Antibiotics for GI bleeds

[gro2001]

I recently got a chance to review the literature on prophylactic antibiotics for cirrhotics with upper GI bleeds, and it surprised me just how great the effect is. In retrospect, what's even more surprising is that of all the things that are drummed in to us in regards to GI bleed, this isn't one of them (at least in my n=1). The GI folks regularly froth at the mouth if I haven't started a nexium drip promptly, but no one has ever given me a hard time for not starting antibiotics on a cirrhotic with GI bleed before they go up...

...so, what are your practices? Antibiotics for cirrhotics with GI bleed: always, sometimes, never (in reality, not what 'should' happen)?

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[docB]

I voted never but it's because I've never heard of doing it. I have some reading to do.

 

[EctopicFetus]

http://www.uphs.upenn.edu/bugdrug/antibiotic_manual/gi.htm

SBP prophylaxis during an active GI bleed (in patients with ESLD)


norfloxacin 400mg PO q12h



If unable to take oral medications

levofloxacin 500mg IV q24h


Duration = 7 days

After a 7 day course, patient may receive prophylaxis with norfloxacin 400mg PO q24h.

http://www.scielo.br/pdf/bjid/v6n5/v6n5a09.pdf

http://www.cghjournal.org/article/S1542-3565(08)01251-2/abstract

 

[xaelia]

Abx for cirrhotics save far more lives than any of the worthless drips.

http://www.thennt.com/antibiotics-for-cirrhotics-with-upper-gi-bleeds/

 

[gro2001]

I voted never but it's because I've never heard of doing it. I have some reading to do.

You are not alone. Also, I suspect that even among people who know/have heard that it's a good idea, since it's not as reinforced as some of the other practices, many don't actually do it that often in practice.

Abx for cirrhotics save far more lives than any of the worthless drips.

Right! Mind = Blown.

 

[MackandBlues]

You are supposed to treat empiric SBP when you have a cirrhosis patient that's having a GI bleed. Ceftriaxone 2g q24 works great. Could consider switching to cefepime if recently hospitalized. Also have to consider allergies of course.

 

[Hamhock]

I was taught to use Cipro in residency and was told there is strong data out there, but I have not gone through it all personally. (have seen some summary slides)

At my current shop, folks use ceftriaxone.

HH

 

[justaregularmed]

Does anyone else realize the irony about the risk of c.diff in the patient getting that PPI and a fluoroquinolone...

The numbers are making my head hurt.

see -> http://www.jfponline.com/Pages.asp?AID=9862

vs

http://www.thennt.com/antibiotics-for-cirrhotics-with-upper-gi-bleeds/

**Found a new number that the mortality from c.diff may be as high as 6%.

 

[gro2001]

Does anyone else realize the irony about the risk of c.diff in the patient getting that PPI and a fluoroquinolone...

The numbers are making my head hurt.

see -> http://www.jfponline.com/Pages.asp?AID=9862

vs

http://www.thennt.com/antibiotics-for-cirrhotics-with-upper-gi-bleeds/

Although hard to dredge up c.diff has a rough mortality rate of 2% from what I see.

To be honest the risk of c diff did not really cross my mind. I think that at least in this very special population (cirrhotics with UGIB), who are a set up for lots of bad infections, the benefit probably outweighs the risk.

 

[justaregularmed]

To be honest the risk of c diff did not really cross my mind. I think that at least in this very special population (cirrhotics with UGIB), who are a set up for lots of bad infections, the benefit probably outweighs the risk.

Well in the wonderful future of our current healthcare reform you just wont get paid or get paid less when your patient gets c.diff but at least they didn't die.

I'm just thinking about this. Give patient ABX to prevent death from SBP. Patient gets c.diff later in the hospital, results in a ding in quality score, patient dies of c. diff, they not only got a nosocomial infection, they died of it. Who's to blame?

 

[Cerberus]

I've never heard of this either (and I see A LOT of GI bleeds). Interesting.

 

[Rendar5]

Recommendations are Ceftriaxone or Cipro as that's what's been studied, but there aren't any documented inferior choices. Also, it's not quite clear last time I did the reading what you're attempting to treat. I don't believe it's been established why antibiotics have such a great mortality benefit, only theorized.

 

[TysonCook]

We do Rocephin for all cirrhotic GI Bleeds. Agree on the NNT for Protonix (not using it, although GI just starts it themselves). I've not seen too much on the C. Diff part, will have to read.

 

[alphaholic06]

Abx for cirrhotics save far more lives than any of the worthless drips.

http://www.thennt.com/antibiotics-for-cirrhotics-with-upper-gi-bleeds/

This is way I always give antibiotics.

 

[Tiger26]

I also do it based on the NNT, however, I likewise am somewhat unsure about the mechanism of why it actually helps

 

[wooster201106]

Antibiotic prophylaxis for variceal hemorrhage in cirrhotic patients has been considered the standard-of-care for several years and is based on practice guidelines issued by the AASLD/ACG. For anyone interested, I've posted a link below to the original AASLD paper published in 2007. Skip to page 8 for the guidelines on management of cirrhotics with acute variceal hemorrhage.


http://www.aasld.org/practiceguidelines/Documents/Bookmarked%20Practice%20Guidelines/Prevention%20and%20Management%20of%20Gastro%20Varices%20and%20Hemorrhage.pdf

The shorter version can be found here:

http://guidelines.gov/content.aspx?id=11370#Section420



For those that don't want to bother with either, the Cliffs Notes version for acute management:

1. Acute gastrointestinal (GI) hemorrhage in a patient with cirrhosis is an emergency that requires prompt attention with intravascular volume support and blood transfusions, being careful to maintain a hemoglobin of ~8 g/dL (Class I, Level B).
2. Short-term (maximum 7 days) antibiotic prophylaxis should be instituted in any patient with cirrhosis and GI hemorrhage (Class I, Level A). Oral norfloxacin (400 mg twice a day [BID]) or intravenous ciprofloxacin (in patients in whom oral administration is not possible) is the recommended antibiotic (Class I, Level A). In patients with advanced cirrhosis intravenous ceftriaxone (1 g/day) may be preferable particularly in centers with a high prevalence of quinolone-resistant organisms (Class I, Level B).
3. Pharmacological therapy (somatostatin or its analogues octreotide and vapreotide; terlipressin) should be initiated as soon as variceal hemorrhage is suspected and continued for 3 to 5 days after diagnosis is confirmed (Class I, Level A).

...Also, it's not quite clear last time I did the reading what you're attempting to treat. I don't believe it's been established why antibiotics have such a great mortality benefit, only theorized.

"...Cirrhotic patients with upper GI bleeding have a high risk of developing severe bacterial infections (spontaneous bacterial peritonitis and other infections) that are associated with early recurrence of variceal hemorrhage and a greater mortality...The use of short-term prophylactic antibiotics in patients with cirrhosis and GI hemorrhage with or without ascites has been shown not only to decrease the rate of bacterial infections but also to increase survival. This improved survival is partly related to a decrease in the incidence of early rebleeding in patients with variceal hemorrhage who
receive prophylactic antibiotics.

Therefore, short-term antibiotic prophylaxis should be considered standard practice in all patients with cirrhosis and acute variceal hemorrhage. The recommended antibiotic schedule is norfloxacin administered orally at a dose of 400 mg BID for 7 days. The rationale behind the oral administration of norfloxacin, a poorly absorbed quinolone, is the selective eradication (or at least reduction) of gram-negative bacteria in the gut, the source of bacteria..."



Liver disease severity (Child classification), whether the patient is already taking abx ppx at the time of the bleed, and high-prevalence of quinolone-resistance at some centers may mitigate the above recommendations.

 

[Venko]

We provide ABs for these patients, but have no set protocol. The 2010 cochrane review on antibiotics for cirrhotics with UGI bleeding concluded that there was a significant reduction in all cause mortality with administration of antibiotics for these patients but did not find it linked to any particular type of antibiotic.

I know its based on some older and weaker literature but in patients with significant uremia (many GI bleed patients), I consider giving DDAVP as well to minimize the effects of platelet dysfunction. Just another topic for debate...

TL

 

[deleted65604]

Rearranging the chairs on the Titanic. Cirrhotics with varices are doomed anyway.

 

[deleted109597]

Rearranging the chairs on the Titanic. Cirrhotics with varices are doomed anyway.

Talk like that will make this a core measure. You don't want the clipboard nurses from knowing you aren't doing everything do you?

 

[Apollyon]

Abx for cirrhotics save far more lives than any of the worthless drips.

http://www.thennt.com/antibiotics-for-cirrhotics-with-upper-gi-bleeds/

You shoot out this dogmatic statement...

[*]Pharmacological therapy (somatostatin or its analogues octreotide and vapreotide; terlipressin) should be initiated as soon as variceal hemorrhage is suspected and continued for 3 to 5 days after diagnosis is confirmed (Class I, Level A).

...then this kid puts up specifics. What ARE the "worthless drips" to which you refer? Honest question. I am all about improving my practice.

Not to attack you, but you also made a stark statement without further attribution that "2mg is not an appropriate starting dose for morphine." For those of us in practice, trained, experienced, and nuanced, we can interpret that. To a newly minted doctor, brand new, unsullied and untested, who hasn't yet really screwed up, this gives them the "bang" without the story that leads to it. It may be your style, but, then again...it's what you do.

Some youngster is going to think "Protonix - worthless!" or "Octreotide - worthless!", because they recall a one-line web posting with a (presumed) journal link/reference following, which "obviously" give it legitimacy.

The TL;DR: if you are going to make a clear statement that seems to stand against the common wisdom, put some meat on the bones.

 

[WilcoWorld]

I voted "sometimes". Because I give them in all GIB patients with known or clinically obvious cirrhosis, but not in those patients without known cirrhosis or obvious jaundice. I only give octreotide in those with known varices, or if they're so sick that I'd give the kitchen sink if I had it in IVP form.

 

[xaelia]

You shoot out this dogmatic statement...

...then this kid puts up specifics. What ARE the "worthless drips" to which you refer? Honest question. I am all about improving my practice.

2010 Cochrane review of PPI - no clinically important benefit:
http://www.ncbi.nlm.nih.gov/pubmed/20614440

2008 Cochrane review of octreotide - no clinically important benefit:
http://www.ncbi.nlm.nih.gov/pubmed/18677774

2003 Cochrane review of terlipressin, which is not available in the United States - benefit:
http://www.ncbi.nlm.nih.gov/pubmed/12535432

My statement should probably be amended to "worthless drips available in the U.S." I am not terribly familiar with terlipressin, since it's not used here.

Not saying Cochrane reviews are the perfect, unbiased vehicle upon which to draw conclusions, but not much better out there. theNNT.com cites them in their conclusions for PPI and octreotide. In a crashing patient, if there's no proven benefit for a treatment, then treatment only exposes them to harms.

 

[Apollyon]

It's good to know - but that abuts the GI guys who come after us. When I was a resident, the IM guys/women would use studies only when they helped them, but would discount them if the study didn't serve their purposes.

What I mean is that I can tell GI that the Protonix doesn't do anything, but that won't change a complaint to my director if I can order it, and affirmatively choose not to do so.

 

[gro2001]

It's good to know - but that abuts the GI guys who come after us. When I was a resident, the IM guys/women would use studies only when they helped them, but would discount them if the study didn't serve their purposes.

What I mean is that I can tell GI that the Protonix doesn't do anything, but that won't change a complaint to my director if I can order it, and affirmatively choose not to do so.

I also order it just to avoid the inevitable argument. The surprising thing is that they don't seem to make nearly as big a deal about the antibiotics, which have much more convincing evidence behind them.

 

[deleted109597]

What I mean is that I can tell GI that the Protonix doesn't do anything, but that won't change a complaint to my director if I can order it, and affirmatively choose not to do so.

So if and when that complaint comes to your director, and he asks you why you do what you do, show him the data. And if he says something flippant like "do what they say", then actively start looking for another job.
I'm sorry so many of you apparently work at places where you can't decide what you do and don't do. NPs can do what they're told without thinking.

 

[Zanegray]

Rearranging the chairs on the Titanic. Cirrhotics with varices are doomed anyway.

Bleeding varices at that!

 

[EM2BE]

I'm doing one of these articles for Journal Club. I had never heard of this, and it will likely change practice. Reading the articles now.

 

[leviathan]

On GI right now, they've stressed that abx has the best evidence of all interventions. And for the record, it's ALL upper GI bleeds, not just variceal bleeds. So even though you're probably dealing with varices in most of your cirrhotic patients, it's still indicated for PUD or other sources. Basically the theory is that blood acts as a medium for the bacteria and raises their risk of translocation / SBP.

 

[gro2001]

On GI right now, they've stressed that abx has the best evidence of all interventions. And for the record, it's ALL upper GI bleeds, not just variceal bleeds. So even though you're probably dealing with varices in most of your cirrhotic patients, it's still indicated for PUD or other sources. Basically the theory is that blood acts as a medium for the bacteria and raises their risk of translocation / SBP.

Like, mallory weiss too? Can you point to literature that shows it to be beneficial for non variceal upper GI bleeding?

 

[leviathan]

Like, mallory weiss too? Can you point to literature that shows it to be beneficial for non variceal upper GI bleeding?

If you have access to UpToDate there's lots of articles cited under the article Approach to acute upper gastrointestinal bleeding in adults. The source of blood isn't the issue, it's just the presence of it in the GI tract where bacteria will start to flourish and then lead to infections.