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Meta-Analysis
. 2010 Sep 8;2010(9):CD002907.
doi: 10.1002/14651858.CD002907.pub2.

Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding

Norberto C Chavez-Tapia  1 , Tonatiuh Barrientos-Gutierrez, Felix I Tellez-Avila, Karla Soares-Weiser, Misael Uribe
Affiliations
Meta-Analysis

Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding

Norberto C Chavez-Tapia et al. Cochrane Database Syst Rev. .

Abstract

Background: Bacterial infections are a frequent complication in patients with cirrhosis and upper gastrointestinal bleeding. Antibiotic prophylaxis seems to decrease the incidence of bacterial infections. Oral antibiotics, active against enteric bacteria, have been commonly used as antibiotic prophylaxis in patients with cirrhosis and upper gastrointestinal bleeding. This is an update of a Cochrane review first published in 2002.

Objectives: To assess the benefits and harms of antibiotic prophylaxis in cirrhotic patients with upper gastrointestinal bleeding.

Search strategy: We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index EXPANDED until June 2010. In addition, we handsearched the references of all identified studies.

Selection criteria: Randomised clinical trials comparing different types of antibiotic prophylaxis with no intervention, placebo, or another antibiotic to prevent bacterial infections in cirrhotic patients with upper gastrointestinal bleeding.

Data collection and analysis: Three authors independently assessed trial quality, risk of bias, and extracted data. We contacted study authors for additional information. Association measures were relative risk (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes.

Main results: Twelve trials (1241 patients) evaluated antibiotic prophylaxis compared with placebo or no antibiotic prophylaxis. All trials were at risk of bias. Antibiotic prophylaxis compared with no intervention or placebo was associated with beneficial effects on mortality (RR 0.79, 95% CI 0.63 to 0.98), mortality from bacterial infections (RR 0.43, 95% CI 0.19 to 0.97), bacterial infections (RR 0.36, 95% CI 0.27 to 0.49), rebleeding (RR 0.53, 95% CI 0.38 to 0.74), days of hospitalisation (MD -1.91, 95% CI -3.80 to -0.02), bacteraemia (RR 0.25, 95% CI 0.15 to 0.40), pneumonia (RR 0.45, 95% CI 0.27 to 0.75), spontaneous bacterial peritonitis (RR 0.29, 95% CI 0.15 to 0.57), and urinary tract infections (RR 0.23, 95% CI 0.12 to 0.41). No serious adverse events were reported. The trials showed no significant heterogeneity of effects. Another five trials (650 patients) compared different antibiotic regimens. Data could not be combined as each trial used different antibiotic regimen. None of the examined antibiotic regimen was superior to the control regimen regarding mortality or bacterial infections.

Authors' conclusions: Prophylactic antibiotic use in patients with cirrhosis and upper gastrointestinal bleeding significantly reduced bacterial infections, and seems to have reduced all-cause mortality, bacterial infection mortality, rebleeding events, and hospitalisation length. These benefits were observed independently of the type of antibiotic used; thus, no specific antibiotic can be preferred. Therefore, antibiotic selection should be made considering local conditions such as bacterial resistance profile and treatment cost.

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Conflict of interest statement

None known.

Figures

1
1
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
O’Brien‐Fleming monitoring boundaries for assessing statistical significance for overall mortality. The solid blue curve presents the cumulative meta‐analysis test‐score and the inward sloping red curves present the adjusted threshold for statistical significance ‐ the two‐sided O'Brien‐Fleming boundaries.
4
4
O’Brien‐Fleming monitoring boundaries for assessing statistical significance for mortality from bacterial infections. The solid blue curve presents the cumulative meta‐analysis test‐score and the inward sloping red curves present the adjusted threshold for statistical significance ‐ the two‐sided O'Brien‐Fleming boundaries.
5
5
O’Brien‐Fleming monitoring boundaries for assessing statistical significance for bacterial infections. The solid blue curve presents the cumulative meta‐analysis test‐score and the inward sloping red curves present the adjusted threshold for statistical significance ‐ the two‐sided O'Brien‐Fleming boundaries.
1.1
1.1. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 1 Mortality.
1.2
1.2. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 2 Mortality from bacterial infections.
1.3
1.3. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 3 Bacterial infections.
1.4
1.4. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 4 Bacteremia.
1.5
1.5. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 5 Pneumonia.
1.6
1.6. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 6 Spontaneous bacterial peritonitis.
1.7
1.7. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 7 Urinary tract infections.
1.8
1.8. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 8 Other infections.
1.9
1.9. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 9 Drop outs before end of study.
1.10
1.10. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 10 Mortality according to trial sample size.
1.11
1.11. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 11 Bacterial infections according to trial sample size.
1.12
1.12. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 12 Mortality sensitivity analysis worst‐best case.
1.13
1.13. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 13 Mortality sensitivity analysis best‐worst case.
1.14
1.14. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 14 Mortality from bacterial infections sensitivity analysis worst‐best case.
1.15
1.15. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 15 Mortality from bacterial infections sensitivity analysis best‐worst case.
1.16
1.16. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 16 Bacterial infections sensitivity analysis worst‐best case.
1.17
1.17. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 17 Bacterial infections sensitivity analysis best‐worst case.
1.18
1.18. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 18 Mortality according to the antibiotic used.
1.19
1.19. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 19 Mortality from bacterial infections according to the antibiotic used.
1.20
1.20. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 20 Bacterial infections according to the antibiotic used.
1.21
1.21. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 21 Rebleeding.
1.22
1.22. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 22 Early rebleeding (up to 7 days).
1.23
1.23. Analysis
Comparison 1 Antibiotics versus no intervention/placebo, Outcome 23 Days of hospitalisation.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Blaise 1994 {published data only}
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References to studies excluded from this review

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References to other published versions of this review

Soares‐Weiser 2002
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