Early antibiotics treatment does not prevent infection in hospitalized cirrhosis patients

Antibiotics are usually prescribed by physicians to patients hospitalized with decompensated cirrhosis even without an infection diagnosis, according to a UK study. However, this practice has neither reduced the overall risk of hospital-acquired infections (HAI) nor improved survival.

“These patients were more unwell than those not prescribed antibiotics, and this was likely to have been to prevent infections in patients considered at high risk of sepsis,” the researchers said. “However, our comprehensive and strikingly consistent analyses showed no overall beneficial impact on preventing HAI, renal dysfunction, and … survival.”

In this study, the researchers assessed HAI during the trial treatment period and mortality in patients with no infection at baseline, grouped by antibiotic prescription or not. Propensity score matching was also performed to account for differences in disease severity.

A total of 408 patients were prescribed antibiotics at enrolment, of whom 203 did not have infection and were more ill than those not given antibiotics. [Am J Gastroenterol 2023;118:105-113]

No differences were seen in subsequent HAI between patients treated and not treated with antibiotics (19.2 percent vs 20.3 percent; p=0.83). However, antibiotic-treated patients had higher 28-day mortality (p=0.004), potentially indicating increased disease severity.

HAI and mortality also did not differ between groups matched by propensity scoring. Likewise, no differences in HAI (p=0.16) or mortality were observed in noninfected patients at enrolment treated with or without rifaximin, confirmed with propensity matching.

Notably, patients on long-term antibiotic prophylaxis at discharge did not differ from nonantibiotic counterparts in terms of mortality at 6 months. However, patients treated with antibiotics presented more infections at trial entry, with numbers too small for matching.

“These data support a policy of prompt de-escalation or discontinuation of empirical antibiotics guided by culture sensitivities at 24–48 hours after commencement if no infection and the patient is improving,” the researchers said.

Antibiotic overuse

Many physicians support early aggressive empirical antibiotic treatment to fight infection in patients with cirrhosis. [https://www.bsg.org.uk/clinical-resource/bsg-basl-decompensated-cirrhosis-care-bundle-first-24-hours/]

The main reason for antibiotic treatment was to prevent infection and sepsis in patients considered at high risk. However, overuse of this agent can cause harm and may lead to antimicrobial resistance (AMR). [Lancet Reg Health Eur 2021;7:100161]

“When compared with other chronic diseases, patients with cirrhosis have increased hospitalizations, longer stays, more invasive procedures, and readmissions, all increasing AMR risk,” according to the researchers. “This heightens the need to reduce unnecessary antibiotic prescriptions.” [J Hepatol 2016;65:1043-1054]

“Our real-world data demonstrate the continued uncertainty around management of infection in decompensated cirrhosis, emphasizing the need for clinicians to search diligently for evidence of this and for further clinical research to identify who might benefit from empirical/prophylactic antibiotic use and for improved molecular diagnostic approaches to infection diagnosis,” they said.