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Tao Z, Pu W, Guo Y, Zhang Y, Tang X, Hou Y, Hu D, Chen J, Yang J, Du Z, Li S, Feng S. Antibiotic prophylaxis vs. on‑demand antibiotic treatment in endoscopic therapy for variceal hemorrhage: A meta‑analysis of randomized controlled trials. Exp Ther Med 2024; 28:340. [PMID: 39006450 PMCID: PMC11240267 DOI: 10.3892/etm.2024.12629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 04/10/2024] [Indexed: 07/16/2024] Open
Abstract
The aim of the present study was to conduct a meta-analysis for elucidating the effects of antibiotic prophylaxis on infection, rebleeding and mortality in patients who underwent endoscopic therapy for variceal hemorrhage. Articles on antibiotic prophylaxis and on-demand antibiotic administration following endoscopic therapy for acute variceal bleeding were searched on PubMed, Embase and Cochrane Library between January 1959 and February 2024, to elucidate whether the use of prophylactic antibiotics was necessary. The quality of randomized controlled trials (RCTs) was assessed using the Cochrane risk-of-bias assessment tool and RevMan software version 5.4.1 was used for meta-analysis of the data. The current meta-analysis included four RCTs and 322 patients with acute variceal bleeding who underwent endoscopic therapy. All included studies were of high quality according to the Cochrane risk-of-bias assessment tool. According to the results of the meta-analysis, the incidence of infection in the prophylactic antibiotic group was significantly lower than that in the on-demand group [odds ratio (OR), 0.31; 95% confidence interval (CI), 0.13-0.74; P=0.009]. The prophylactic antibiotic group also exhibited a lower incidence of rebleeding compared with that of the on-demand group (OR, 0.37; 95% CI, 0.19-0.72; P=0.003). No significant differences were noted in the incidence of mortality between the two groups (OR, 0.92; 95% CI, 0.45-1.92; P=0.83). In conclusion, the data indicated that antibiotic prophylaxis is recommended to be used in patients who have undergone endoscopic therapy for variceal hemorrhage.
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Affiliation(s)
- Zhang Tao
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China
| | - Wenfeng Pu
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China
| | - Yuhong Guo
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China
| | - Yan Zhang
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China
| | - Xiaobo Tang
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China
| | - Ying Hou
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China
| | - Dan Hu
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China
| | - Jian Chen
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China
| | - Juan Yang
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China
| | - Zhonghan Du
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China
| | - Siqing Li
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China
| | - Shenggang Feng
- Department of Gastroenterology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, Sichuan 637000, P.R. China
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Xu Z, Zhang X, Chen J, Shi Y, Ji S. Bacterial Infections in Acute-on-chronic Liver Failure: Epidemiology, Diagnosis, Pathogenesis, and Management. J Clin Transl Hepatol 2024; 12:667-676. [PMID: 38993512 PMCID: PMC11233977 DOI: 10.14218/jcth.2024.00137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/05/2024] [Accepted: 05/27/2024] [Indexed: 07/13/2024] Open
Abstract
Acute-on-chronic liver failure (ACLF) is a distinct condition characterized by the abrupt exacerbation of pre-existing chronic liver disease, often leading to multi-organ failures and significant short-term mortalities. Bacterial infection is one of the most frequent triggers for ACLF and a common complication following its onset. The impact of bacterial infections on the clinical course and outcome of ACLF underscores their critical role in the pathogenesis of systemic inflammation and organ failures. In addition, the evolving epidemiology and increasing prevalence of multidrug-resistant bacteria in cirrhosis and ACLF highlight the importance of appropriate empirical antibiotic use, as well as accurate and prompt microbiological diagnosis. This review provided an update on recent advances in the epidemiology, diagnosis, pathogenesis, and management of bacterial infections in ACLF.
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Affiliation(s)
- Zhaoyu Xu
- China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Xiuding Zhang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jiyang Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yu Shi
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Shangwei Ji
- Department of Infectious Diseases, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
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Aguirre-Villarreal D, García-Juárez I. Navigating the controversy regarding antibiotic prophylaxis in acute variceal bleeding. World J Gastroenterol 2024; 30:2485-2487. [PMID: 38764763 PMCID: PMC11099386 DOI: 10.3748/wjg.v30.i18.2485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 03/08/2024] [Accepted: 04/16/2024] [Indexed: 05/11/2024] Open
Abstract
Antibiotic prophylaxis in patients with cirrhosis and acute variceal bleeding is part of the standard of care according to most clinical guidelines. However, with recent evidence arguing against antibiotic prophylaxis, the role of this intervention has become less clear.
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Affiliation(s)
- David Aguirre-Villarreal
- Department of Gastroenterology and Liver Transplant Unit, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Ignacio García-Juárez
- Department of Gastroenterology and Liver Transplant Unit, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
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Ichita C, Goto T, Okada Y, Uojima H, Iwagami M, Sasaki A, Shimizu S. Development and validation of a scoring system for in-hospital mortality following band ligation in esophageal variceal bleeding. Dig Endosc 2024. [PMID: 38462957 DOI: 10.1111/den.14773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/29/2024] [Indexed: 03/12/2024]
Abstract
OBJECTIVES We aimed to develop and validate a simple scoring system to predict in-hospital mortality after endoscopic variceal ligation (EVL) for esophageal variceal bleeding. METHODS Data from a 13-year study involving 46 Japanese institutions were split into development (initial 7 years) and validation (last 6 years) cohorts. The study subjects were patients hospitalized for esophageal variceal bleeding and treated with EVL. Variable selection was performed using least absolute shrinkage and selection operator regression, targeting in-hospital all-cause mortality as the outcome. We developed the Hospital Outcome Prediction following Endoscopic Variceal Ligation (HOPE-EVL) score from β coefficients of multivariate logistic regression and assessed its discrimination and calibration. RESULTS The study included 980 patients: 536 in the development cohort and 444 in the validation cohort. In-hospital mortality was 13.6% and 10.1% for the respective cohorts. The scoring system used five variables: systolic blood pressure (<80 mmHg: 2 points), Glasgow Coma Scale (≤12: 1 point), total bilirubin (≥5 mg/dL: 1 point), creatinine (≥1.5 mg/dL: 1 point), and albumin (<2.8 g/dL: 1 point). The risk groups (low: 0-1, middle: 2-3, high: ≥4) in the validation cohort corresponded to observed and predicted mortality probabilities of 2.0% and 2.5%, 19.0% and 22.9%, and 57.6% and 71.9%, respectively. In this cohort, the HOPE-EVL score demonstrated excellent discrimination ability (area under the curve [AUC] 0.890; 95% confidence interval [CI] 0.850-0.930) compared with the Model for End-stage Liver Disease score (AUC 0.853; 95% CI 0.794-0.912) and the Child-Pugh score (AUC 0.798; 95% CI 0.727-0.869). CONCLUSIONS The HOPE-EVL score practically and effectively predicts in-hospital mortality. This score could facilitate the appropriate allocation of resources and effective communication with patients and their families.
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Affiliation(s)
- Chikamasa Ichita
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kanagawa, Japan
- Department of Health Data Science, Yokohama City University, Kanagawa, Japan
| | - Tadahiro Goto
- Department of Health Data Science, Yokohama City University, Kanagawa, Japan
- TXP Research, TXP Medical Co., Ltd, Tokyo, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Yohei Okada
- Department of Preventive Services, Graduate School of Medicine, Kyoto University, Kyoto, Japan
- Health Services and Systems Research, Duke-NUS Medical School, Singapore City, Singapore
| | - Haruki Uojima
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kanagawa, Japan
- Department of Genome Medical Sciences Project, Research Institute, National Center for Global Health and Medicine, Chiba, Japan
| | - Masao Iwagami
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Chiba, Japan
| | - Akiko Sasaki
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kanagawa, Japan
| | - Sayuri Shimizu
- Department of Health Data Science, Yokohama City University, Kanagawa, Japan
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Wong YJ, Teng M, Sim A, Thet HM, Teoh X, De Roza MA, Sen Kew G, Koh JH, Loi PL, Lim K, Kang G, Kuang J, Low EXS, Ho JL, Cher LYG, Sze K, Wong GW, Kwek BYA, Yang WL, Abraldes JG, Chang J. Full adherence to cirrhosis quality indicators is associated with lower mortality in acute variceal bleeding: Nationwide audit. Hepatology 2024:01515467-990000000-00764. [PMID: 38381716 DOI: 10.1097/hep.0000000000000793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 01/23/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND AND AIMS Acute variceal bleeding (AVB) is a major complication in patients with cirrhosis. Using a nationwide AVB audit, we performed a nested cohort study to determine whether full adherence to the AVB quality indicator (QI) improves clinical outcomes in patients with cirrhosis and AVB. APPROACH AND RESULTS We assessed real-world adherence to AVB QI among patients with cirrhosis admitted for AVB in all public hospitals in Singapore between January 2015 and December 2020. Full adherence was considered when all 5 QIs were fulfilled: prophylactic antibiotics, vasoactive agents, timely endoscopy, endoscopic hemostasis during index endoscopy, and nonselective beta-blockers after AVB. We compare 6-week mortality between the full adherence and suboptimal adherence groups using a propensity-matched cohort.A total of 989 patients with AVB were included. Full adherence to all AVB QI was suboptimal (56.5%). Analysis of the propensity-matched cohort with comparable baseline characteristics showed that full adherence was associated with a lower risk of early infection (20.0% vs. 26.9%), early rebleeding (5.2% vs. 10.2%), and mortality at 6 weeks (8.2% vs. 19.7%) and 1 year (21.3% vs. 35.4%) ( p <0.05 for all). While full adherence was associated with a lower 6-week mortality regardless of the MELD score, nonadherence was associated with a higher 6-week mortality despite a lower predicted risk of 6-week mortality. Despite high adherence to the recommended process measures, patients with CTP-C remain at a higher risk of rebleeding, 6-week and 1-year mortality. CONCLUSIONS Full adherence to the AVB QI should be the target for quality improvement in patients with cirrhosis.
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Affiliation(s)
- Yu Jun Wong
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore
- Duke-NUS Academic Clinical Program, SingHealth, Singapore
- Liver unit, Division of Gastroenterology & Hepatology, University of Alberta, Canada
| | - Margaret Teng
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore
| | - Alyssa Sim
- Department of Gastroenterology & Hepatology, Tan Tock Seng General Hospital, Singapore
| | - Htay Myat Thet
- Department of Medicine, Division of Gastroenterology & Hepatology, Ng Teng Fong Hospital, Singapore
| | - Xuhui Teoh
- Department of General Medicine, Division of Gastroenterology, Khoo Teck Puat Hospital, Singapore
| | | | - Guan Sen Kew
- Department of Medicine, Woodlands Health, Singapore
| | - Jia Hong Koh
- Division of Gastroenterology and Hepatology, National University Hospital, Singapore
| | - Pooi Ling Loi
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| | - Kai Lim
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
| | - Garrett Kang
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore
| | - Jonathan Kuang
- Department of Gastroenterology & Hepatology, Tan Tock Seng General Hospital, Singapore
| | - En Xian Sarah Low
- Department of Medicine, Division of Gastroenterology & Hepatology, Ng Teng Fong Hospital, Singapore
| | | | - Liu Yuan Gabriel Cher
- Department of General Medicine, Division of Gastroenterology, Khoo Teck Puat Hospital, Singapore
| | - Kenny Sze
- Department of General Medicine, Division of Gastroenterology, Khoo Teck Puat Hospital, Singapore
| | - Guan Wee Wong
- Department of Medicine, Division of Gastroenterology & Hepatology, Ng Teng Fong Hospital, Singapore
| | - Boon Yew Andrew Kwek
- Department of Gastroenterology & Hepatology, Changi General Hospital, Singapore
- Duke-NUS Academic Clinical Program, SingHealth, Singapore
| | - Wei Lyn Yang
- Department of Gastroenterology & Hepatology, Tan Tock Seng General Hospital, Singapore
| | - Juan G Abraldes
- Liver unit, Division of Gastroenterology & Hepatology, University of Alberta, Canada
| | - Jason Chang
- Duke-NUS Academic Clinical Program, SingHealth, Singapore
- Department of Gastroenterology & Hepatology, Singapore General Hospital, Singapore
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Ichita C, Goto T, Shimizu S. Considerations for evaluating antibiotic prophylaxis in cirrhotic patients with upper gastrointestinal bleeding in real-world data. J Gastroenterol 2024; 59:160-161. [PMID: 38112796 DOI: 10.1007/s00535-023-02066-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 12/05/2023] [Indexed: 12/21/2023]
Affiliation(s)
- Chikamasa Ichita
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, 1370-1, Okamoto, Kamakura, Kanagawa, 247-8533, Japan.
- Department of Health Data Science, Yokohama City University, 22-2, Seto, Kanazawa-ku, Yokohama, Kanagawa, 236-0027, Japan.
| | - Tadahiro Goto
- Department of Health Data Science, Yokohama City University, 22-2, Seto, Kanazawa-ku, Yokohama, Kanagawa, 236-0027, Japan
- TXP Medical Co., Ltd., 41-1 H1O Kanda 706, Kanda Higashimatsushita-cho, Chiyoda-ku, Tokyo, 101-0042, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Sayuri Shimizu
- Department of Health Data Science, Yokohama City University, 22-2, Seto, Kanazawa-ku, Yokohama, Kanagawa, 236-0027, Japan
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Ueno M, Fujiwara T, Tokumasu H, Mizuno M. Reply to "Considerations for evaluating antibiotic prophylaxis in cirrhotic patients with upper gastrointestinal bleeding in real-world data". J Gastroenterol 2024; 59:162-163. [PMID: 38091120 DOI: 10.1007/s00535-023-02067-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 12/05/2023] [Indexed: 01/26/2024]
Affiliation(s)
- Masayuki Ueno
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki, Okayama, 710-8602, Japan.
- Department of Gastroenterology and Hepatology, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| | - Takashi Fujiwara
- Department of Public Health Research, Kurashiki Clinical Research Institute, Okayama, Japan
- Department of Otolaryngology/Head and Neck Surgery, Kurashiki Central Hospital, Okayama, Japan
| | - Hironobu Tokumasu
- Department of Public Health Research, Kurashiki Clinical Research Institute, Okayama, Japan
| | - Motowo Mizuno
- Department of Gastroenterology and Hepatology, Kurashiki Central Hospital, Miwa 1-1-1, Kurashiki, Okayama, 710-8602, Japan
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Ichita C, Shimizu S, Goto T, Haruki U, Itoh N, Iwagami M, Sasaki A. Effectiveness of antibiotic prophylaxis for acute esophageal variceal bleeding in patients with band ligation: A large observational study. World J Gastroenterol 2024; 30:238-251. [PMID: 38314133 PMCID: PMC10835525 DOI: 10.3748/wjg.v30.i3.238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Revised: 12/12/2023] [Accepted: 01/03/2024] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND Esophageal variceal bleeding is a severe complication associated with liver cirrhosis and typically necessitates endoscopic hemostasis. The current standard treatment is endoscopic variceal ligation (EVL), and Western guidelines recommend antibiotic prophylaxis following hemostasis. However, given the improvements in prognosis for variceal bleeding due to advancements in the management of bleeding and treatments of liver cirrhosis and the global concerns regarding the emergence of multidrug-resistant bacteria, there is a need to reassess the use of routine antibiotic prophylaxis after hemostasis. AIM To evaluate the effectiveness of antibiotic prophylaxis in patients treated for EVL. METHODS We conducted a 13-year observational study using the Tokushukai medical database across 46 hospitals. Patients were divided into the prophylaxis group (received antibiotics on admission or the next day) and the non-prophylaxis group (did not receive antibiotics within one day of admission). The primary outcome was composed of 6-wk mortality, 4-wk rebleeding, and 4-wk spontaneous bacterial peritonitis (SBP). The secondary outcomes were each individual result and in-hospital mortality. A logistic regression with inverse probability of treatment weighting was used. A subgroup analysis was conducted based on the Child-Pugh classification to determine its influence on the primary outcome measures, while sensitivity analyses for antibiotic type and duration were also performed. RESULTS Among 980 patients, 790 were included (prophylaxis: 232, non-prophylaxis: 558). Most patients were males under the age of 65 years with a median Child-Pugh score of 8. The composite primary outcomes occurred in 11.2% of patients in the prophylaxis group and 9.5% in the non-prophylaxis group. No significant differences in outcomes were observed between the groups (adjusted odds ratio, 1.11; 95% confidence interval, 0.61-1.99; P = 0.74). Individual outcomes such as 6-wk mortality, 4-wk rebleeding, 4-wk onset of SBP, and in-hospital mortality were not significantly different between the groups. The primary outcome did not differ between the Child-Pugh subgroups. Similar results were observed in the sensitivity analyses. CONCLUSION No significant benefit to antibiotic prophylaxis for esophageal variceal bleeding treated with EVL was detected in this study. Global reassessment of routine antibiotic prophylaxis is imperative.
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Affiliation(s)
- Chikamasa Ichita
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura 247-8533, Kanagawa, Japan
- Department of Health Data Science, Yokohama City University, Yokohama 236-0027, Kanagawa, Japan
| | - Sayuri Shimizu
- Department of Health Data Science, Yokohama City University, Yokohama 236-0027, Kanagawa, Japan
| | - Tadahiro Goto
- Department of Health Data Science, Yokohama City University, Yokohama 236-0027, Kanagawa, Japan
- TXP Research, TXP Medical Co., Ltd., Chiyoda-ku 101-0042, Tokyo, Japan
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Bunkyo-ku 113-0033, Tokyo, Japan
| | - Uojima Haruki
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura 247-8533, Kanagawa, Japan
- Department of Genome Medical Sciences Project, Research Institute, National Center for Global Health and Medicine, Ichikawa 272-8516, Chiba, Japan
| | - Naoya Itoh
- Division of Infectious Diseases, Aichi Cancer Center, Nagoya 464-8681, Aichi, Japan
| | - Masao Iwagami
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Tsukuba 305-8575, Ibaraki, Japan
| | - Akiko Sasaki
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura 247-8533, Kanagawa, Japan
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