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The risk of organ failure or mortality from infection or sepsis remains high in patients with decompensated cirrhosis. Today’s session featured two absorbing discussions around the challenges associated with antibiotic use in this patient population.

The first discussion debated the use of antibiotic prophylaxis for patients with advanced cirrhosis. The central argument in favour was the association of bacterial infections, particularly spontaneous bacterial peritonitis, with high mortality and denial of liver transplant. Long-term prophylaxis with norfloxacin seems to confer a survival benefit in those with low ascitic fluid protein, as well as to reduce the occurrence of bacterial infection. However it does not have an impact on mortality in all patients with advanced cirrhosis. This was a key point in the counter argument that there should not be a ‘one size fits all’ approach. It was argued that within advanced cirrhosis there is a wide profile of disease that means antibiotic prophylaxis will not be appropriate in all patients. In particular, the increasing risk of multidrug resistance (MDR) was cited as a major reason for a more tailored approach to antibiotic prophylaxis and use of non-antibiotic approaches to infection prevention. After hearing both sides of the argument the audience voted overwhelmingly in favour for the use of antibiotic prophylaxis for specific criteria only (96%) with 4% never using prophylactic antibiotics and 6% using them in the majority of patients.

The second discussion addressed the use of broad-spectrum anti-microbial therapy and the role of early cessation as an integral part of the treatment strategy. Broad-spectrum antibiotics is the most important measure to improve survival in patients with cirrhosis and bacterial infections, independent of the presence of ACLF. Data were presented that supported their mandatory use for nosocomial infections, healthcare-associated infections in areas of high rates of MDR, and in patients with sepsis and septic shock. Although less than 0.1% of antibiotic use is in patients with advanced cirrhosis and is therefore unlikely to contribute to global development of MDR, antibiotic stewardship is critical and administration of empirical antibiotic regimens must be optimised. This should be achieved with rapid de-escalation to increase efficacy and reduce the likelihood of resistance. Strategies are required to guide this process, including rapid microbiological techniques, biomarkers and epidemiological surveillance.