Antibiotic Prophylaxis Does Not Prevent Hospital-Acquired Infection

Patients given long-term antibiotic prophylaxis at discharge had no differences in 6-month mortality those who did not receive antibiotics.

Approximately half of patients with decompensated cirrhosis are prescribed antibiotics despite lack of infection at baseline. However, antibiotic prophylaxis does not reduce the incidence of hospital-acquired infections nor improve 28-day mortality rates compared with patients not receiving antibiotics, according to study findings published in American Journal of Gastroenterology.

Researchers in the United Kingdom conducted  a trial in 35 hospitals across England, Wales, and Scotland and compared incidence of hospital-acquired infections in 777 patients with decompensated cirrhosis who received antibiotics (except rifaximin) vs those who did not.

Of the 777 participants admitted to the hospital with decompensated cirrhosis, 563 demonstrated no evidence of bacterial infection at baseline. The researchers excluded 11 patients who received rifaximin and prophylactic antibiotics prior to admission.

Out of the 563 participants without infection at baseline, 203 (36%) were prescribed antibiotics. Patients without infections accounted for half (49.8%) of all patients who initiated antibiotic treatment at baseline (203 of 408). The most frequently prescribed antibiotic treatments included piperacillin-tazobactam (33%), co-amoxiclav (25%), and ciprofloxacin (9.5%).

These data support a policy of prompt de-escalation or discontinuation of empirical antibiotics guided by culture sensitivities at 24–48 hours after commencement if no infection and an improving patient.

Among patients without initial bacterial infections, 39 patients in the antibiotic treatment group acquired hospital infections compared with 73 patients in the nonantibiotic treated group (19.2% vs. 20.3%; P =.83). The most common infections included respiratory (39%), spontaneous bacterial peritonitis (10%), urinary tract infections (8%), and skin/soft tissue infections (8%). Causative organisms included staphylococcal, enterococci, and Escherichia coli (7 each) with 4 coliforms.

Additionally, those treated with antibiotics demonstrated a significantly higher 28-day mortality rate compared with those in the non-treated group (P =.004); however, this trend did not continue at months 3 or 6. This reflected increased disease severity among participants treated with antibiotics.

Following a propensity-matched analysis, the researchers continued to observe similar trends in which antibiotic treatment did not significantly impact mortality or prevent hospital-acquired infections compared with nonantibiotic treatment among uninfected patients at baseline (P =.16).

Renal dysfunction remained similar regardless of treatment received.

Study limitations included lack of randomization, lack of assessment of other high-risk groups that might benefit from antibiotics, and lack of comprehensive collection of certain data, such as microbiology of infections, transplant listings, subsequent infections, ongoing alcohol consumption, or hospital readmissions after discharge.

The study authors conclude, “[C]onsistent analyses showed no overall beneficial impact on preventing HAI, nor renal dysfunction and no impact on survival. These data support a policy of prompt de-escalation or discontinuation of empirical antibiotics guided by culture sensitivities at 24–48 hours after commencement if no infection and an improving patient.”

References:

Kutmutia R, Tittanegro T, China L, et al. Evaluating the role of antibiotics in patients admitted to hospital with decompensated cirrhosis: Lessons from the ATTIRE trial. Am J Gastroenterol. Published online November 25, 2022. doi:10.14309/ajg.0000000000001937