Risk factors and antibiotic prophylaxis of cellulitis in cirrhosis

We read the article by Hamza et al with great interest [1]. The authors have investigated the risk factors and whether antibiotic prophylaxis helps prevent recurrence of cellulitis in cirrhosis. We agree with the authors that bacterial infections are frequent in cirrhotic patients because of their defective defense mechanisms and that these infections precipitate decompensation of cirrhosis. Of note, an association between high MELD for end-stage liver disease score and hepatic encephalopathy with cellulitis are expected as mentioned in phase 1 results of the study.

However, since the most common infection in advanced cirrhosis is spontaneous bacterial peritonitis (SBP), antibiotics for selective intestinal decontamination, such as quinolones, are often prescribed as prophylaxis against SBP recurrence [2]. The effect of widespread norfloxacin use on the epidemiology of severe infections in cirrhotic patients is poorly known. A 5-year retrospective study evaluated the effect of long-term administration of norfloxacin on the epidemiology of severe hospital-acquired infections and showed that long-term norfloxacin administration resulted in a sharp increase in staphylococcal SBP and bacteremia, while the prevalence of Enterobacteriaceae and streptococci fell and did not change, respectively [3].

Although gram-negative bacteria-induced cellulitis has been reported in cirrhotic patients [4], gram-positive bacteria are still the predominant organism isolated from cellulitis [5]. Recommended use of broad-spectrum antibiotics as prophylactic treatment of such patients may lead to the emergence of gram-positive pathogens rather than preventation of skin infections.