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Outcomes in Patients With Cirrhosis on Primary Compared to Secondary Prophylaxis for Spontaneous Bacterial Peritonitis

Bajaj, Jasmohan S., MD1; Tandon, Puneeta2; O'Leary, Jacqueline G.3; Wong, Florence4; Biggins, Scott W.5,6; Garcia-Tsao, Guadalupe7; Kamath, Patrick S.8; Maliakkal, Benedict9,10; Fallon, Michael B.11,12; Lai, Jennifer C.13; Thuluvath, Paul J.14; Vargas, Hugo E.15; Subramanian, Ram M.16; Thacker, Leroy R.1; Reddy, K. Rajender17

American Journal of Gastroenterology: April 2019 - Volume 114 - Issue 4 - p 599–606
doi: 10.14309/ajg.0000000000000044

OBJECTIVES: Antibiotic prophylaxis is recommended for prevention of the first episode of spontaneous bacterial peritonitis (SBP; primary prophylaxis 1°) and subsequent episodes (secondary prophylaxis 2°). We aimed to compare outcomes in cirrhotic inpatients on 1° vs 2° SBP prophylaxis.

METHODS: Data from North American Consortium for the Study of End-Stage Liver Disease were evaluated for cirrhosis details, reasons for admission/medications, inpatient course recorded, and outcomes over 90 days. Outcomes (intensive care units, acute kidney injury, inpatient/90-day mortality) were compared between the 2 groups after propensity-matching on admission model for end-stage liver disease (MELD) score and serum albumin.

RESULTS: Among the 2,731 patients enrolled, 305 were on 1° and 187 on 2° SBP prophylaxis. After propensity-matching, 154 patients remained in each group. Patients on 1° prophylaxis were more likely to have admission systemic inflammatory response syndrome (P = 0.02), with higher intensive care unit admissions (31% vs 21%; P = 0.05) and inpatient mortality (19% vs 9%; P = 0.01) than the 2° prophylaxis group. Patients on 2° prophylaxis had higher total (22% vs 10%; P = 0004), readmission (16% vs 9%; P = 0.03), and nosocomial (6% vs 0.5%; P = 0.01) SBP rates with predominant Gram-negative organisms compared to 1° prophylaxis patients. At 90 days, 1° prophylaxis patients had a higher mortality (35% vs 22%; P = 0.02) and acute kidney injury incidence (48% vs 30%; P = 0.04) compared to 2° prophylaxis patients.

DISCUSSION: In this inpatient cirrhosis study, despite prophylaxis, a high proportion of patients developed SBP, which was associated with mortality. Cirrhotic inpatients on 1° prophylaxis had worse outcomes than those on 2° prophylaxis when propensity-matched for the MELD score and serum albumin during the index admission and 90-day follow-up.

1Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia, USA;

2University of Alberta, Edmonton, Alberta, Canada;

3Dallas VA Medical Center and Baylor University Medical Center, Dallas, Texas, USA;

4University of Toronto, Toronto, Ontario, Canada;

5University of Washington, Seattle, Washington, USA;

6University of Denver, Denver, Colorado, USA;

7Yale University Medical Center, West Haven, Connecticut, USA;

8Mayo Clinic, Rochester, Minnesota, USA;

9University of Tennessee, Memphis, Tennessee;

10University of Rochester, Rochester, New York, USA;

11University of Arizona, Phoenix, Arizona, USA;

12University of Texas, Houston, Texas, USA;

13University of California, San Francisco, California, USA;

14Mercy Medical Center, Baltimore, Maryland, USA;

15Mayo Clinic, Scottsdale, Arizona, USA;

16Emory University Medical Center, Atlanta, Georgia, USA;

17University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Correspondence: Jasmohan S. Bajaj, MD. E-mail:

Portions of this manuscript were presented at the Plenary Oral Session at the European Association for the Study of Liver Diseases (EASL) Meeting in April 2018 and at the Digestive Disease Week 2018.

SUPPLEMENTARY MATERIAL accompanies this paper at and

Received July 21, 2018

Accepted November 07, 2018

© The American College of Gastroenterology 2019. All Rights Reserved.
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