Why is Ceftriaxone (a third-generation cephalosporin antibiotic) administered to patients with decompensated liver cirrhosis?

From the Guidelines

Ceftriaxone is given to patients with decompensated cirrhosis primarily as prophylaxis against spontaneous bacterial peritonitis (SBP) and other infections, with a recommended dose of 1g IV every 24 hours, as it has been shown to be effective in preventing infections and improving outcomes in these patients 1. The use of ceftriaxone in patients with decompensated cirrhosis is supported by several studies, including a 2018 guideline by the European Association for the Study of the Liver (EASL), which recommends antibiotic prophylaxis in cirrhotic patients with acute GI bleeding to reduce the incidence of infections and improve control of bleeding and survival 1. Some key points to consider when using ceftriaxone in patients with decompensated cirrhosis include:

• The typical dosing is ceftriaxone 1g IV every 24 hours 1
• Ceftriaxone is preferred because of its broad-spectrum coverage against enteric organisms, once-daily dosing convenience, and good penetration into ascitic fluid 1
• It's especially indicated for patients with gastrointestinal bleeding, low ascitic fluid protein levels, or previous episodes of SBP 1
• The duration of prophylaxis depends on the clinical scenario but typically continues until the acute decompensation resolves or the patient undergoes liver transplantation 1
• Regular monitoring for antibiotic resistance and side effects is important, as prolonged use can lead to resistant organisms and adverse effects like Clostridium difficile infection 1 A study published in 2017 also supports the use of ceftriaxone in patients with decompensated cirrhosis, highlighting its effectiveness in preventing infections and improving outcomes in these patients 1. Overall, the use of ceftriaxone in patients with decompensated cirrhosis is a crucial aspect of their management, and its effectiveness in preventing infections and improving outcomes makes it a recommended treatment option 1.

From the FDA Drug Label

Patients with Renal or Hepatic Impairment Ceftriaxone is excreted via both biliary and renal excretion (see CLINICAL PHARMACOLOGY). Therefore, patients with renal failure normally require no adjustment in dosage when usual doses of ceftriaxone are administered Dosage adjustments should not be necessary in patients with hepatic dysfunction; however, in patients with both hepatic dysfunction and significant renal disease, caution should be exercised and the ceftriaxone dosage should not exceed 2 grams daily. Effect on Prothrombin Time Alterations in prothrombin times have occurred in patients treated with ceftriaxone Monitor prothrombin time during ceftriaxone treatment in patients with impaired vitamin K synthesis or low vitamin K stores (e.g., chronic hepatic disease and malnutrition).

We give Ceftriaxone to patients with decompensated cirrhosis because it can be used in patients with hepatic dysfunction without the need for dosage adjustments, although caution is advised in those with both hepatic dysfunction and significant renal disease. Additionally, Ceftriaxone may affect prothrombin time, so monitoring is necessary in patients with impaired vitamin K synthesis or low vitamin K stores, which can be common in patients with chronic hepatic disease 2.

From the Research

Rationale for Ceftriaxone Use in Decompensated Cirrhosis

• Ceftriaxone is used to treat spontaneous bacterial peritonitis (SBP) in patients with decompensated cirrhosis due to its effectiveness in resolving the infection 3, 4.
• The use of ceftriaxone has been shown to reduce mortality rates in patients with SBP, a common complication in decompensated cirrhosis 5.
• Ceftriaxone is a third-generation cephalosporin, which is often recommended as an empirical antibiotic treatment for SBP due to its broad-spectrum activity and penetration into ascitic fluid 6, 7.

Mechanism and Efficacy

• Ceftriaxone works by inhibiting the growth of bacteria, including those that cause SBP, such as Escherichia coli 4.
• The efficacy of ceftriaxone in treating SBP has been demonstrated in several studies, with resolution rates ranging from 73% to 94% 3, 4.
• Ceftriaxone has also been shown to be safe and effective in patients with decompensated cirrhosis, with a low risk of adverse events 3, 7.

Treatment Guidelines

• The use of ceftriaxone for SBP is recommended in various treatment guidelines, including those for the management of decompensated cirrhosis 5, 6.
• The duration of ceftriaxone treatment for SBP is typically 5-7 days, although this may vary depending on the severity of the infection and the patient's response to treatment 3, 4.
• Ceftriaxone may be used in combination with other treatments, such as albumin, to improve outcomes in patients with SBP 6.