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Prophylactic antibiotic use in cirrhotic patients with an upper GI bleed has been demonstrated to have a mortality benefit in multiple randomized clinical trials. Some trials as well demonstrated a decreased risk of rebleeding as well as a shorter hospital length of stay (1,2).
The exact means of protection is not entirely clear and its benefit is seen in both variceal and nonvariceal hemorrhages as well as in cirrhotic patient both with and without ascites.
There does appears to be a close interplay between cirrhosis bleeding risk and infection, with infection being a common precipitating factor for upper GI bleed.
The antibiotic of choice is ceftriaxone 1 gram IV daily for seven days. Although in case of allergy/intolerance, fluoroquinolones or aminoglycosides may be used as alternatives (3).
Bottom line:
All forms of upper GI hemorrhage in cirrhotic patients warrant prophylactic antibiotic use (regardless of the presence of ascites) as well as a diligent search and exclusion of possible infectious sources.
References
1. Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila FI, Soares-Weiser K, Uribe M. Antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2010 Sep 8;2010(9):CD002907. doi: 10.1002/14651858.CD002907.pub2. PMID: 20824832; PMCID: PMC7138054.
2. Wong YJ, Tan CK, Yii YL, et al. Antibiotic prophylaxis in cirrhosis patients with upper gastrointestinal bleeding: An updated systematic review and meta?analysis. Portal Hypertension & Cirrhosis. 2022;1(3):167-177. doi:10.1002/poh2.35
3. Sanchez?Jimenez B, Chavez?Tapia NC, Jakobsen JC, Nikolova D, Gluud C. Antibiotic prophylaxis for people with cirrhosis and variceal bleeding. Cochrane Database Syst Rev. 2018 Dec 4;2018(12):CD013214. doi: 10.1002/14651858.CD013214. PMCID: PMC6517118.