AP-HP, service d'Hépato-gastroentérologie, Groupe hospitalier Pitié-Salpêtrière, 47 bd de l'hôpital, 75013, Paris, France
Patients with cirrhosis are at high risk of developing bacterial infections. Among them, spontaneous bacterial peritonitis (SBP) is the most specific, common and best studied. Risk factors for developing SBP have been clearly identified: (1) gastrointestinal hemorrhage; (2) low total protein levels in ascitic fluid (<15 g/L); (3) prior episodes of SBP. In these three situations, antibiotic prophylaxis is efficient and improves survival. In the setting of gastrointestinal hemorrhage, a seven-day oral course of norfloxacin (400 mg bid) improves re-bleeding rate and in-hospital survival. In patients with low protein levels in ascites, especially those with altered hepatic function or impaired renal function (who are at very high risk of developing SBP), norfloxacin (400 mg a day) reduces the incidence of SBP, delays the development of hepato-renal syndrom, and improves survival when compared to placebo. In patients with prior episodes of SBP, norfloxacin (400 mg a day) has been shown to decrease the 1-year probability of SBP occurrence. Prophylaxis should be continued forever or until liver transplantation or resolution of ascites. In those three situations, economic analysis studies have shown substantial cost savings. Although gastrointestinal endoscopy, by increasing bacteriemia, could be a risk factor for SBP occurrence, the incidence of SBP after colonoscopy or band ligation has not been studied so far. Thus, antibiotic prophylaxis should not be given in the setting of non emergency endoscopy. Further studies are needed to address this issue.