Journal of clinical and experimental hepatology · 2026
On-demand and Shorter Duration Versus Standard-duration Antibiotic Prophylaxis in Cirrhotic Patients With Variceal Bleeding: A Systematic Review and Meta-analysis.
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Bot Kimberly K I M, de Wit Koos, Remmelzwaal Sharon, Maan Raoel, Drenth Joost P H, Lantinga Marten A
Аннотация
BACKGROUND: The optimal duration of antibiotic prophylaxis in cirrhotic patients with variceal bleeding remains debated. Current guidelines (European Association for the Study of the Liver, American Association for the Study of Liver Disease, and Baveno VII) recommend 5-7 days of antibiotics, largely based on pre-2010 studies. While ceftriaxone reduces mortality, rebleeding, and infections, prolonged use may increase antimicrobial resistance, hospital length of stay, and costs. We evaluated whether shorter or on-demand antibiotic strategies are comparable to standard prophylaxis.
AIM: This systematic review and meta-analysis compared standard prophylaxis (5-7 days) with shorter (<5 days) or on-demand strategies. The primary outcomes were rebleeding and bacterial infections. The secondary outcomes included length of stay, infection subtypes, bilirubin at admission, and all-cause mortality.
RESULTS: Thirteen studies including 2194 patients were analysed; 10 were randomised controlled trials, and three were retrospective studies. Heterogeneity was high (I 2 >50%). The pooled odds ratio in favour of standard treatment strategies was 1.22 (95% confidence interval [CI]: 0.64-2.32) for rebleeding and 1.53 (95% CI 0.66-3.54) for bacterial infections. Recent studies reported lower risk estimates than earlier studies. Meta-regression showed a downward trend in infection risk over time (P ≤ 0.0001). The secondary outcomes did not differ significantly.
CONCLUSION: Although pooled estimates numerically favoured standard prophylaxis, recent evidence suggests that alternative strategies may be as effective. While this generates the hypothesis that current guideline recommendations may no longer reflect modern practice, the prevailing uncertainty emphasises the need for new and adequately powered randomised trials before clinical practice can be definitively altered.
AIM: This systematic review and meta-analysis compared standard prophylaxis (5-7 days) with shorter (<5 days) or on-demand strategies. The primary outcomes were rebleeding and bacterial infections. The secondary outcomes included length of stay, infection subtypes, bilirubin at admission, and all-cause mortality.
RESULTS: Thirteen studies including 2194 patients were analysed; 10 were randomised controlled trials, and three were retrospective studies. Heterogeneity was high (I 2 >50%). The pooled odds ratio in favour of standard treatment strategies was 1.22 (95% confidence interval [CI]: 0.64-2.32) for rebleeding and 1.53 (95% CI 0.66-3.54) for bacterial infections. Recent studies reported lower risk estimates than earlier studies. Meta-regression showed a downward trend in infection risk over time (P ≤ 0.0001). The secondary outcomes did not differ significantly.
CONCLUSION: Although pooled estimates numerically favoured standard prophylaxis, recent evidence suggests that alternative strategies may be as effective. While this generates the hypothesis that current guideline recommendations may no longer reflect modern practice, the prevailing uncertainty emphasises the need for new and adequately powered randomised trials before clinical practice can be definitively altered.