Limited effects of antibiotic prophylaxis in patients with Child–Pugh class A/B cirrhosis and upper gastrointestinal bleeding

Chang, Te Sheng; Tsai, Ying Huang; Lin, Yuxi; Chen, Chun‐Hsien; Lu, Chung Kuang; Huang, Weiya; Chen, Wei Ming; Hsieh, Yung‐Yu; Wu, Yi; Tung, Shui‐Yi; Huang, Yen Hua

doi:10.1371/journal.pone.0229101

Cited by 9 publications

(23 citation statements)

References 22 publications

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“…Chang et al evaluated the use of antibiotic prophylaxis in this subset of patients and compared antibiotic prophylaxis to an on-demand antibiotic regimen. The rate of bacterial infection within 14 days and the overall mortality rate within 42 days did not differ between the groups 66 .…”

Section: Pre-endoscopy Management Of Acute Egvhmentioning

confidence: 78%

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Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

et al. 2022

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Main Recommendations 1 ESGE recommends that patients with compensated advanced chronic liver disease (ACLD; due to viruses, alcohol, and/or nonobese [BMI < 30 kg/m2] nonalcoholic steatohepatitis) and clinically significant portal hypertension (hepatic venous pressure gradient [HVPG] > 10 mmHg and/or liver stiffness by transient elastography > 25 kPa) should receive, if no contraindications, nonselective beta blocker (NSBB) therapy (preferably carvedilol) to prevent the development of variceal bleeding.Strong recommendation, moderate quality evidence. 2 ESGE recommends that in those patients unable to receive NSBB therapy with a screening upper gastrointestinal (GI) endoscopy that demonstrates high risk esophageal varices, endoscopic band ligation (EBL) is the endoscopic prophylactic treatment of choice. EBL should be repeated every 2–4 weeks until variceal eradication is achieved. Thereafter, surveillance EGD should be performed every 3–6 months in the first year following eradication.Strong recommendation, moderate quality evidence. 3 ESGE recommends, in hemodynamically stable patients with acute upper GI hemorrhage (UGIH) and no history of cardiovascular disease, a restrictive red blood cell (RBC) transfusion strategy, with a hemoglobin threshold of ≤ 70 g/L prompting RBC transfusion. A post-transfusion target hemoglobin of 70–90 g/L is desired.Strong recommendation, moderate quality evidence. 4 ESGE recommends that patients with ACLD presenting with suspected acute variceal bleeding be risk stratified according to the Child–Pugh score and MELD score, and by documentation of active/inactive bleeding at the time of upper GI endoscopy.Strong recommendation, high quality of evidence. 5 ESGE recommends the vasoactive agents terlipressin, octreotide, or somatostatin be initiated at the time of presentation in patients with suspected acute variceal bleeding and be continued for a duration of up to 5 days.Strong recommendation, high quality evidence. 6 ESGE recommends antibiotic prophylaxis using ceftriaxone 1 g/day for up to 7 days for all patients with ACLD presenting with acute variceal hemorrhage, or in accordance with local antibiotic resistance and patient allergies.Strong recommendation, high quality evidence. 7 ESGE recommends, in the absence of contraindications, intravenous erythromycin 250 mg be given 30–120 minutes prior to upper GI endoscopy in patients with suspected acute variceal hemorrhage.Strong recommendation, high quality evidence. 8 ESGE recommends that, in patients with suspected variceal hemorrhage, endoscopic evaluation should take place within 12 hours from the time of patient presentation provided the patient has been hemodynamically resuscitated.Strong recommendation, moderate quality evidence. 9 ESGE recommends EBL for the treatment of acute esophageal variceal hemorrhage (EVH).Strong recommendation, high quality evidence. 10 ESGE recommends that, in patients at high risk for recurrent esophageal variceal bleeding following successful endoscopic hemostasis (Child–Pugh C ≤ 13 or Child–Pugh B > 7 with active EVH at the time of endoscopy despite vasoactive agents, or HVPG > 20 mmHg), pre-emptive transjugular intrahepatic portosystemic shunt (TIPS) within 72 hours (preferably within 24 hours) must be considered.Strong recommendation, high quality evidence. 11 ESGE recommends that, for persistent esophageal variceal bleeding despite vasoactive pharmacological and endoscopic hemostasis therapy, urgent rescue TIPS should be considered (where available).Strong recommendation, moderate quality evidence. 12 ESGE recommends endoscopic cyanoacrylate injection for acute gastric (cardiofundal) variceal (GOV2, IGV1) hemorrhage.Strong recommendation, high quality evidence. 13 ESGE recommends endoscopic cyanoacrylate injection or EBL in patients with GOV1-specific bleeding.Strong recommendations, moderate quality evidence. 14 ESGE suggests urgent rescue TIPS or balloon-occluded retrograde transvenous obliteration (BRTO) for gastric variceal bleeding when there is a failure of endoscopic hemostasis or early recurrent bleeding.Weak recommendation, low quality evidence. 15 ESGE recommends that patients who have undergone EBL for acute EVH should be scheduled for follow-up EBLs at 1- to 4-weekly intervals to eradicate esophageal varices (secondary prophylaxis).Strong recommendation, moderate quality evidence. 16 ESGE recommends the use of NSBBs (propranolol or carvedilol) in combination with endoscopic therapy for secondary prophylaxis in EVH in patients with ACLD.Strong recommendation, high quality evidence.

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Section: Pre-endoscopy Management Of Acute Egvhmentioning

confidence: 78%

“…Strong recommendation, high quality evidence. infection within 14 days and the overall mortality rate within 42 days did not differ between the groups [66].…”

Section: Recommendationmentioning

confidence: 79%

Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

et al. 2022

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“…In this way, abnormal blood perfusion of portal vein and portal artery occurs. [19][20][21] It has been pointed out by some studies that significant differences were observed between hAEF of cirrhosis of different severity and that of normal control group 22,23 , suggesting that the severity of patients' condition may be determined by testing hAEF. In this study, hAEF and H/S values of patients with different Child-Pugh grades were analyzed, and the results showed that the AUC of hAEF and H/S values in evaluating the degree of liver function impairment of patients were 0.716 and 0.770, respectively, indicating that hAEF and H/S values are valuable in evaluating the degree of liver function impairment of patients with hepatitis B cirrhosis.…”

Section: Discussionmentioning

confidence: 99%

Clinical value of AEF in the post-processing technique of liver perfusion-like phase III enhanced CT scan in evaluating the degree of liver function impairment in patients with Hepatitis-B cirrhosis

Wang¹,

Sun

2022

Pak J Med Sci

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Objectives: To investigate the value of CT arterial enhancement fraction (AEF) in the post-processing technique of liver perfusion-like phase III enhanced CT scan in evaluating the degree of liver function impairment in patients with hepatitis B cirrhosis. Methods: The study included 85 patients with hepatitis B cirrhosis admitted to the Department of Radiology, The Affiliated Huai’an Hospital of Xuzhou Medical University from May 2018 to October 2020 were selected as the experimental group, and 71 patients with liver fibrosis during the same period were selected as the control group. All patients underwent routine liver CT phase III perfusion scan, and hepatic AEF (hAEF) and liver/spleen ratio (H/S) were compared between the two groups to analyze the differential value of hAEF and H/S for liver fibrosis and hepatitis B cirrhosis. Patients were divided into the mild group (Grade-A) and the severe group (Grade-B and C) according to Child-Pugh grading. hAEF and H/S values of the two groups were compared, and the evaluation value of AEF on the degree of impairment of hepatitis B cirrhosis was analyzed. Results: hAEF and H/S values of the experimental group were greater than those of the control group (P<0.05), and the AUCs of hAEF and H/S values for distinguishing hepatitis B and cirrhosis were 0.727 (95%CI: 0.650-0.795) and 0.791 (95%CI: 0.718-0.852), respectively. Moreover, hAEF and H/S values of the severe group were greater than those of the mild group (P<0.05), and the AUCs of hAEF and H/S values in evaluating the degree of liver function impairment were 0.746 (95%CI: 0.627-0.834) and 0.770 (95%CI: 0.705-0.928), respectively. Conclusions: AEF boasts the value of differentiating liver fibrosis and cirrhosis, and of evaluating the degree of liver function impairment in patients with hepatitis B cirrhosis. doi: https://doi.org/10.12669/pjms.38.7.5362 How to cite this:Wang N, Sun Z. Clinical value of AEF in the post-processing technique of liver perfusion-like phase III enhanced CT scan in evaluating the degree of liver function impairment in patients with Hepatitis-B cirrhosis. Pak J Med Sci. 2022;38(7):---------. doi: https://doi.org/10.12669/pjms.38.7.5362 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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“…The characteristics of all 18 studies involving 3180 subjects (1142 received prophylactic antibiotics) were summarized in Table 1. 8,9,13,14,16,[18][19][20][21][22][30][31][32][33][34][35][36][37] There were 12 randomized studies and 6 retrospective cohort studies. Study populations were representative with studies included from Asia (n = 9), Europe (n = 7), North America (n = 1), and Australia (n = 1).…”

Section: Characteristics and Quality Of The Studiesmentioning

confidence: 99%

“…A total of 15 studies (1933 subjects) reported outcome data on mortality risk among cirrhosis patients with UGIB. 8,9,13,14,16,[18][19][20][21][22]30,32,[34][35][36][37] The pooled risk of 6week mortality (CTP-A: 0%, CTP-B: 4.7%, CTP-C: 20.0%) increased proportionally with the underlying CTP class. Antibiotic prophylaxis reduces the risk of 6week mortality (RR = 0.72, 95% CI = 0.57-0.90, I 2 = 0%) (Figure 1).…”

Section: Mortalitymentioning

confidence: 99%

Antibiotic prophylaxis in cirrhosis patients with upper gastrointestinal bleeding: An updated systematic review and meta‐analysis

Wong

Tan

Yii

et al. 2022

Portal Hypertension & Cirrhosis

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ObjectiveEmerging evidence suggest that antibiotic prophylaxis may be omitted in early cirrhosis patients with upper gastrointestinal bleeding (UGIB), which question the benefits of antibiotic prophylaxis on rebleeding, mortality related to ongoing bleeding, and the need for salvage therapy. As the management of UGIB has improved over time since the last review a decade ago, we performed an updated meta‐analysis to review the benefits of antibiotic prophylaxis in cirrhosis patients with UGIB.MethodSix electronic databases including PubMed/MEDLINE, EMBASE, Scopus, Web of Science, Cochrane library, and ClinicalTrial.gov were systematically searched up to December 1, 2021. The primary outcome was 6 weeks mortality. Secondary outcomes include the risk of infection, rebleeding at 7 days and 6 weeks, mortality related to ongoing bleeding, need for salvage therapy, and infection‐related mortality.ResultEighteen studies (12 randomized controlled trials [RCT], 6 non‐RCT) from 3180 subjects were identified among 2129 citations. Antibiotic prophylaxis reduces mortality at 6 weeks, risk of infection, and infection‐related mortality (pooled relative risk: 0.72, 0.39, and 0.41, respectively). Although antibiotics reduce the risk of rebleeding and the amount of blood transfusion, they did not reduce the risk of mortality from ongoing bleeding nor the need for salvage therapy. Antibiotic prophylaxis may shorten the length of stay in the intensive care unit.ConclusionAntibiotic prophylaxis reduces rebleeding, 6‐week mortality, and infection‐related mortality. Due to the low risk of infection and death, dedicated studies are warranted to evaluate the benefit of antibiotic prophylaxis in early cirrhosis with UGIB.

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Limited effects of antibiotic prophylaxis in patients with Child–Pugh class A/B cirrhosis and upper gastrointestinal bleeding

Cited by 9 publications

References 22 publications

Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

Clinical value of AEF in the post-processing technique of liver perfusion-like phase III enhanced CT scan in evaluating the degree of liver function impairment in patients with Hepatitis-B cirrhosis

Antibiotic prophylaxis in cirrhosis patients with upper gastrointestinal bleeding: An updated systematic review and meta‐analysis

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