JAMA Internal Medicine recently published a systematic review and Bayesian meta-analysis looking at the utility of prophylactic antibiotics in cirrhotics with acute upper GI bleeding

TLDR: shorter durations of antibiotics (including no antibiotics!) had a 97.3% probability of noninferiority for all-cause mortality

Additional Information

This meta-analysis and systematic review explored the practice of giving prophylactic antibiotics to patients with cirrhosis and upper GI bleeding, which is strongly recommended in the current guidelines.

14 RCTs were included in the analysis, with 1322 patients. Authors compared 1) any prophylaxis vs none; and 2) 5-7 duration vs 2-3 duration of third generation cephalosporins. 

-Shorter durations (including 0 days) had a 97.3% probability of noninferiority for all-cause mortality (RD 0.9%, 95%CrI -2.6 to 4.9). -

Secondary outcomes:

-Shorter durations had a 73.8% probability (RD 2.9%, 95%CrI -4.2 to 10) of noninferiority for early rebleeding (with substantial heterogenetity and low certainty of evidence)

-Shorter durations (especially 0 days) were associated with more study-defined infections (RD 15.2%, 95%CrI 5.0 to 25.9), probability not given.

Conclusions: 

The authors argue that existing evidency does not support a mortality benefit from 5-7 days of antibiotic prophylaxis, and they further point out that the current guidelines are not based on high-quality evidence. They suggest that shorter or no prophylaxis may be reasonable, but admit that high-quality, large, double-blinded RCTs could help support this conclusion. 

Fun Fact:

Annals also did a systematic review snapshot of this article: Arbab Z, Long B, Gottlieb M. Do Prophylactic Antibiotics Improve Outcomes in Patients With Cirrhosis and Upper Gastrointestinal Bleeding?. Ann Emerg Med. Published online December 9, 2025. doi:10.1016/j.annemergmed.2025.10.019

References

Prosty C, Noutsios D, Dubé LR, et al. Prophylactic Antibiotics for Upper Gastrointestinal Bleeding in Patients With Cirrhosis: A Systematic Review and Bayesian Meta-Analysis. JAMA Intern Med. 2025;185(10):1194-1203. doi:10.1001/jamainternmed.2025.3832

Arbab Z, Long B, Gottlieb M. Do Prophylactic Antibiotics Improve Outcomes in Patients With Cirrhosis and Upper Gastrointestinal Bleeding?. Ann Emerg Med. Published online December 9, 2025. doi:10.1016/j.annemergmed.2025.10.019