Written by Ketan Patel
Spoon Feed
In cirrhotic upper GI bleeding (UGIB) patients, guidelines recommending routine 5–7 days of prophylactic antibiotics did not lower mortality compared with shorter courses, or no antibiotics, in a contemporary Bayesian meta-analysis.
Bayesian analysis strikes a first blow to current standards
Despite entrenched guidelines recommending antibiotic prophylaxis for cirrhotic UGIB, recent studies have undermined the longstanding clinical benefit, perhaps due to advances in modern endoscopy, vasoactive treatments, restrictive transfusions, and rescue TIPS procedures. This study aims to reassess antibiotic prophylaxis considering newer evidence.
This study considered whether shorter (or no) antibiotics are noninferior to longer prophylaxis for cirrhotic UGIB. A systematic review and Bayesian meta-analysis of 14 RCTs (n=1,322 showed that shorter courses had a 97.3% probability of noninferiority for all-cause mortality (RD 0.9%; 95%CrI −2.6 to 4.9). Probability of noninferiority for early rebleeding was 73.8% (RD 2.9%; 95%CrI −4.2 to 10.0). Bacterial infections were more frequent with shorter or no prophylaxis (RD 15.2%; 95%CrI 5.0 to 25.9) across included trials, but definitions of infections were broad and poorly defined across studies.
Limitations abound, as study quality was moderate to poor. Most trials were unblinded. Definitions of infection and infection screening varied. Some outcomes were underpowered, adverse events were sparsely reported, and publication bias for mortality was detected. Rightly so, they concluded their findings are hypothesis-generating but do not overthrow current standards.
How does this change my practice?
It is hard to go against level A1 evidence and recommendations which have been widely accepted and incorporated in practice, including my own. This study shows the value of reassessing guidelines regularly as medicine modernizes and new evidence is added. Antibiotics are not without adverse effects, and I look forward to higher-quality evidence to discern the role of prophylaxis in this patient population.
Source
Prophylactic Antibiotics for Upper Gastrointestinal Bleeding in Patients With Cirrhosis: A Systematic Review and Bayesian Meta-Analysis. JAMA Intern Med. 2025 Aug 11:e253832. doi: 10.1001/jamainternmed.2025.3832. Epub ahead of print. PMID: 40788637; PMCID: PMC12340683.
