Norfloxacin vs Ceftriaxone in the Prophylaxis of Infections in Patients With Advanced Cirrhosis and Hemorrhage

IMDM and IDIBAPS, Liver Unit, Hospital Clínic, University of Barcelona, Villaroel 170, 08036 Barcelona, Spain.
Gastroenterology (Impact Factor: 16.72). 10/2006; 131(4):1049-56; quiz 1285. DOI: 10.1053/j.gastro.2006.07.010
Source: PubMed


Oral norfloxacin is the standard of therapy in the prophylaxis of bacterial infections in cirrhotic patients with gastrointestinal hemorrhage. However, during the last years, the epidemiology of bacterial infections in cirrhosis has changed, with a higher incidence of infections caused by quinolone-resistant bacteria. This randomized controlled trial was aimed to compare oral norfloxacin vs intravenous ceftriaxone in the prophylaxis of bacterial infection in cirrhotic patients with gastrointestinal bleeding.
One hundred eleven patients with advanced cirrhosis (at least 2 of the following: ascites, severe malnutrition, encephalopathy, or bilirubin >3 mg/dL) and gastrointestinal hemorrhage were randomly treated with oral norfloxacin (400 mg twice daily; n = 57) or intravenous ceftriaxone (1 g/day; n = 54) for 7 days. The end point of the trial was the prevention of bacterial infections within 10 days after inclusion.
Clinical data were comparable between groups. The probability of developing proved or possible infections, proved infections, and spontaneous bacteremia or spontaneous bacterial peritonitis was significantly higher in patients receiving norfloxacin (33% vs 11%, P = .003; 26% vs 11%, P = .03; and 12% vs 2%, P = .03, respectively). The type of antibiotic used (norfloxacin), transfusion requirements at inclusion, and failure to control bleeding were independent predictors of infection. Seven gram-negative bacilli were isolated in the norfloxacin group, and 6 were quinolone resistant. Non-enterococcal streptococci were only isolated in the norfloxacin group. No difference in hospital mortality was observed between groups.
Intravenous ceftriaxone is more effective than oral norfloxacin in the prophylaxis of bacterial infections in patients with advanced cirrhosis and hemorrhage.

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    • "These bacterial infections are present in 35% to 66% of liver cirrhosis patients with variceal bleeding, and is a risk factor for early rebleeding.20 Prophylactic antibiotics can increase the survival rate;21 therefore, the administration of antibiotics in patients with variceal bleeding is essential and is performed as soon as the patient arrives at the hospital.22 Norfloxacin selectively works against the gram-negative bacteria of the gastrointestinal tract and is orally administered at a dose of 400 mg, twice daily, for 1 week.23 When oral administration of antibiotics are impossible, quinolones such as ciprofloxacin or ofloxacin may be administered intravenously. "
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    • "First, administration of intravenous antibiotics is theoretically more appropriate than those administered orally in the prophylaxis of infection in patients with active UGIB. Second, it was reported that intravenous ceftriaxone is more effective than fluoroquinolone in areas of a high prevalence of quinolone-resistant organisms [13]. "
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    • "Development of gastroesophageal varices and variceal hemorrhage are the most direct consequence of portal hypertension.1 When variceal bleeding is suspected, patients should be hemodynamically stabilized, vasopressors, antibiotic2,3 and endoscopic therapy4 can be performed to control the hemorrhage. However, when medical or endoscopic control of bleeding was not achievable, surgical procedures are needed.5 "
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