From the Guidelines
Antibiotics should be started immediately in patients with upper gastrointestinal bleeding (UGIB) who have cirrhosis, as this reduces the incidence of infections and improves control of bleeding and survival. For patients with cirrhosis, intravenous ceftriaxone 1g daily for up to 7 days is recommended, as stated in the EASL clinical practice guidelines 1. This approach is supported by a meta-analysis of 12 RCTs, which found that antibiotic prophylaxis in cirrhotic patients with UGIB reduces the occurrence rate of infections and rebleeding, as well as improves survival 1.
Key Considerations
- The rationale for antibiotic use in these scenarios is to prevent bacterial infections, particularly spontaneous bacterial peritonitis in cirrhotic patients, which can worsen outcomes.
- Bacterial translocation from the gut is increased during bleeding episodes, and cirrhotic patients have impaired immune function.
- Antibiotics have been shown to reduce mortality, rebleeding rates, and infection risk in these high-risk groups.
Patient Selection
- Routine antibiotic prophylaxis is not recommended for all UGIB patients, particularly those without cirrhosis who are not undergoing endoscopic intervention, as this could contribute to antibiotic resistance without clear benefit.
- For non-cirrhotic patients undergoing endoscopic procedures, a single dose of IV antibiotics (such as ceftriaxone 1g) prior to the procedure may be appropriate, although the evidence for this is less clear.
Treatment Details
- Ceftriaxone (1 g/24 h) is the first choice in patients with decompensated cirrhosis, those already on quinolone prophylaxis, and in hospital settings with high prevalence of quinolone-resistant bacterial infections 1.
- Oral quinolones (norfloxacin 400 mg b.i.d) should be used in the remaining patients 1.
From the Research
Timing of Antibiotics for Upper Gastrointestinal Bleeding (UGIB)
- The optimal timing for starting antibiotics in patients with UGIB is not universally agreed upon, but several studies provide guidance 2, 3, 4, 5, 6.
- For patients with cirrhosis and UGIB, antibiotics are recommended to improve outcomes, with some studies suggesting that a shorter course of antibiotics (3 days) may be sufficient if there is no active infection 2.
- In patients with cirrhosis and suspected variceal bleeding, antibiotics are recommended 4, 5, 6.
- The use of antibiotics in patients without cirrhosis or variceal bleeding is not well established, but may be considered in certain high-risk cases 3, 6.
Patient-Specific Factors
- Patients with cirrhosis and UGIB may benefit from earlier initiation of antibiotics, particularly if they have variceal bleeding or are at high risk of rebleeding 3, 4, 5, 6.
- Older patients (>55 years) and those with multiple comorbidities may also benefit from antibiotic prophylaxis 3.
- The presence of ascites and high MELD-Na scores may increase the risk of infection and warrant earlier antibiotic initiation 2.
Clinical Outcomes
- The use of antibiotics in patients with UGIB has been shown to reduce the risk of rebleeding and infection, particularly in those with cirrhosis and variceal bleeding 2, 3, 4, 5, 6.
- However, the optimal duration of antibiotic therapy is not well established, and further studies are needed to determine the most effective treatment strategy 2, 3, 6.