Long-Term Prophylaxis of Spontaneous Bacterial Peritonitis in Patients with Cirrhosis

Norfloxacin with itopride versus norfloxacin alone in secondary prophylaxis of spontaneous bacterial peritonitis: a randomized trial

Background

Bacterial translocation is considered the pathophysiological hallmark in the development of spontaneous bacterial peritonitis (SBP). Prokinetics can increase gastrointestinal (GIT) motility, reduce small bowel transit time, decrease bacterial translocation, and the possibility of SBP. The aim of this work was to compare the effectiveness and safety of itopride and norfloxacin versus norfloxacin only in secondary prophylaxis for cirrhotic ascitic patients with spontaneous bacterial peritonitis.

Results

Regarding the baseline clinical manifestations and laboratory investigations, there was no significant difference between both groups. The incidence of a recurrent SBP in group I, who had received itopride plus norfloxacin, reduced with a significant difference than other group II (P=0.018). The median time for recurrence of SBP was highly longer in group I than group II with a significant difference (P=0.042).

Conclusions

The combined usage of itopride with norfloxacin in patients with cirrhosis and ascites can decrease the occurrence of a recurrent SBP and significantly improve the survival of patients.

Trial registration

ClinicalTrials.gov Identifier: NCT04161768.

Spontaneous bacterial peritonitis: How to deal with this life-threatening cirrhosis complication?

Spontaneous bacterial peritonitis (SBP) is one of the most common and life-threatening complications of cirrhosis. It occurs in 10% to 30% of patients admitted to hospital and recent studies tend to demonstrate that SBP incidence seems to be decreasing in its frequency. A bacterial overgrowth with translocation through the increased permeable small intestinal wall and impaired defense mechanisms is considered to be the main mechanism associated with its occurrence. The Gram-negative aerobic bacteria are the major responsible for SBP episodes and Gram-positive bacteria, mainly Staphylococcus aureus, are being considered an emergent agent causing SBP. The prompt diagnosis of SBP is the key factor for reduction observed in mortality rates in recent years. The clinical diagnosis of SBP is neither sensitive nor specific and the search for new practical and available tools for a rapid diagnosis of SBP is an important endpoint of current studies. Reagent strips were considered a promising and faster way of SBP diagnosis. The prompt use of empirical antibiotics, mostly cefotaxime, improves significantly the short-term prognosis of cirrhotic patients with SBP. The recurrence rate of SBP is high and antibiotic prophylaxis has been recommended in high-risk settings. Unfortunately, the long-term prognosis remains poor.

Antibiotic prophylaxis for prevention of spontaneous bacterial peritonitis in patients without gastrointestinal bleeding

OBJECTIVE

To review relevant studies for both primary and secondary antibiotic prophylaxis of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis without gastrointestinal bleeding.

DATA SOURCES

A search of PubMed (1980-July 2010) was conducted using the terms prophylaxis, SBP, and antibiotics. A manual review of bibliographies was conducted for inclusion of relevant articles.

STUDY SELECTION AND DATA EXTRACTION

Prospective studies and meta-analyses published in English were included.

DATA SYNTHESIS

Ten trials and 3 meta-analyses were included. Of the 10 trials, 2 examined the use of secondary prophylaxis for prevention of subsequent episodes of SBP, 4 examined the use of primary prophylaxis to prevent an initial SBP episode, and 4 examined the use of antibiotic prophylaxis in a mixed population. Seven trials evaluated the use of an antibiotic compared to placebo or no treatment. Only 1 trial evaluated norfloxacin versus trimethoprim/sulfamethoxazole. Trial duration varied from 24 days to 12 months. In general, trials examining norfloxacin as secondary prophylaxis found significantly decreased occurrence of SBP but no significant difference in mortality rates. Primary prophylaxis studies found no significant difference in the incidence of infections, including SBP, with norfloxacin or ciprofloxacin treatment but significantly lower incidence of gram-negative infections. Mixed population studies found a significantly decreased incidence of SBP but no significant difference in mortality. In the 3 meta-analyses, a significant decrease in mortality and an overall decrease in SBP incidence in the treatment groups were noted.

CONCLUSIONS

Based on currently available data, the use of prophylactic antibiotic therapy is warranted for the prevention of recurrent SBP in patients with cirrhosis and ascites. In patients with low ascetic fluid protein and at least 1 more risk factor, primary prophylaxis may be considered. Further studies with improved methodology are needed to determine whether prophylactic antibiotic therapy has an impact on mortality.

Dental management of patients with end-stage liver disease

This article presents a review of end-stage chronic liver disease (cirrhosis) with emphasis on the clinical presentation, diagnosis, and complications of cirrhosis, along with their medical and surgical management and prognosis. This article also discusses the evaluation and management of the dental patients with cirrhosis, including the implications decreased hepatic function has on drugs commonly used in dental treatment.