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      Limited effects of antibiotic prophylaxis in patients with Child–Pugh class A/B cirrhosis and upper gastrointestinal bleeding

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          Abstract

          Current guidelines recommend antibiotic prophylaxis for all patients with various degrees of cirrhosis and upper gastrointestinal (UGI) bleeding. This study assessed the need for antibiotic prophylaxis in patients with low Child–Pugh scores. We retrospectively screened all patients with cirrhosis who underwent upper endoscopies for UGI bleeding in a referral hospital in Taiwan between 2003 and 2014, from which 913 patients were enrolled after excluding patients with active bacterial infections, recent antibiotic use, early death, and Child–Pugh class C cirrhosis. Among them, 73 (8%) received prophylactic antibiotics, and 45 (4.9%) exhibited 14-day bacterial infection. Neither Child–Pugh score nor model for end stage liver disease score were optimal for predicting bacterial infection because their areas under the curves were 0.610 (95% confidence interval [CI]: 0.529–0.691) and 0.666 (95% CI: 0.591–0.742), respectively. Antibiotic prophylaxis did not reduce the risks of 14-day bacterial infection (relative risk [RR]: 0.932, 95% CI: 0.300–2.891, P = 0.902), 14-day rebleeding (RR: 0.791, 95% CI: 0.287–2.181, P = 0.650), or 42-day mortality (RR: 2.710, 95% CI: 0.769–9.524, P = 0.121). The results remained similar after propensity score adjustment. On-demand antibiotic treatment might suffice for patients with Child–Pugh class A/B cirrhosis and UGI bleeding.

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          Management of adult patients with ascites due to cirrhosis: an update.

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            Immune dysfunction and infections in patients with cirrhosis.

            Patients with cirrhosis are immunocompromised and susceptible to infections. Although detection and treatment of spontaneous bacterial peritonitis (SBP) have improved, overall survival rates have not increased greatly in recent decades-infection still increases mortality 4-fold among patients with cirrhosis. Hospitalized patients with cirrhosis have the highest risk of developing infections, especially patients with gastrointestinal (GI) hemorrhage. Bacterial infections occur in 32% to 34% of patients with cirrhosis who are admitted to the hospital and 45% of patients with GI hemorrhage. These rates are much higher than the overall rate of infection in hospitalized patients (5%-7%). The most common are SBP (25% of infections), urinary tract infection (20%), and pneumonia (15%). Bacterial overgrowth and translocation from the GI tract are important steps in the pathogenesis of SBP and bacteremia-these processes increase levels of endotoxins and cytokines that induce the inflammatory response and can lead to septic shock, multiorgan dysfunction, and death. A number of other bacterial and fungal pathogens are more common and virulent in patients with cirrhosis than in the overall population. We review the pathogenesis of infections in these patients, along with diagnostic and management strategies. Copyright © 2011 AGA Institute. Published by Elsevier Inc. All rights reserved.
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              Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding - an updated Cochrane review.

              Antibiotic prophylaxis seems to decrease the incidence of bacterial infections in patients with cirrhosis and upper gastrointestinal bleeding and is considered standard of care. However, there is no updated information regarding the effects of this intervention.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: ResourcesRole: Writing – original draft
                Role: ConceptualizationRole: Writing – original draft
                Role: Data curationRole: Formal analysis
                Role: Data curationRole: Formal analysisRole: InvestigationRole: Resources
                Role: Data curationRole: Formal analysisRole: InvestigationRole: Resources
                Role: ConceptualizationRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: InvestigationRole: Resources
                Role: ConceptualizationRole: Writing – review & editing
                Role: ConceptualizationRole: Writing – review & editing
                Role: ConceptualizationRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                21 February 2020
                2020
                : 15
                : 2
                : e0229101
                Affiliations
                [1 ] Department of Gastroenterology and Hepatology, Chang Gung Memorial Hospital, Chiayi, Taiwan
                [2 ] College of Medicine, Chang Gung University, Taoyuan, Taiwan
                [3 ] Department of Biochemistry and Molecular Cell Biology, College of Medicine, Taipei Medical University, Taipei, Taiwan
                [4 ] Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
                [5 ] Research Center for Cell Therapy and Regeneration Medicine, Taipei Medical University, Taipei, Taiwan
                [6 ] Division of Colon and Rectal Surgery, Department of Surgery, Chang Gung Memorial Hospital, Chiayi, Taiwan
                [7 ] Department of Traditional Chinese Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
                [8 ] Health Information and Epidemiology Laboratory of Chang Gung Memorial Hospital, Chiayi, Taiwan
                [9 ] Graduate Institute of Medical Sciences, College of Medicine, Taipei Medical University, Taipei, Taiwan
                [10 ] Center for Reproductive Medicine, Taipei Medical University Hospital, Taipei, Taiwan
                [11 ] Comprehensive Cancer Center of Taipei Medical University, Taipei, Taiwan
                [12 ] International PhD Program for Cell Therapy and Regeneration Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
                Epicentre, CAMEROON
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Author information
                http://orcid.org/0000-0001-6020-9998
                Article
                PONE-D-19-23985
                10.1371/journal.pone.0229101
                7034903
                32084186
                83146e55-db4b-4d28-9923-ee99cbc40476
                © 2020 Chang et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 25 August 2019
                : 29 January 2020
                Page count
                Figures: 2, Tables: 6, Pages: 16
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/100012553, Chang Gung Memorial Hospital;
                Award ID: CORPG6F0053
                Award Recipient :
                This work was supported by research grants from Chang Gung Memorial Hospital, Taiwan (CORPG6F0053) to TSC, and the Ministry of Science and Technology, Taiwan (MOST 106-2314-B-182-065 to TSC; MOST108-2314-B-038-006 and MOST108-2321-B-038-003 to YHH). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine and Health Sciences
                Diagnostic Medicine
                Signs and Symptoms
                Hemorrhage
                Medicine and Health Sciences
                Pathology and Laboratory Medicine
                Signs and Symptoms
                Hemorrhage
                Medicine and Health Sciences
                Vascular Medicine
                Hemorrhage
                Medicine and Health Sciences
                Public and Occupational Health
                Preventive Medicine
                Prophylaxis
                Antibiotic Prophylaxis
                Medicine and Health Sciences
                Gastroenterology and Hepatology
                Liver Diseases
                Cirrhosis
                Medicine and Health Sciences
                Pharmacology
                Drugs
                Antimicrobials
                Antibiotics
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                Microbial Control
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                Flaviviruses
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                Biology and life sciences
                Microbiology
                Medical microbiology
                Microbial pathogens
                Viral pathogens
                Hepatitis viruses
                Hepatitis C virus
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                Pathogens
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