Antibiotic Stewardship in Cirrhosis: Current Recommendations and Clinical Challenges

Bacterial infections are a major cause of mortality in cirrhosis, with antibiotic prophylaxis and empirical treatment embedded in international guidelines. However, the prevalence of multidrug-resistant organisms and the epidemiology of infections have shifted considerably in recent decades. This review critically appraises the evidence underlying guideline recommendations on antibiotic prophylaxis for spontaneous bacterial peritonitis and acute variceal bleeding in cirrhosis, and antimicrobial management in acute liver failure. The evidence-underlying current recommendations is limited and predates the current era of widespread antimicrobial resistance, challenging their applicability in current practice. Emerging evidence suggests that primary prophylaxis should be reconsidered, alternatives such as rifaximin warrant further evaluation against established fluoroquinolone regimens, and shorter antibiotic courses may be non-inferior to standard durations. New double-blind placebo-controlled, non-inferiority and Bayesian trials are needed to evaluate antibiotic regimens and microbiome- and barrier-directed interventions, supported by improved diagnostics, while minimising treatment duration, toxicity and selection for antimicrobial resistance.