Rifaximin: A reasonable alternative for norfloxacin in the prevention of spontaneous bacterial peritonitis in patients with HCV-related liver cirrhosis

Abstract

Background: Norfloxacin is the most commonly used agent for the prophylaxis  against spontaneous bacterial peritonitis (SBP) in patients with liver cirrhosis. Rifaximin, another broad spectrum antibiotic, is used for the treatment of traveler’s diarrhea and hepatic encephalopathy.
Objective: We aimed to test the efficacy of rifaximin versus norfloxacin for  prevention of SBP in patients with hepatitis C virus (HCV)-related liver cirrhosis.
Patients and methods: 86 patients with HCV-related liver cirrhosis and ascites were enrolled and divided into two groups of matching age, sex and Child–Pugh  class. Group I was given norfloxacin 400 mg/day as single dose, and group II  rifaximin 1200 mg/day in three divided doses. They were followed for up to one year. Study endpoints were SBP, hepatocellular carcinoma, compliance failure, death, or liver transplantation.
Results: More than 70% of patients received the antimicrobial as primary prophylaxis and the rest were given secondary prophylaxis against SBP. The mean follow-up period was 10.16 ± 2.64 months for norfloxacin and 10.26 ±2.32 months for rifaximin (p= 0.863). Although statistically insignificant (p= 0.265), patients on rifaximin developed fewer episodes of SBP than those on norfloxacin (4.7% vs. 14%). Also, the infection-free duration before SBP was longer (p=0.129) with rifaximin than norfloxacin (9.5 vs. 5.0 months). Rifaximin significantly reduced the rate of new compared to past episodes of SBP by 20.9% (p=0.007) vs. 13.9% for norfloxacin (p= 0.112). Overall survival was equal in both groups. Patients adhered to therapy regimen of norfloxacin for significantly longer time than rifaximin (p=0.010).
Conclusion: Rifaximin is – at least – as good as norfloxacin. It seems to be an  appropriate alternative for long-term primary and secondary prophylaxis of SBP in cirrhotic patients with ascites. Modification of dose regimen should be considered to improve patient’s compliance to rifaximin.

Keywords: Rifaximin; Norfloxacin; Spontaneous bacterial peritonitis, SBP; Prophylaxis; Hepatitis C; Cirrhosis