Do More Antibiotics Improve Outcomes More In Bleeding Cirrhotics? A Retrospective Analysis

INTRODUCTION: Administration of antibiotics in patients with cirrhosis and upper gastrointestinal (GI) bleeding has been shown to improve outcomes. Seven days of antibiotics are generally recommended but duration has not been compared to clinical outcomes in available literature. The goal of our study was to study the effect of antibiotic duration on patient outcomes. METHODS: We conducted a retrospective study of patients with cirrhosis presenting with upper GI bleeding at our institute from 2010 to 2018. Patients were divided into three cohorts based on duration of antibiotic administration for prophylaxis: 1–3 days of antibiotics, 4–6 days of antibiotics and 7 days or more of antibiotics. Rates of infection within 30 days, time to infection, rebleeding, and mortality were compared between the three groups with Chi square, Fisher Exact and Kruskall-Wallace tests. RESULTS: Medical charts of 943 patients with cirrhosis and upper GI bleed during the study period were reviewed. 303 patients with upper gastrointestinal bleeding did not have concomitant confirmed or suspected infection on presentation, of these 243 patients received antibiotics for prophylaxis and were included for analysis. Seventy-seven patients received antibiotic therapy for 3 days or less, 69 patients for 4 to 6 days, and 97 patients longer than 6 days. The three groups were well matched in demographic and clinical variables. 27 patients developed infections within 30 days of bleed. Rates of infection were not statistically different between the three antibiotic groups. (P = 0.78). In the 30 days following the GI bleed, pneumonia was the most diagnosed infection (11 patients) followed by urinary tract infections (eight patients). Four patients developed spontaneous bacterial peritonitis and three were diagnosed with bacteremia. There was no difference in time to infection (Kruskall Wallace test P = 0.75), early re-bleeding (P = 0.81), late re-bleeding (P = 0.37) and in-hospital mortality (P = 0.94) in the three groups. Six patients in the cohort developed C. Difficile infection; no patient in the short antibiotic group developed C. Difficile infection. CONCLUSION: Short course of antibiotics for prophylaxis (3 days) appears safe and adequate for prophylaxis in cirrhotics with upper gastrointestinal bleeding if bleeding has abated and there is no active infection.