The use of prophylactic antibiotic treatment has been shown to decrease bleeding-related mortality, mortality from bacterial infections, development of bacterial infections, and rebleeding 1.
- Cirrhotic patients with upper GI bleeding have a high risk of developing severe bacterial infections, which are associated with early recurrence of variceal hemorrhage and a greater mortality 1.
- Short-term antibiotic prophylaxis has been shown to decrease the rate of bacterial infections and increase survival in patients with cirrhosis and GI hemorrhage 1.
Recommended Antibiotic Regimen
- Intravenous ceftriaxone (1 g every 24 hours) is recommended for short-term (maximum 7 days) antibiotic prophylaxis in patients with acute variceal bleeding 1.
- Alternatively, oral norfloxacin (400 mg every 12 hours) can be used, but the choice of antibiotic should be based on local antimicrobial susceptibility patterns 1.
Importance of Early Administration
- Antibiotic prophylaxis should be initiated as soon as possible, together with vasoactive agents, before diagnostic endoscopy 1.
- Early administration of antibiotics can help reduce the risk of bacterial infections and improve outcomes in patients with acute variceal bleeding 1.
From the Research
Administration of Antibiotics in Esophageal Variceal Hemorrhages
- Antibiotics are administered in esophageal variceal hemorrhages to prevent infections, which are common in cirrhotic patients with acute variceal bleeding, occurring in 20% within 48 hours 2.
- The use of prophylactic antibiotics has been shown to reduce the incidence of infection and rebleeding in patients who have undergone endoscopic therapy for variceal hemorrhage 3.
- A meta-analysis of randomized controlled trials found that the incidence of infection in the prophylactic antibiotic group was significantly lower than that in the on-demand group, with an odds ratio of 0.31 and a 95% confidence interval of 0.13-0.74 3.
- Another study found that early bacterial infections develop in 14% of cirrhotic patients with acute variceal hemorrhage despite antibiotic prophylaxis, and have a negative impact on six-week mortality 4.
Benefits of Antibiotic Prophylaxis
- Antibiotic prophylaxis has been shown to reduce the incidence of bacteremia and spontaneous bacterial peritonitis in cirrhotic patients with variceal bleeding 2.
- Fluoroquinolones, such as ciprofloxacin and norfloxacin, have the most robust evidence for short-term use (7 days) and are recommended in most expert guidelines 2.
- Short-term intravenous cephalosporin, such as ceftriaxone, has been shown to be beneficial in high-risk patients with advanced cirrhosis 2.
Controversies and Limitations
- Some studies have suggested that universal antibiotic prophylaxis may no longer be necessary for patients with acute variceal bleeding, as the rates of bacterial infection, in-hospital mortality, and rebleeding have decreased significantly with improvements in care 5.
- A randomized trial found that the differences in incidence of infection, early rebleeding, and late rebleeding between the prophylaxis group and the on-demand group were not significant, suggesting that routine use of antibiotics in all patients may not be necessary 6.
- Further studies with larger sample sizes and longer follow-up periods are required to validate the usefulness of antibiotics in patients with esophageal variceal hemorrhages 6.