title: Antibiotic prophylaxis in cirrhosis: Good and bad.
abstract: Patients with cirrhosis, particularly those with decompensated cirrhosis, are at increased risk of bacterial infections that may further precipitate other liver decompensations including acute-on-chronic liver failure. Infections constitute the main cause of death in patients with advanced cirrhosis, and strategies to prevent them are essential. The main current strategy is the use of prophylactic antibiotics targeted at specific subpopulations at high risk of infection: prior episode of spontaneous bacterial peritonitis, upper gastrointestinal bleeding, and low-protein ascites with associated poor liver function. Antibiotic prophylaxis effectively prevents not only the development of bacterial infections in all these indications but also further decompensation (variceal bleeding, hepatorenal syndrome) and improves survival. However, antibiotic prophylaxis is also associated with a clinically relevant and increasing drawback, the development of infections due to multidrug-resistant organisms. Several strategies have been suggested to balance the risks and benefits of antibiotic prophylaxis.
  
  
  
  Antibiotic stewardship principles such as the restriction of antibiotic prophylaxis to subpopulations at a very high risk for infection, the avoidance of antibiotic overuse, and early deescalation policies are key to achieve this balance; nonantibiotic prophylactic measures such as probiotics, prokinetics, bile acids, statins, and hematopoietic growth factors could also contribute to ameliorate the development and spread of multidrug-resistant bacteria in cirrhosis. (Hepatology 2016;63:2019-2031).
authors.affiliation: Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain.|Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Barcelona, Spain.|Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Barcelona, Spain.
authors.forename: Javier
authors.initials: J
authors.lastname: Fernández
authors.affiliation: Cirrhosis Care Clinic, Cirrhosis Care, Liver Unit, Division of Gastroenterology, University of Alberta, Edmonton, Canada.
authors.forename: Puneeta
authors.initials: P
authors.lastname: Tandon
authors.affiliation: Infectious Disease Department, Hospital Clínic, University of Barcelona, Barcelona, Spain.
authors.forename: Jose
authors.initials: J
authors.lastname: Mensa
authors.affiliation: Section of Digestive Diseases, Yale University School of Medicine, New Haven, CT.|Section of Digestive Diseases, VA-CT Healthcare System, West Haven, CT.
authors.forename: Guadalupe
authors.initials: G
authors.lastname: Garcia-Tsao
mesh_terms: D000900:Anti-Bacterial Agents / Q000009:adverse effects*; D019072:Antibiotic Prophylaxis; D001424:Bacterial Infections / Q000517:prevention & control*; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*
chemical_list: D000900:Anti-Bacterial Agents