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Low rate of adherence with primary spontaneous bacterial prophylaxis in patients with cirrhosis: a single-center experience

Nghia Nguyen (University of California San Diego Department of Medicine), Sridevi Pokala (University of California San Diego Department of Medicine), Paulette Gabbai-saldate (University of California San Diego Department of Medicine), Irine Vodkin (University of California San Diego Division of Gastroenterology and Hepatology), Mohammad Farkhondehpour (University of California San Diego Division of Hospital Medicine), Gregory Seymann (University of California San Diego Division of Hospital Medicine)

Background

Spontaneous bacterial peritonitis (SBP) is a complication of advanced liver disease which significantly increases morbidity, mortality, and healthcare-related costs in patients with cirrhosis.  Although there is a proven mortality benefit associated with primary SBP prophylaxis, previous reports have suggested a low rate of adherence, representing a key gap in care.

Objectives

A meta-analysis of four randomized controlled trials on primary SBP prophylaxis has suggested a significant reduction in SBP (~80%) and mortality (~40%) in patients who received primary SBP prophylaxis when ascitic total protein was <1.5 g/dL. The American Association for the Study of Liver Diseases (AASLD) recommends giving primary prophylaxis to patients with ascitic total protein <1.5 g/L and features of advanced liver disease or renal dysfunction.  In this study, we examined the proportion of patients that received SBP prophylaxis prior to discharge.

Methods

We consecutively reviewed charts from June – December 2017 in adult patients with cirrhosis who had an ascitic total protein value collected during their hospital admission. Inclusion criteria included cirrhosis from chronic liver disease, alive at time of discharge, paracentesis during hospitalization, no prior episode of SBP and/or not on SBP prophylaxis on admission, and ascitic total protein <1.5 g/dL. Primary outcome was proportion of patients eligible for primary SBP prophylaxis and received antibiotic prior to discharge based on either ascitic total protein <1.5 g/dL or the AASLD criteria of ascitic total protein <1.5 g/dL AND the presence of renal dysfunction (serum sodium <130, BUN >25, creatinine >1.2) or liver failure (Child score >9 and bilirubin >3).

Results

We reviewed 186 charts; a total of 32 patients had data available for analysis. Overall, only 44% of patients who were eligible for primary SBP prophylaxis received antibiotics on discharge. When stratified by patients who met SBP prophylaxis by low protein-ascites only versus AASLD criteria, 33% of patients in the low-protein ascites only cohort received prophylaxis while 46% of patients who met AASLD criteria received prophylaxis, indicating an overall low rate of adherence regardless of the criteria selected (see Figure 1).

Conclusion

Many patients (~56%) eligible for primary SBP prophylaxis were not prescribed antibiotics on discharge and this finding was consistent across two different sets of criteria, including the more stringent AASLD criteria. In addition to the mortality benefit, primary SBP prophylaxis could confer a significant healthcare savings. Based on Medicare 2015 data, cost for one episode of SBP (Diagnosis Related Group 371, 372, or 373) can range from $6405-$15570, while the cost of antibiotic prophylaxis with ciprofloxacin 500 mg daily is $1104 annually (Costco retail price).

Implications for the Patient

Because primary SBP prophylaxis is associated with large reductions in rates of SBP and mortality among cirrhotics, hospital interventions focused on increasing adherence to primary SBP prophylaxis offer improved patient outcomes and have the potential to confer significant healthcare savings.