There remains considerable uncertainty on whether antibiotic prophylaxis for spontaneous bacterial peritonitis is beneficial in people with liver cirrhosis, according to the results of a meta-analysis study. Moreover, if beneficial, it is also uncertain which antibiotics may provide the most benefit in people with cirrhosis and ascites with low protein or history of spontaneous bacterial peritonitis. These results were published in The Cochrane Database of Systematic Reviews1.

A total of 23 trials including 2587 participants were included for >1 outcome(s) of this review; the trials compared 10 interventions.

According to investigators, approximately 2.5% of all hospitalizations in patients with liver cirrhosis are due to spontaneous bacterial peritonitis. Based on the findings of the review, there is very low-certainty evidence concerning antibiotic prophylaxis. Furthermore, direct comparisons of 10 different antibiotics demonstrated no differences. There was also no evidence of any differences in the subgroup analyses that evaluate effects of primary vs secondary prophylaxis. Therefore, they recommended that future work consists of adequately powered randomized clinical trials, employ blinding, avoid postrandomization dropouts, or perform intention-to-treat analysis, and use clinically important outcomes such as mortality, health-related quality of life, and decompensation events.

Approximately 20% of individuals with cirrhosis develop ascites, which is a major risk factor for spontaneous bacterial peritonitis.1 One of the major causes of cirrhosis is chronic hepatitis C viral (HCV) infection, however, according to data from the United States Preventive Services Task Force published in JAMA,2 direct evidence on the effects of HCV screening on clinical outcomes remains unavailable.  


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The report in JAMA also found that direct acting antiviral therapy regimens were associated with sustained virologic response rates >95% with few short-term harms that were relative to older antiviral therapies. Furthermore, a sustained virologic response after antiviral therapy was associated with improved clinical outcomes compared to nonresponse as well as a significantly decreased risk for all-cause mortality (hazard ratio, 0.40; 95%CI, 0.28-0.56). This may demonstrate an avenue by which to decrease the progression of HCV infection to cirrhosis, and therefore potentially decrease the incidence of spontaneous bacterial peritonitis.

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Further research is therefore needed to determine factors associated with improved clinical outcomes, such as decreasing the rates of cirrhosis.

References

  1. Komolafe O, Roberts D, Freeman SC, et al. Antibiotic prophylaxis to prevent spontaneous bacterial peritonitis in people with liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev. 2020;1:CD013125.
  2. Chou R, Dana T, Fu R, et al. Screening for hepatitis C virus infection in adolescents and adults: Updated evidence report and systematic review for the US Preventive Services Task Force. [published online March 2 2020]. JAMA. doi:10.1001/jama.2019.20788