Rethinking Antibiotic Prophylaxis for Spontaneous Bacterial Peritonitis in Patients With Cirrhosis: First, Do No Harm.

The article critically examines the longstanding practice of antibiotic prophylaxis for spontaneous bacterial peritonitis prophylaxis (SBPPr) in patients with cirrhosis, highlighting that despite its widespread use since the 1990s, the supporting evidence is weak and shows no clear mortality benefit. It discusses the risks associated with lifelong antibiotic use, including the rise of antimicrobial resistance (AMR), increased incidence of multidrug-resistant infections, adverse drug effects, and disruptions to the gut microbiome. Current guidelines recommend primary and secondary prophylaxis in specific clinical scenarios, but recent data call for individualized decision-making and caution due to potential harms. The article emphasizes the urgent need for updated, high-quality randomized controlled trials and collaborative efforts among hepatology, infectious diseases, and antimicrobial stewardship experts to develop revised, evidence-based approaches to SBPPr.