DOI: http://dx.doi.org/10.18203/2319-2003.ijbcp20184329

Effect of trimethoprim-sulfamethoxazole vs. norfloxacin on fecal E. coli resistance pattern and efficacy in patients receiving prophylaxis for spontaneous bacterial peritonitis

Siddhartha Dutta, Shalini Chawla, Siddharth Srivastava, Poonam Loomba, Vandana Roy

Abstract


Background: Spontaneous Bacterial Peritonitis (SBP) is an infection of ascitic fluid. It is highly mortal and recurrent condition, so prophylaxis with Norfloxacin (NOR) or Trimethoprim-sulfamethoxazole (TMP-SMX) seems to play an important role in the prevention of further episodes of SBP. Aims of the study were to assess the effect of TMP-SMX/NOR on the sensitivity pattern of fecal E. coli after long term prophylaxis in Spontaneous Bacterial Peritonitis (SBP) and to compare the efficacy of TMP-SMX and NOR in prophylaxis of SBP.

Methods: An interventional, prospective, open label, single center study conducted in Maulana Azad medical college, New Delhi, India. 52 patients of SBP or with high risk of SBP were screened and finally 39 patients were recruited. Stool sensitivity testing of fecal E. coli was done and they were divided into TMP-SMX group(n=18) and NOR group(n=21) according to sensitivity. After 45±3 days (7 weeks) their stool sample was re-examined for change sensitivity pattern of E. coli. Efficacy variables like any episode of SBP, fever (FEV) resolution of ascites (ASC), bacteremia (BACT), extraperitoneal infection (EPI), liver transplantation (LT) or death (D) were noted throughout the period of 24 weeks.

Results: Resistance developed in 60% vs. 48% in TMP-SMX vs. NOR group(p=0.46) after 45 days of prophylaxis. By the end of 24 weeks, Incidence of SBP (29%vs. 25%, p>0.99), episodes of FEV(P=0.60), EPI(p>0.99), ASC(p>0.99) and death (14% vs. 16%, p>0.99) were almost similar in both the groups (TMP-SMX vs. NOR) respectively.

Conclusions: Both TMP-SMX and NOR showed same degree of resistance and found equi-efficacious when administered as long-term prophylactic therapy in SBP. TMP-SMX can be a suitable as well as cost effective alternative to NOR for the prophylaxis of SBP.


Keywords


Bacterial resistance, E. coli, Liver cirrhosis, Norfloxacin, Spontaneous bacterial peritonitis, Trimethoprim-sulfamethoxazole

Full Text:

PDF

References


Hoefs JC, Canawati HN, Sapico FL, Hopkins RR, Weiner J, Montgomerie JZ. Spontaneous bacterial peritonitis. Hepatology. 1982;2:399-407.

Runyon A. Spontaneous bacterial peritonitis: An explosion of information. Hepatology. 1988;8:171-5.

Runyon BA, McHutchinson JG, Antillon MR. Short course vs. long course antibiotic treatment of spontaneous bacterial peritonitis: A randomized controlled trial of 100 patients. Gastroenterology. 1991;100:1737-42.

Tito L, Rimola A, Gines P. Recurrence of spontaneous bacterial peritonitis in cirrhosis: Frequency and predictive factors. Hepatology. 1988;8:27-31.

Rimola A, Soto R, Bory F, Arroyo V, Piera C, Rodes J. Reticuloendothelial system phagocytic activity in cirrhosis and its relationship to bacterial infections and prognosis. Hepatology. 1984;4:53-8.

Runyon BA. Patients with deficient ascitic fluid opsonic activity are predisposed to spontaneous bacterial peritonitis. Hepatology. 1988;8:632-5.

Garcia-Tsao G. Spontaneous bacterial peritonitis. Gastroenterol Clin N Am. 1992;21:257-75.

Rimola A. Infections in liver disease. In: McIntyre N, Benhamou JP, Bircher J, Rizzetto M, Rodes J, eds. Oxford Textbook of Clinical Hepatology. Oxford: Oxford University Press; 1991:1272-1284.

Fernandez J, Navasa M, Gómez J, Colmenero J, Vila J, Arroyo V, et al. Bacterial infections in cirrhosis: epidemiological changes with invasive procedures and norfloxacin prophylaxis. Hepatology. 2002;35:140-8.

Garcia-Tsao G, Albillos A, Barden GE, West AB. Bacterial translocation in acute and chronic portal hypertension. Hepatology. 1993;17:1081-5.

Gines P, Rimola A, Planas R. Norfloxacin prevents spontaneous bacterial peritonitis recurrence in cirrhosis: Results of a double-blind, placebo-controlled trial. Hepatology. 1990;12:716-24.

Mowat C, Stanley AJ. Review article. Spontaneous bacterial peritonitis- diagnosis, treatment and prevention. Aliment Pharmacol Ther. 2001;15:1851-9.

Dupeyron C, Manganey N, Sedrati L, Campillo B, Fouet P, Leluan G. Rapid emergence of quinolone resistance in cirrhotic patients treated with norfloxacin to prevent spontaneous bacterial peritonitis. Antimicrob Agents Chemother. 1994;38:340-4.

Runyon BA. The American Association for the Study of Liver Diseases; Practice guidelines Management of Adult Patients with Ascites Due to Cirrhosis Update 2012: Spontaneous Bacterial peritonitis [Internet]. 2012. Available at: http://www.aasld.org/sites/default/files/guideline_documents/adultascitesenhanced.pdf. Accessed Aug 2 2018

European Association for the Study of the Liver; EASL clinical practice guidelines on management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis: Spontaneous bacterial peritonitis [Internet]; 2010. Available at: http://www.easl.eu /research/our-contributions/clinical-practice- guidelines/detail/management-ofascites-spontaneous-bacterial-peritonitis-and-hepatorenal- syndrome-in-cirrhosis/report/4. Accessed Aug 2 2018.

Aparicio JR, Such J, Pascual S, Arroyo A, Plazas J, Girona E, et al. Development of quinolone-resistant strains of Escherichia coli in stools of patients with cirrhosis undergoing norfloxacin prophylaxis: clinical consequences. J Hepatol. 1999 Aug;31(2):277-83.

Carratala J, Fernandez-Sevilla A, Tubau F, Dominguez MA, Gudiol F. Emergence of fluoroquinolone-resistant Escherichia coli in fecal flora of cancer patient receiving norfloxacin prophylaxis. Antimicrob Agents Chemother. 1996 Feb;40(2):503-5.

Novella M, Sola R, Soriano G, Andreu M, Gana J, Ortiz J, et al. Continuous versus inpatient prophylaxis of the first episode of spontaneous bacterial peritonitis with norfloxacin. Hepatology. 1997;25(3):532-6.

Lontos S, Gow PJ, Vaughan RB, Angus PW. Norfloxacin and trimethoprim-sulfamethoxazole have similar efficacy in the prevention of spontaneous bacterial peritonitis. Hepatology. 2008;23:252-5.

Alvarez RF, Mattos AA, Correa EB, Cotrim HP, Nascimento TV. Trimethoprim- sulfamethoxazole versus norfloxacin in the prophylaxis of spontaneous bacterial peritonitis in cirrhosis. Arquivos de Gastroenterologia. 2005;42:256-62.

Lontos S, Shelton E, Angus P W, Vaughan R, Roberts SK, Gordon A. et al. A randomized controlled study of trimethoprim-sulfamethoxazole versus norfloxacin for the prevention of infection in cirrhotic patients. Journal of Digestive Diseases. 2014;15:260-7.

Huovinen P, Mattila T, Kiminki O, Pulkkinen L, Huovinen S, Koskela M, et al. Emergence of Trimethoprim Resistance in Fecal Flora. Antimicrob. Agents Chemother. August 1985; 8(2):354-6.

Mavromanolakis E, Maraki S, Samonis G, Tselentis Y, Cranidis A. Effect of norfloxacin, trimethoprim-sulfamethoxazole and nitrofurantoin on fecal flora of women with recurrent urinary tract infections. J Chemother. 1997 Jun; 9(3):203-7.

Fernández J, Navasa M, Planas R, Montoliu S, Monfort D, Soriano G, et al. Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis. Gastroenterology. 2007;133:818-24.

Singh N, Gayowski T, Yu VL, Wagener MM. Trimethoprim-sulfamethoxazole for the prevention of spontaneous bacterial peritonitis in cirrhosis: a randomized trial. Ann Intern Med. 1995;122:595-8.

Caly WR, Strauss E. A prospective study of bacterial infections in patients with cirrhosis. J Hepatol. 1993;18:353-8.