From the Guidelines
Antibiotics safe to use in patients with liver failure (hepatic insufficiency) include ceftriaxone and norfloxacin.
Key Points
- Ceftriaxone is the first choice in patients with advanced cirrhosis, in those on quinolone prophylaxis, and in hospital settings with high prevalence of quinolone-resistant bacterial infections, administered at a dose of 1 g/24 h for up to 7 days 1, 2.
- Norfloxacin can be used in patients without advanced cirrhosis or quinolone-resistant bacterial infections, although its use is limited due to the emergence of quinolone-resistant organisms 3, 1.
- The choice of antibiotic should be based on individual patient-risk characteristics and local antimicrobial susceptibility patterns 1, 2.
- Antibiotic prophylaxis is recommended in patients with cirrhosis presenting with GI hemorrhage to decrease the development of infections, recurrent hemorrhage, and death 2.
Rationale
The use of antibiotics in patients with liver failure requires careful consideration of the risk of infection, the severity of the infection, and local resistance patterns. Ceftriaxone and norfloxacin are commonly used antibiotics in this setting, with ceftriaxone being the preferred choice due to its effectiveness against quinolone-resistant organisms. The duration of antibiotic prophylaxis is typically short-term, for a maximum of 7 days. It is essential to note that the specific antibiotic recommended should be based on individual patient-risk characteristics and local antimicrobial susceptibility patterns.
From the Research
Antibiotic Safety in Liver Failure
The following antibiotics are considered safe to use in patients with liver failure (hepatic insufficiency):
- Broad-spectrum beta-lactam antibiotics, such as acylureidopenicillins, which are active against Enterococci and most enteric, pulmonary, and urinary pathogens, including Escherichia coli and Streptococcus pneumoniae 4
- Third-generation cephalosporins, which have a high level of intrinsic activity against the most commonly encountered pathogens and are safe to use at high doses for patients with liver insufficiency 5
- Meropenem monotherapy, which is effective and safe for the initial therapeutic regimen of bacterial infection 4
- Fluoroquinolones, which may be useful for the treatment of infections in liver cirrhosis, but have limited activity against S. pneumoniae 4, 5
Dosage Adjustments
Dosage adjustments are necessary for patients with liver failure:
- A reduction in dosages is necessary for beta-lactam antibiotics, such as piperacillin, to minimize the risk of leukopenia 4
- The dose of antibiotics that are eliminated in active form through the kidneys or metabolized through the liver should be adjusted according to the level of renal or hepatic impairment 6
Antibiotics to Avoid
The following antibiotics should be used with caution or avoided in patients with liver failure: