Antibiotic treatment for spontaneous bacterial peritonitis in people with decompensated liver cirrhosis: a network meta-analysis

L Iogna Prat, Peter Wilson, S Freeman, A Sutton, N Cooper, D Roccarina, A Benmassaoud, MC Plaz Torres, N Hawkins, M Cowlin, EJ Milne, D Thorburn, C Pavlov, BR Davidson, E Tsochatzis, KS Gurusamy

Research output: Contribution to journalReview article

1 Citation (Scopus)

Abstract


Background

Approximately 2.5% of all hospitalisations in people with cirrhosis are for spontaneous bacterial peritonitis (SBP). Antibiotics, in addition to supportive treatment (fluid and electrolyte balance, treatment of shock), form the mainstay treatments of SBP. Various antibiotics are available for the treatment of SBP, but there is uncertainty regarding the best antibiotic for SBP.
Objectives

To compare the benefits and harms of different antibiotic treatments for spontaneous bacterial peritonitis (SBP) in people with decompensated liver cirrhosis.
Search methods

We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until November 2018 to identify randomised clinical trials on people with cirrhosis and SBP.
Selection criteria

We included only randomised clinical trials (irrespective of language, blinding, or publication status) in adults with cirrhosis and SBP. We excluded randomised clinical trials in which participants had previously undergone liver transplantation.
Data collection and analysis

Two review authors independently identified eligible trials and collected data. The outcomes for this review included mortality, serious adverse events, any adverse events, resolution of SBP, liver transplantation, and other decompensation events. We performed a network meta‐analysis with OpenBUGS using Bayesian methods and calculated the odds ratio, rate ratio, and hazard ratio with 95% credible intervals (CrIs) based on an available‐case analysis, according to the National Institute of Health and Care Excellence (NICE) Decision Support Unit guidance.
Main results

We included a total of 12 trials (1278 participants; 13 antibiotics) in the review. Ten trials (893 participants) were included in one or more outcomes in the review. The trials that provided the information included patients having cirrhosis with or without other features of decompensation of varied aetiologies. The follow‐up in the trials ranged from one week to three months. All the trials were at high risk of bias. Only one trial was included under each comparison for most of the outcomes. Because of these reasons, there is very low certainty in all the results. The majority of the randomised clinical trials used third‐generation cephalosporins, such as intravenous ceftriaxone, cefotaxime, or ciprofloxacin as one of the interventions.

Overall, approximately 75% of trial participants recovered from SBP and 25% of people died within three months. There was no evidence of difference in any of the outcomes for which network meta‐analysis was possible: mortality (9 trials; 653 participants), proportion of people with any adverse events (5 trials; 297 participants), resolution of SBP (as per standard definition, 9 trials; 873 participants), or other features of decompensation (6 trials; 535 participants). The effect estimates in the direct comparisons (when available) were very similar to those of network meta‐analysis. For the comparisons where network meta‐analysis was not possible, there was no evidence of difference in any of the outcomes (proportion of participants with serious adverse events, number of adverse events, and proportion of participants requiring liver transplantation). Due to the wide CrIs and the very low‐certainty evidence for all the outcomes, significant benefits or harms of antibiotics are possible.

None of the trials reported health‐related quality of life, number of serious adverse events, or symptomatic recovery from SBP.

Funding: the source of funding for two trials were industrial organisations who would benefit from the results of the trial; the source of funding for the remaining 10 trials was unclear.
Authors' conclusions

Short‐term mortality after SBP is about 25%. There is significant uncertainty about which antibiotic therapy is better in people with SBP.

We need adequately powered randomised clinical trials, with adequate blinding, avoiding post‐randomisation dropouts (or performing intention‐to‐treat analysis), and using clinically important outcomes, such as mortality, health‐related quality of life, and adverse events.
Original languageEnglish
Article numberCD013120
Number of pages67
JournalCochrane Database of Systematic Reviews
Volume2019
Issue number9
DOIs
Publication statusPublished - 16 Sep 2019

Fingerprint

Peritonitis
Liver Cirrhosis
Anti-Bacterial Agents
Randomized Controlled Trials
Therapeutics
Fibrosis
Liver Transplantation
Water-Electrolyte Balance
Mortality
Network Meta-Analysis
Uncertainty
Quality of Life
Bayes Theorem
Cefotaxime
Ceftriaxone
National Institutes of Health (U.S.)
Cephalosporins
Ciprofloxacin
MEDLINE
Registries

ASJC Scopus subject areas

  • Pharmacology (medical)

Cite this

Antibiotic treatment for spontaneous bacterial peritonitis in people with decompensated liver cirrhosis : a network meta-analysis. / Iogna Prat, L; Wilson, Peter; Freeman, S; Sutton, A; Cooper, N; Roccarina, D; Benmassaoud, A; Plaz Torres, MC; Hawkins, N; Cowlin, M; Milne, EJ; Thorburn, D; Pavlov, C; Davidson, BR; Tsochatzis, E; Gurusamy, KS.

In: Cochrane Database of Systematic Reviews, Vol. 2019, No. 9, CD013120, 16.09.2019.

Research output: Contribution to journalReview article

Iogna Prat, L, Wilson, P, Freeman, S, Sutton, A, Cooper, N, Roccarina, D, Benmassaoud, A, Plaz Torres, MC, Hawkins, N, Cowlin, M, Milne, EJ, Thorburn, D, Pavlov, C, Davidson, BR, Tsochatzis, E & Gurusamy, KS 2019, 'Antibiotic treatment for spontaneous bacterial peritonitis in people with decompensated liver cirrhosis: a network meta-analysis' Cochrane Database of Systematic Reviews, vol. 2019, no. 9, CD013120. https://doi.org/10.1002/14651858.CD013120.pub2
Iogna Prat, L ; Wilson, Peter ; Freeman, S ; Sutton, A ; Cooper, N ; Roccarina, D ; Benmassaoud, A ; Plaz Torres, MC ; Hawkins, N ; Cowlin, M ; Milne, EJ ; Thorburn, D ; Pavlov, C ; Davidson, BR ; Tsochatzis, E ; Gurusamy, KS. / Antibiotic treatment for spontaneous bacterial peritonitis in people with decompensated liver cirrhosis : a network meta-analysis. In: Cochrane Database of Systematic Reviews. 2019 ; Vol. 2019, No. 9.
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title = "Antibiotic treatment for spontaneous bacterial peritonitis in people with decompensated liver cirrhosis: a network meta-analysis",
abstract = "BackgroundApproximately 2.5{\%} of all hospitalisations in people with cirrhosis are for spontaneous bacterial peritonitis (SBP). Antibiotics, in addition to supportive treatment (fluid and electrolyte balance, treatment of shock), form the mainstay treatments of SBP. Various antibiotics are available for the treatment of SBP, but there is uncertainty regarding the best antibiotic for SBP.ObjectivesTo compare the benefits and harms of different antibiotic treatments for spontaneous bacterial peritonitis (SBP) in people with decompensated liver cirrhosis.Search methodsWe searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until November 2018 to identify randomised clinical trials on people with cirrhosis and SBP.Selection criteriaWe included only randomised clinical trials (irrespective of language, blinding, or publication status) in adults with cirrhosis and SBP. We excluded randomised clinical trials in which participants had previously undergone liver transplantation.Data collection and analysisTwo review authors independently identified eligible trials and collected data. The outcomes for this review included mortality, serious adverse events, any adverse events, resolution of SBP, liver transplantation, and other decompensation events. We performed a network meta‐analysis with OpenBUGS using Bayesian methods and calculated the odds ratio, rate ratio, and hazard ratio with 95{\%} credible intervals (CrIs) based on an available‐case analysis, according to the National Institute of Health and Care Excellence (NICE) Decision Support Unit guidance.Main resultsWe included a total of 12 trials (1278 participants; 13 antibiotics) in the review. Ten trials (893 participants) were included in one or more outcomes in the review. The trials that provided the information included patients having cirrhosis with or without other features of decompensation of varied aetiologies. The follow‐up in the trials ranged from one week to three months. All the trials were at high risk of bias. Only one trial was included under each comparison for most of the outcomes. Because of these reasons, there is very low certainty in all the results. The majority of the randomised clinical trials used third‐generation cephalosporins, such as intravenous ceftriaxone, cefotaxime, or ciprofloxacin as one of the interventions.Overall, approximately 75{\%} of trial participants recovered from SBP and 25{\%} of people died within three months. There was no evidence of difference in any of the outcomes for which network meta‐analysis was possible: mortality (9 trials; 653 participants), proportion of people with any adverse events (5 trials; 297 participants), resolution of SBP (as per standard definition, 9 trials; 873 participants), or other features of decompensation (6 trials; 535 participants). The effect estimates in the direct comparisons (when available) were very similar to those of network meta‐analysis. For the comparisons where network meta‐analysis was not possible, there was no evidence of difference in any of the outcomes (proportion of participants with serious adverse events, number of adverse events, and proportion of participants requiring liver transplantation). Due to the wide CrIs and the very low‐certainty evidence for all the outcomes, significant benefits or harms of antibiotics are possible.None of the trials reported health‐related quality of life, number of serious adverse events, or symptomatic recovery from SBP.Funding: the source of funding for two trials were industrial organisations who would benefit from the results of the trial; the source of funding for the remaining 10 trials was unclear.Authors' conclusionsShort‐term mortality after SBP is about 25{\%}. There is significant uncertainty about which antibiotic therapy is better in people with SBP.We need adequately powered randomised clinical trials, with adequate blinding, avoiding post‐randomisation dropouts (or performing intention‐to‐treat analysis), and using clinically important outcomes, such as mortality, health‐related quality of life, and adverse events.",
author = "{Iogna Prat}, L and Peter Wilson and S Freeman and A Sutton and N Cooper and D Roccarina and A Benmassaoud and {Plaz Torres}, MC and N Hawkins and M Cowlin and EJ Milne and D Thorburn and C Pavlov and BR Davidson and E Tsochatzis and KS Gurusamy",
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day = "16",
doi = "10.1002/14651858.CD013120.pub2",
language = "English",
volume = "2019",
journal = "The Cochrane Library",
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TY - JOUR

T1 - Antibiotic treatment for spontaneous bacterial peritonitis in people with decompensated liver cirrhosis

T2 - a network meta-analysis

AU - Iogna Prat, L

AU - Wilson, Peter

AU - Freeman, S

AU - Sutton, A

AU - Cooper, N

AU - Roccarina, D

AU - Benmassaoud, A

AU - Plaz Torres, MC

AU - Hawkins, N

AU - Cowlin, M

AU - Milne, EJ

AU - Thorburn, D

AU - Pavlov, C

AU - Davidson, BR

AU - Tsochatzis, E

AU - Gurusamy, KS

PY - 2019/9/16

Y1 - 2019/9/16

N2 - BackgroundApproximately 2.5% of all hospitalisations in people with cirrhosis are for spontaneous bacterial peritonitis (SBP). Antibiotics, in addition to supportive treatment (fluid and electrolyte balance, treatment of shock), form the mainstay treatments of SBP. Various antibiotics are available for the treatment of SBP, but there is uncertainty regarding the best antibiotic for SBP.ObjectivesTo compare the benefits and harms of different antibiotic treatments for spontaneous bacterial peritonitis (SBP) in people with decompensated liver cirrhosis.Search methodsWe searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until November 2018 to identify randomised clinical trials on people with cirrhosis and SBP.Selection criteriaWe included only randomised clinical trials (irrespective of language, blinding, or publication status) in adults with cirrhosis and SBP. We excluded randomised clinical trials in which participants had previously undergone liver transplantation.Data collection and analysisTwo review authors independently identified eligible trials and collected data. The outcomes for this review included mortality, serious adverse events, any adverse events, resolution of SBP, liver transplantation, and other decompensation events. We performed a network meta‐analysis with OpenBUGS using Bayesian methods and calculated the odds ratio, rate ratio, and hazard ratio with 95% credible intervals (CrIs) based on an available‐case analysis, according to the National Institute of Health and Care Excellence (NICE) Decision Support Unit guidance.Main resultsWe included a total of 12 trials (1278 participants; 13 antibiotics) in the review. Ten trials (893 participants) were included in one or more outcomes in the review. The trials that provided the information included patients having cirrhosis with or without other features of decompensation of varied aetiologies. The follow‐up in the trials ranged from one week to three months. All the trials were at high risk of bias. Only one trial was included under each comparison for most of the outcomes. Because of these reasons, there is very low certainty in all the results. The majority of the randomised clinical trials used third‐generation cephalosporins, such as intravenous ceftriaxone, cefotaxime, or ciprofloxacin as one of the interventions.Overall, approximately 75% of trial participants recovered from SBP and 25% of people died within three months. There was no evidence of difference in any of the outcomes for which network meta‐analysis was possible: mortality (9 trials; 653 participants), proportion of people with any adverse events (5 trials; 297 participants), resolution of SBP (as per standard definition, 9 trials; 873 participants), or other features of decompensation (6 trials; 535 participants). The effect estimates in the direct comparisons (when available) were very similar to those of network meta‐analysis. For the comparisons where network meta‐analysis was not possible, there was no evidence of difference in any of the outcomes (proportion of participants with serious adverse events, number of adverse events, and proportion of participants requiring liver transplantation). Due to the wide CrIs and the very low‐certainty evidence for all the outcomes, significant benefits or harms of antibiotics are possible.None of the trials reported health‐related quality of life, number of serious adverse events, or symptomatic recovery from SBP.Funding: the source of funding for two trials were industrial organisations who would benefit from the results of the trial; the source of funding for the remaining 10 trials was unclear.Authors' conclusionsShort‐term mortality after SBP is about 25%. There is significant uncertainty about which antibiotic therapy is better in people with SBP.We need adequately powered randomised clinical trials, with adequate blinding, avoiding post‐randomisation dropouts (or performing intention‐to‐treat analysis), and using clinically important outcomes, such as mortality, health‐related quality of life, and adverse events.

AB - BackgroundApproximately 2.5% of all hospitalisations in people with cirrhosis are for spontaneous bacterial peritonitis (SBP). Antibiotics, in addition to supportive treatment (fluid and electrolyte balance, treatment of shock), form the mainstay treatments of SBP. Various antibiotics are available for the treatment of SBP, but there is uncertainty regarding the best antibiotic for SBP.ObjectivesTo compare the benefits and harms of different antibiotic treatments for spontaneous bacterial peritonitis (SBP) in people with decompensated liver cirrhosis.Search methodsWe searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trials registers until November 2018 to identify randomised clinical trials on people with cirrhosis and SBP.Selection criteriaWe included only randomised clinical trials (irrespective of language, blinding, or publication status) in adults with cirrhosis and SBP. We excluded randomised clinical trials in which participants had previously undergone liver transplantation.Data collection and analysisTwo review authors independently identified eligible trials and collected data. The outcomes for this review included mortality, serious adverse events, any adverse events, resolution of SBP, liver transplantation, and other decompensation events. We performed a network meta‐analysis with OpenBUGS using Bayesian methods and calculated the odds ratio, rate ratio, and hazard ratio with 95% credible intervals (CrIs) based on an available‐case analysis, according to the National Institute of Health and Care Excellence (NICE) Decision Support Unit guidance.Main resultsWe included a total of 12 trials (1278 participants; 13 antibiotics) in the review. Ten trials (893 participants) were included in one or more outcomes in the review. The trials that provided the information included patients having cirrhosis with or without other features of decompensation of varied aetiologies. The follow‐up in the trials ranged from one week to three months. All the trials were at high risk of bias. Only one trial was included under each comparison for most of the outcomes. Because of these reasons, there is very low certainty in all the results. The majority of the randomised clinical trials used third‐generation cephalosporins, such as intravenous ceftriaxone, cefotaxime, or ciprofloxacin as one of the interventions.Overall, approximately 75% of trial participants recovered from SBP and 25% of people died within three months. There was no evidence of difference in any of the outcomes for which network meta‐analysis was possible: mortality (9 trials; 653 participants), proportion of people with any adverse events (5 trials; 297 participants), resolution of SBP (as per standard definition, 9 trials; 873 participants), or other features of decompensation (6 trials; 535 participants). The effect estimates in the direct comparisons (when available) were very similar to those of network meta‐analysis. For the comparisons where network meta‐analysis was not possible, there was no evidence of difference in any of the outcomes (proportion of participants with serious adverse events, number of adverse events, and proportion of participants requiring liver transplantation). Due to the wide CrIs and the very low‐certainty evidence for all the outcomes, significant benefits or harms of antibiotics are possible.None of the trials reported health‐related quality of life, number of serious adverse events, or symptomatic recovery from SBP.Funding: the source of funding for two trials were industrial organisations who would benefit from the results of the trial; the source of funding for the remaining 10 trials was unclear.Authors' conclusionsShort‐term mortality after SBP is about 25%. There is significant uncertainty about which antibiotic therapy is better in people with SBP.We need adequately powered randomised clinical trials, with adequate blinding, avoiding post‐randomisation dropouts (or performing intention‐to‐treat analysis), and using clinically important outcomes, such as mortality, health‐related quality of life, and adverse events.

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DO - 10.1002/14651858.CD013120.pub2

M3 - Review article

VL - 2019

JO - The Cochrane Library

JF - The Cochrane Library

SN - 1361-6137

IS - 9

M1 - CD013120

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