Clinical question: In the context of increasing antibiotic resistance and changing microbiology of Spontaneous Bacterial Peritonitis (SBP), does secondary SBP prophylaxis reduce the recurrence of SBP in patients with cirrhosis?
Background: The risk of SBP increases with advanced stages of cirrhosis and the development of ascites. SBP is associated with significant morbidity, mortality, and a high rate of recurrence. Over recent decades, the spectrum of bacteria causing SBP has shifted, and resistance rates have increased. This prompted the authors to re-evaluate the risks and benefits of secondary SBP prophylaxis.
Study design: Retrospective cohort study using two large national databases
Setting: Veterans Affairs (VA) and TriNetX community databases from 2009 to 2019
Synopsis: This trial created a VA cohort with 4,673 cirrhotic patients who survived their index SBP episode. 54.3% were started on secondary SBP prophylaxis (84% of those on fluoroquinolones). The majority were white males, with an average age of 61. 38% of patients had alcoholic cirrhosis with an average MELD-Na score of 18. They compared patients who received secondary SBP prophylaxis to those who did not, with time to SBP recurrence as the primary outcome over two years of follow-up. All-cause mortality and liver transplant rates were treated as competing risks. Overall, the cohort that received secondary SBP prophylaxis had higher baseline MELD-Na scores and Charlson Comorbidity Index, suggesting greater overall illness severity. Crude rates of SBP recurrence were 24.1% in those who received secondary SBP prophylaxis versus 13.7% in those who did not. On multivariable analysis, patients who received secondary SBP prophylaxis were more likely to develop SBP recurrence with a hazard ratio of 1.64 (1.40-1.91). Patients receiving SBP prophylaxis were more likely to receive a liver transplant, but this had no effect on all-cause mortality on multivariate analysis. The results from the TriNetX cohort (6,708 patients, but a more limited database) showed similar results on two-year follow-up with SBP recurrence in patients receiving secondary SBP prophylaxis with a hazard ratio of 1.68 (1.33-1.80) on multivariable adjustment.
Bottom line: In this retrospective analysis of more than 11,000 patients, patients who received secondary SBP prophylaxis had 64-68% higher rates of recurrent SBP. These results challenge the current guideline recommendation and suggest the need for reevaluation of this quality metric.
Citation: Silvey S, et al. Higher Rate of Spontaneous Bacterial Peritonitis Recurrence With Secondary Spontaneous Bacterial Peritonitis Prophylaxis Compared With No Prophylaxis in 2 National Cirrhosis Cohorts. Am J Gastroenterol. 2025;120(5):1066-1075. doi:10.14309/ajg.0000000000003075.
Dr. Badawy is an academic hospitalist at UT Health San Antonio and an associate professor/clinical in the division of internal medicine at Joe R. & Teresa Lozano Long School of Medicine.