What antibiotics are recommended for patients with upper gastrointestinal bleeding?

Antibiotic Prophylaxis for Upper Gastrointestinal Bleeding in Cirrhosis

Third-generation cephalosporins, particularly IV ceftriaxone 1g daily for 7 days, are strongly recommended as prophylactic antibiotics for patients with cirrhosis and upper gastrointestinal bleeding. 1, 2

Rationale for Antibiotic Prophylaxis

Bacterial infections are a major complication in cirrhotic patients with upper gastrointestinal bleeding (UGIB), occurring in 25-65% of patients within 48 hours of admission. These infections significantly impact clinical outcomes:

• Increase mortality risk
• Increase risk of rebleeding
• Lead to failure to control bleeding
• Prolong hospitalization

A meta-analysis of 12 randomized controlled trials (1,241 patients) demonstrated that antibiotic prophylaxis in cirrhotic patients with UGIB was associated with:

• Reduced all-cause mortality (RR 0.79; 95% CI 0.63-0.98)
• Decreased bacterial infections (RR 0.35; 95% CI 0.26-0.47)
• Reduced bacteremia (RR 0.25; 95% CI 0.15-0.40)
• Fewer rebleeding episodes (RR 0.53; 95% CI 0.38-0.74)
• Decreased spontaneous bacterial peritonitis (RR 0.45; 95% CI 0.27-0.75) 1

Antibiotic Selection Algorithm

First-line options:

1. For patients with advanced cirrhosis (Child-Pugh B/C or with ascites, encephalopathy, severe malnutrition, or bilirubin >3 mg/dL):

   • IV ceftriaxone 1g daily for 7 days 2

2. For patients with less severe cirrhosis (Child-Pugh A without advanced features):

   • Oral norfloxacin 400 mg twice daily for 7 days, OR
   • Oral ciprofloxacin 500 mg twice daily for 7 days 2

Important considerations:

• Start antibiotics as soon as possible, even before endoscopy
• Consider local antimicrobial resistance patterns when selecting antibiotics
• Third-generation cephalosporins are preferred over quinolones in areas with high quinolone resistance 2

Timing and Duration

• Initiate antibiotics immediately upon presentation with suspected UGIB
• Standard duration is 7 days 1
• Some emerging evidence suggests shorter courses (3 days) may be adequate if there is no active infection 3, but this is not yet incorporated into guidelines

Special Considerations

Spontaneous Bacterial Peritonitis (SBP)

For patients who develop SBP, treatment should include:

• Broad-spectrum antibiotics
• Albumin infusion (1.5 g/kg on day 1 and 1 g/kg on day 3) 1

This combination has been shown to reduce:

• Renal impairment (10% vs 33%; P=0.002)
• Mortality (22% vs 41%; P=0.03) 1

Recent Evidence and Controversies

A 2023 systematic review and Bayesian meta-analysis questioned the mortality benefit of antibiotic prophylaxis in the modern era of advanced interventions 4. However, this does not override the strong recommendations from current guidelines that consistently support antibiotic prophylaxis.

Pitfalls to Avoid

1. Delaying antibiotic administration - Start immediately upon presentation
2. Ignoring local resistance patterns - Consider local antimicrobial susceptibility when selecting antibiotics
3. Failing to recognize the connection between infection and rebleeding - Bacterial infections increase rebleeding risk, which increases mortality
4. Overlooking antibiotic prophylaxis in patients without ascites - All cirrhotic patients with UGIB need prophylaxis, regardless of ascites status
5. Using quinolones in areas with high resistance - In such settings, ceftriaxone is preferred

Summary

Antibiotic prophylaxis is a cornerstone in the management of cirrhotic patients with upper gastrointestinal bleeding. The evidence strongly supports the use of third-generation cephalosporins, particularly IV ceftriaxone 1g daily for 7 days, to reduce infections, rebleeding, and mortality in these high-risk patients.