2024 Top Story in Gastroenterology: Secondary Antibiotic Prophylaxis

Secondary antibiotic prophylaxis is the standard of care for patients with cirrhosis and ascites who develop spontaneous bacterial peritonitis (SBP) to reduce the risk of recurrent SBP.¹ Some studies leading to the recommendation for secondary SBP prophylaxis date back decades² before the shift to more gram-positive SBP infections and increases in antibiotic resistance.

Silvey et al retrospectively analyzed two national databases, one from the Veteran Affairs system and another consisting of non-veterans, with a total sample size of more than 11,000 to compare the rate of recurrent SBP between patients who received secondary prophylaxis and those who did not.³ Only about one-half of the patients who had SBP in both datasets were subsequently treated with prophylactic antibiotics. The results were quite similar in the two populations. In the multivariable analysis adjusting for relevant covariates, secondary prophylaxis was associated with a 63% to 68% increase in recurrent SBP over a 2-year period, and the risk of recurrence increased with time. Secondary prophylaxis was associated with fluoroquinolone resistance in a small subset of patients from the Veteran Affairs system for whom resistance data were available.

The findings regarding secondary SBP prophylaxis build on a previous study by Bajaj et al, which identified the risks associated with primary SBP prophylaxis.⁴ The current study highlights the importance of critically evaluating the risks and benefits of established practices as conditions evolve. If confirmed, the findings on secondary prophylaxis for SBP could have a significant impact on patient care.