What is the prophylaxis for spontaneous bacterial peritonitis (SBP) in patients with upper gastrointestinal (GI) bleed?

From the Guidelines

Patients with upper gastrointestinal bleeding (UGIB) and cirrhosis should receive spontaneous bacterial peritonitis (SBP) prophylaxis with antibiotics, with ceftriaxone 1 gram intravenously daily being the recommended regimen during the acute bleeding episode, typically for 5-7 days or until bleeding resolves, as supported by the most recent and highest quality study 1.

Rationale for Prophylaxis

The rationale for prophylaxis is that antibiotics reduce bacterial translocation from the gut, decrease portal pressure, and improve hemostasis, ultimately reducing rebleeding rates and improving survival in these high-risk patients. UGIB increases intestinal permeability and bacterial translocation, significantly raising the risk of infections including SBP in cirrhotic patients. These infections can worsen outcomes by increasing rebleeding risk and mortality.

Recommended Regimen

• Ceftriaxone 1 gram intravenously daily during the acute bleeding episode, typically for 5-7 days or until bleeding resolves, is recommended for patients with advanced cirrhosis or in hospital settings with high prevalence of quinolone-resistant bacterial infections 1.
• For long-term prophylaxis after the acute bleeding episode, norfloxacin 400 mg orally daily or ciprofloxacin 500 mg orally daily is recommended, especially in patients with advanced cirrhosis 1.
• Alternative options include trimethoprim-sulfamethoxazole (one double-strength tablet daily) if fluoroquinolones cannot be used.

Importance of Local Resistance Patterns

The choice of antibiotic should be guided by local resistance patterns, as the prevalence of quinolone-resistant bacterial infections can vary significantly between different regions and hospital settings 1.

Conclusion is not allowed, so the answer just ends here.

From the Research

Upper GI Bleed SBP Prophylaxis

• The use of antibiotic prophylaxis in patients with cirrhosis and upper gastrointestinal bleeding has been shown to improve outcomes, including reducing the incidence of bacterial infections and mortality 2, 3.
• A study published in 2023 found that a short course of antibiotics (3 days) appears safe and adequate for prophylaxis in patients with cirrhosis and upper gastrointestinal bleeding, if there is no active infection 2.
• Another study published in 2010 found that antibiotic prophylaxis significantly reduced bacterial infections, and seems to have reduced all-cause mortality, bacterial infection mortality, rebleeding events, and hospitalization length in patients with cirrhosis and upper gastrointestinal bleeding 3.
• The benefits of antibiotic prophylaxis were observed independently of the type of antibiotic used, and therefore, antibiotic selection should be made considering local conditions such as bacterial resistance profile and treatment cost 3.
• A study published in 2020 found that cirrhotic patients without major complications who suffered from upper gastrointestinal bleeding were benefited by the use of antibiotics to prevent rebleeding within 4 weeks after endoscopic treatment of upper gastrointestinal bleeding, especially for those with age > 55, high CCI score ≥ 4, and upper gastrointestinal bleeding of variceal etiologies 4.
• The use of antibiotics did not significantly impact 6-week mortality in cirrhotic patients without major complications who suffered from upper gastrointestinal bleeding 4.
• Guidelines recommend the use of proton pump inhibitors in patients with upper gastrointestinal bleeding, and high-dose proton pump inhibitor treatment for the first 72 hours post-endoscopy, as this is when rebleeding risk is highest 5.

SBP Prophylaxis in Specific Patient Populations

• Patients with cirrhosis and upper gastrointestinal bleeding are at high risk of developing spontaneous bacterial peritonitis (SBP), and antibiotic prophylaxis has been shown to reduce the incidence of SBP in these patients 2, 3.
• The use of antibiotics in cirrhotic patients without major complications who suffered from upper gastrointestinal bleeding has been shown to prevent rebleeding within 4 weeks after endoscopic treatment of upper gastrointestinal bleeding, especially for those with age > 55, high CCI score ≥ 4, and upper gastrointestinal bleeding of variceal etiologies 4.

Antibiotic Regimens

• The optimal duration of antibiotic prophylaxis in patients with cirrhosis and upper gastrointestinal bleeding is not well established, but a short course of antibiotics (3 days) appears safe and adequate for prophylaxis in patients with cirrhosis and upper gastrointestinal bleeding, if there is no active infection 2.
• The choice of antibiotic regimen should be based on local conditions such as bacterial resistance profile and treatment cost, and there is no evidence to suggest that one antibiotic regimen is superior to another in preventing bacterial infections or reducing mortality in patients with cirrhosis and upper gastrointestinal bleeding 3.