What antibiotics are recommended for patients with cirrhosis?

Antibiotic Recommendations for Patients with Cirrhosis

Third-generation cephalosporins, particularly cefotaxime and ceftriaxone, are the first-line antibiotics recommended for treatment of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis. 1

Treatment of Spontaneous Bacterial Peritonitis (SBP)

First-line Treatment Options

• For community-acquired SBP, intravenous cefotaxime (2g every 6-8 hours) or ceftriaxone (1g every 12-24 hours) for 5-10 days is recommended 1
• These third-generation cephalosporins are effective against the most common causative organisms: Escherichia coli, Klebsiella pneumoniae, and Streptococcus species 1
• Resolution rates with cefotaxime range from 69-98%, while ceftriaxone shows 73-100% resolution rates 1
• Alternative options with similar efficacy include:
  • Amoxicillin-clavulanic acid (1g/0.2g IV every 8 hours) 1
  • Ciprofloxacin (500mg every 12 hours) in uncomplicated cases 1, 2

Special Considerations

• For hospital-acquired SBP, consider broader coverage due to higher risk of resistant organisms, particularly extended-spectrum beta-lactamase (ESBL)-producing bacteria 1
• Oral ofloxacin may be used in patients without complications (no GI bleeding, renal dysfunction, hepatic encephalopathy, ileus, or shock) 1
• Caution is needed with quinolones due to increasing resistance rates (up to 31.7% for E. coli in some studies) 1
• Antibiotic selection should be adjusted based on culture results and local resistance patterns 1

Prophylactic Antibiotics for SBP Prevention

Secondary Prophylaxis (After First SBP Episode)

• Patients who have recovered from an episode of SBP should receive prophylaxis with one of the following: 1
  • Norfloxacin (400mg once daily)
  • Ciprofloxacin (500mg once daily)
  • Co-trimoxazole (800mg sulfamethoxazole/160mg trimethoprim daily)

Primary Prophylaxis (High-Risk Patients Without Prior SBP)

• Consider for patients with ascitic protein count <1.5 g/dL 1
• Antibiotic choice should be guided by local resistance patterns 1
• Norfloxacin or ciprofloxacin have shown efficacy in reducing SBP occurrence in high-risk patients 1

Prophylaxis in Gastrointestinal Bleeding

• Patients with cirrhosis and GI bleeding should receive prophylactic antibiotics 1
• Ceftriaxone is the preferred choice in patients with severe liver disease 1
• For less severe liver disease, oral norfloxacin or alternative quinolones may be used 1
• Short-course prophylaxis (≤3 days) appears adequate if there is no active infection 3

Monitoring and Follow-up

• A second diagnostic paracentesis at 48 hours should be considered to check treatment efficacy, especially in patients with inadequate response or suspected secondary bacterial peritonitis 1
• Adjust antibiotics according to culture results and clinical response 1
• Monitor for adverse effects of antibiotics, particularly nephrotoxicity with aminoglycosides 4

Pitfalls and Caveats

• Aminoglycosides should be avoided or used with extreme caution due to high risk of nephrotoxicity in cirrhotic patients 4
• Increasing bacterial resistance is a concern, particularly for quinolones and in patients with previous antibiotic exposure 1
• Hospital-acquired SBP has higher mortality rates due to increased antibiotic resistance 1
• Paradoxically, some studies suggest that patients on primary prophylaxis may have worse outcomes than those on secondary prophylaxis when matched for disease severity 5
• Prolonged antibiotic use increases the risk of developing resistant organisms and C. difficile infection 3