The use of antibiotics as primary prophylaxis for spontaneous bacterial peritonitis in decompensated liver failure is an area of uncertainty and conflicting opinion. Concerns regarding increasing anti-microbial resistance (AMR) alongside lack of evidence for antibiotic choice are cited as reasons for this.1Spontaneous bacterial peritonitis (SBP) is the most common serious infection in cirrhosis with significant mortality.2 While antibiotic prophylaxis to prevent further infection is established following a prior episode of SBP, there remains considerable uncertainty over primary prophylaxis for SBP.1 3 This is important as 90% of SBP cases present in those with no previous episode.4Methods
We conducted a national survey of primary prophylaxis for SBP through the British Society of Gastroenterology trial development group with responses from 23 centres. We requested information on the centres’ current guidelines and criteria for prescription.Results
Nine centres reported that they routinely used antibiotics as primary prophylaxis for SBP, seven did not routinely prescribe and seven responded that they intermittently prescribe prophylaxis on a case-by-case or clinician dependent basis. The antibiotics prescribed were ciprofloxacin (60%), norfloxacin (20%) or cotrimoxazole (20%). Two hospitals used rifaximin as combined prophylaxis against hepatic encephalopathy (HE) and SBP. The majority (eight) of the centres with trust guidelines for prescription included patients with ascitic fluid protein <1.5 g/dl or Childs score B or C.Conclusions
Responses demonstrated a wide variation in clinical practice between both centres and clinicians. Respondents indicated that due to lack of clear evidence, prescription was frequently on a case-by-case basis, often influenced by previous personal experience. They highlighted the increasing concerns from the participating hospitals’ microbiology departments over the use of quinolones due to the risks of selecting drug resistant organisms and Clostridium difficile (C. difficile) associated diarrhoea. Rifaximin is licensed in use for HE but may have beneficial role in SBP prevention without the high risk of drug resistance, however high costs remains a barrier to its use.Conclusions
SBP continues to be a significant problem in the management of patients with decompensated liver failure. The Results from these centres demonstrate an evident lack of clarity over the optimum strategy for primary prophylaxis throughout the United Kingdom and hence the need for further high quality research to provide clear guidelines.