Bacterial infection in the pathogenesis of variceal bleeding. Is there any role for antibiotic prophylaxis in the cirrhotic patient?
Bacterial infections are frequent in cirrhotic patients particularly
in those admitted to hospital. Several risk factors
have been implicated to explain the propensity of cirrhotic
patients to develop bacterial infections, such as iatrogenic
factors that may disrupt the natural defense barriers, the
occurrence of bacterial translocation from the intestinal
lumen to extraintestinal sites, the depression of hepatic
reticuloendothelial system function and the decreased opsonic
activity of serum and ascitic fluid seen in cirrhosis.
Particularly in cirrhotic patients with gastrointestinal hemorrhage,
bacterial infections have an incidence of 35% to
66% and are closely related to the recurrence of hemorrhage
and survival. Although gastrointestinal hemorrhage can
predispose cirrhotic patients to bacteremia there is recent
data that support the hypothesis that bacterial infection
may initiate gastrointestinal hemorrhage, particularly
variceal bleeding in cirrhosis. The strong association between
bacterial infections and gastrointestinal hemorrhage
in cirrhosis has led to the use of antibiotic prophylaxis in
the setting of acute variceal bleeding. A recent meta-analysis
demonstrated that antibiotic prophylaxis in cirrhotic
patients with gastrointestinal bleeding decreases the rate
of bacterial infections and increases short-term survival.
Spontaneous bacterial peritonitis (SBP) is the most characteristic
infectious complication of cirrhotic patients and
it is diagnosed according to certain diagnostic criteria.
Third-generation cephalosporins are the first-choice antibiotic
treatment in SBP, although selected patients with
uncomplicated SBP may be treated with oral quinolones.Selective intestinal decontamination with norfloxacin is safe
and effective in the primary and secondary prophylaxis of
Fourth Department of Medicine, Aristotle University