The effect of prophylactic antibiotics in acute upper gastrointestinal bleeding patients in the emergency department

doi:10.5847/wjem.j.1920-8642.2023.062

Abstract

Abstract:

BACKGROUND: Currently, prophylactic antibiotics are recommended only for cirrhotic patients with acute upper gastrointestinal bleeding (AUGIB); however, the benefit for other AUGIB patients remains undetermined. We aimed to compare the clinical outcomes between patients with AUGIB with and without prophylactic antibiotics to identify the population that requires this therapy.

METHODS: Patients with AUGIB admitted between 1^st January 2019 and 31^st December 2021 in the Emergency Department of Peking Union Medical College Hospital were enrolled. Patients were divided into the antibiotic and non-antibiotic groups. The primary outcome was in-hospital mortality, and the secondary outcome was the onset of new infection. The risk factors for mortality and infection were analyzed, and stratification analysis of prophylactic antibiotics was performed. Continuous data were analyzed using the t-test or nonparametric rank sum test, and categorical data were analyzed using the Chi-square test or Fisher’s exact test. Indicators with significant differences between the groups were included for logistic regression analysis. A P-value <0.05 was considered statistically significant.

RESULTS: A total of 392 individuals were included, among them, 281 patients received prophylactic antibiotics, and 111 patients did not receive prophylactic antibiotics. The mortality rates were significantly lower in the antibiotic group than in the non-antibiotics group (6.41% vs. 17.12%, P=0.001). The risk factors for infection were varicose veins (P=0.045) and endotracheal intubation (P=0.005) in the prophylactic antibiotic group, and endoscopic treatment (P=0.010) in the non-prophylactic antibiotic group. Stratified analyses showed that patients with age ≥ 65 years, endotracheal intubation, endoscopic treatment, and AUGIB of variceal etiologies benefited from prophylactic antibiotics.

CONCLUSION AUGIB patients may benefit from prophylactic antibiotics to decrease mortality, especially those aged ≥ 65 years and those with endotracheal intubation, endoscopic treatment, and variceal etiologies.

Key words: Acute upper gastrointestinal bleeding, Prophylactic antibiotics, Stratification

Miao Gan, Liang Zong, Xuezhong Yu, Jun Xu. The effect of prophylactic antibiotics in acute upper gastrointestinal bleeding patients in the emergency department[J]. World Journal of Emergency Medicine, 2023, 14(6): 442-447.

Figures/Tables 3

Table 1.

The characteristics of enrolled patients between the prophylactic antibiotic and non-prophylactic antibiotic groups

Variables		Antibiotics (n=281)	Non-antibiotics (n=111)	t/χ²	P-value
Age, year		60.99±14.67	61.05±15.05	-0.041	0.967
Gender, n (%)
	Male	186 (66.19)	72 (64.86)	0.062	0.803
	Female	95 (33.81)	39 (35.14)	0.062	0.803
Underlying diseases, n (%)
	Coronary heart disease	39 (13.88)	24 (21.62)	3.536	0.060
	Hypertension	111 (39.50)	49 (44.14)	0.710	0.399
	Diabetes	210 (74.73)	71 (63.96)	0.294	0.107
	Cerebrovascular disease	38 (13.52)	17 (15.32)	0.212	0.645
	Liver cirrhosis	81 (28.83)	35 (31.53)	0.280	0.597
	Chronic kidney disease	19 (6.76)	12 (10.81)	1.791	0.181
	Tumor	49 (17.44)	26 (23.42)	1.843	0.175
	Autoimmune disease	18 (6.41)	7 (6.31)	0.001	0.971
	Blood system disease	10 (3.56)	9 (8.11)	3.571	0.059
History of digestive system surgery, n (%)		27 (9.61)	16 (14.41)	1.882	0.170
History of bleeding, n (%)
	0	160 (56.94)	80 (72.07)	8.863	0.012
	≥1	121 (43.06)	31 (27.93)	8.863	0.012
Previous hormone use, n (%)		14 (4.98)	6 (5.41)	0.029	0.864
Causes of bleeding, n (%)
	Esophagogastric varices	104 (37.01)	52 (46.85)	3.213	0.073
	Non-varices	177 (62.99)	59 (53.15)	3.213	0.073
Vital signs, n (%)
	Shock index >1	139 (49.47)	60 (54.05)	0.670	0.413
	Oxygenation index <300	4 (1.42)	2 (1.80)	-	0.678
	GCS<15	20 (7.12)	11 (9.91)	0.852	0.356
	Fever	25 (8.90)	9 (8.11)	0.062	0.803
Laboratory examination
	WBC, ×10⁹/L	10.77±7.95	10.18±5.99	0.705	0.481
	NLR	8.31±7.33	7.88±6.25	0.540	0.589
	Hb_min, g/L	62.43±17.27	58.66±17.37	1.947	0.052
	PLT, ×10⁹/L	160.25±90.43	172.04±108.47	-1.098	0.273
	Alb, g/L	31.46±5.81	30.59±6.20	1.316	0.189
	CRP_max, mg/L	42.39±57.92	31.23±44.03	-2.060	0.040
	PCT_max, ng/mL	2.41±9.29	3.67±11.95	-1.107	0.269
	Amon_max, μmol/L	61.78±57.79	57.16±77.70	0.643	0.520
	INR_max	1.47±0.72	1.53±0.75	-0.720	0.472
AIMS65 score, n (%)
	0-1	241 (85.77)	91 (81.98)	3.916	0.562
	2-5	40 (14.23)	20 (18.02)	3.916	0.562
Treatment, n (%)
	Tracheal intubation	45 (16.01)	23 (20.72)	1.229	0.268
	Endoscopy exam	106 (37.72)	40 (36.04)	0.097	0.756
	Endoscopy treatment	122 (43.42)	42 (37.84)	1.018	0.313
	No endoscopy performed	53 (18.86)	29 (26.13)	2.539	0.111
	Angiography and surgery	25 (8.90)	10 (9.01)	0.001	0.972

Table 1.

Table 2.

Risk factors associated with mortality in AUGIB patients

Variables		Death (n=37)	Survival (n=355)	t/χ²	P-value
Age, years		70.03±10.68	60.06±14.81	3.981	<0.001
Gender, n (%)
	Male	30 (81.08)	228 (64.23)	4.231	0.040
	Female	7 (18.92)	127 (35.77)	4.231	0.040
Underlying diseases
	Coronary heart disease	7 (18.92)	56 (15.77)	0.246	0.620
	Hypertension	18 (48.65)	142 (40)	1.038	0.308
	Diabetes	10 (27.03)	98 (27.61)	0.006	0.940
	Cerebrovascular disease	5 (13.51)	50 (14.08)	0.009	0.924
	Liver cirrhosis	10 (27.03)	106 (29.86)	0.129	0.719
	Chronic kidney disease	4 (10.81)	27 (7.61)	0.473	0.492
	Tumor	8 (21.62)	67 (18.87)	0.164	0.686
	Autoimmune disease	3 (8.11)	22 (6.20)	0.205	0.651
	Blood system disease	3 (8.11)	16 (4.61)	0.942	0.332
History of digestive system surgery, n (%)		3 (8.11)	40 (11.27)	0.342	0.558
History of bleeding, n (%)
	0	23 (62.16)	249 (70.14)	2.627	0.269
	≥1	14 (37.84)	106 (29.86)	2.627	0.269
Previous hormone use, n (%)		4 (10.81)	16 (4.51)	2.750	0.097
Causes of bleeding, n (%)				0.203	0.653
	Esophagogastric varices	16 (43.24)	140 (39.44)
	Non-varices	21 (56.76)	215 (60.56)
Vital signs, n (%)
	Shock index >1	23 (62.16)	176 (49.58)	2.123	0.145
	Oxygenation index <300	0	6 (1.69)	-	1.000
	GCS<15	5 (13.51)	26 (7.32)	1.763	0.184
	Fever	6 (16.22)	28 (7.89)	2.934	0.087
Laboratory examination
	WBC, ×10⁹/L	8.96±4.61	10.77±7.66	-1.416	0.158
	NLR	7.36±4.98	8.27±7.22	-0.753	0.452
	Hb_min, g/L	59.89±12.99	61.52±17.76	-0.542	0.588
	PLT, ×10⁹/L	126.59±93.59	167.44±95.43	-2.522	0.015
	Alb, g/L	30.3±5.61	31.31±5.96	-0.986	0.325
	CRP_max, mg/L	46.46±57.55	33.13±47.44	1.592	0.112
	PCT_max, ng/mL	1.45±2.79	2.90±10.58	-0.828	0.408
	Amon_max, μmol/L	48.79±40.51	61.69±65.87	-1.167	0.244
	INR_max	1.82±1.02	1.45±0.68	2.970	0.003
AIMS65 score, n (%)
	0-1	26 (70.27)	306 (86.20)	20.097	0.001
	2-5	11 (29.73)	49 (13.80)	20.097	0.001
Treatment, n (%)
	Prophylactic antibiotics	18 (48.65)	263(74.08)	16.892	<0.001
	Tracheal intubation	20 (54.05)	48 (13.52)	38.395	<0.001
	Endoscopy exam	8 (21.62)	138 (38.87)	4.267	0.039
	Endoscopy treatment	12 (32.43)	152 (42.82)	1.485	0.223
	No endoscopy performed	17 (45.95)	65 (18.31)	15.470	<0.001
	Angiography and surgery	2 (5.41)	33 (9.30)	0.624	0.430
New symptoms, n (%)
	Myocardial injury	30 (81.08)	125 (35.21)	29.491	<0.001
	Encephalopathy	4 (10.81)	17 (4.79)	2.397	0.122
	Infections	17 (45.95)	82 (23.10)	9.226	0.002

Table 2.

Table 3.

References 25

1	Raju GS, Gerson L, Das A, Lewis B; American Gastroenterological Association. American Gastroenterological Association (AGA) Institute technical review on obscure gastrointestinal bleeding. Gastroenterology. 2007; 133(5):1697-717. doi: 10.1053/j.gastro.2007.06.007 pmid: 17983812
2	Kamboj AK, Hoversten P, Leggett CL. Upper gastrointestinal bleeding: etiologies and management. Mayo Clin Proc. 2019; 94(4): 697-703.
3	Fouad TR, Abdelsameea E, Abdel-Razek W, Attia A, Mohamed A, Metwally K, et al. Upper gastrointestinal bleeding in Egyptian patients with cirrhosis: post-therapeutic outcome and prognostic indicators. J Gastroenterol Hepatol. 2019; 34(9): 1604-10. doi: 10.1111/jgh.v34.9
4	Christensen S, Riis A, Nørgaard M, Sørensen HT, Thomsen RW. Short-term mortality after perforated or bleeding peptic ulcer among elderly patients: a population-based cohort study. BMC Geriatr. 2007;7: 8.
5	Hearnshaw SA, Logan RF, Lowe D, Travis SP, Murphy MF, Palmer KR. Acute upper gastrointestinal bleeding in the UK: patient characteristics, diagnoses and outcomes in the 2007 UK audit. Gut. 2011; 60(10): 1327-35. doi: 10.1136/gut.2010.228437 pmid: 21490373
6	Laine L, Yang HY, Chang SC, Datto C. Trends for incidence of hospitalization and death due to GI complications in the United States from 2001 to 2009. Am J Gastroenterol. 2012; 107(8): 1190-5;quiz1196. doi: 10.1038/ajg.2012.168 pmid: 22688850
7	van Leerdam ME. Epidemiology of acute upper gastrointestinal bleeding. Best Pract Res Clin Gastroenterol. 2008; 22(2):209-24. doi: 10.1016/j.bpg.2007.10.011
8	The Emergency Physician Branch of the Chinese Medical Doctor Association, the Emergency Medicine Branch of the Chinese Medical Association, the Military Emergency Medicine Professional Committee, the China Association of Emergency Specialists, and the Beijing Association of Emergency Medicine. Expert consensus on emergency diagnosis and treatment process of acute upper gastrointestinal bleeding. Chin J Emerg Med. 2021; 30(1):15-24.
9	Karstensen JG, Ebigbo A, Bhat P, Dinis-Ribeiro M, Gralnek I, Guy C, et al. Endoscopic treatment of variceal upper gastrointestinal bleeding: European Society of Gastrointestinal Endoscopy (ESGE) Cascade Guideline. Endosc Int Open. 2020 ;8(7):E990-E997.
10	Buchanan PM, Kramer JR, El-Serag HB, Asch SM, Assioun Y, Bacon BR, et al. The quality of care provided to patients with varices in the department of Veterans Affairs. Am J Gastroenterol. 2014; 109(7): 934-40. doi: 10.1038/ajg.2013.487 pmid: 24989087
11	Yadav RS, Bargujar P, Pahadiya HR, Yadav RK, Upadhyay J, Gupta A, et al. Acute upper gastrointestinal bleeding in hexagenerians or older (≥60 years) versus younger (<60 years) patients: clinico-endoscopic profile and outcome. Cureus. 2021;13(2):e13521.
12	Sourabh S, Sharma N, Sharma R, Kumar R, Thakur S, Bodh V, et al. Clinical profile, severity and outcome of acute upper gastrointestinal bleeding in elderly patients compared to non-elderly patients: a prospective observational study. J Assoc Physicians India. 2019; 67(9):30-2. pmid: 31561685
13	Hwang JH, Shergill AK, Acosta RD, Chandrasekhara V, Chathadi KV, et al. The role of endoscopy in the management of variceal hemorrhage. Gastrointest Endosc. 2014; 80(2):221-7. doi: 10.1016/j.gie.2013.07.023 pmid: 25034836
14	de Franchis R; Baveno V Faculty. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol. 2010; 53(4):762-8.
15	Avgerinos A, Armonis A, Manolakopoulos S, Rekoumis G, Argirakis G, Viazis N, et al. Endoscopic sclerotherapy plus propranolol versus propranolol alone in the primary prevention of bleeding in high risk cirrhotic patients with esophageal varices: a prospective multicenter randomized trial. Gastrointest Endosc. 2000; 51(6): 652-8. pmid: 10840295
16	Carbonell N, Pauwels A, Serfaty L, Fourdan O, Lévy VG, Poupon R. Improved survival after variceal bleeding in patients with cirrhosis over the past two decades. Hepatology. 2004; 40(3): 652-9. doi: 10.1002/hep.20339 pmid: 15349904
17	Lau JY, Barkun A, Fan DM, Kuipers EJ, Yang YS, Chan FK. Challenges in the management of acute peptic ulcer bleeding. Lancet. 2013; 381(9882): 2033-43. doi: 10.1016/S0140-6736(13)60596-6 pmid: 23746903
18	Merkel C, Marin R, Angeli P, Zanella P, Felder M, Bernardinello E, et al. A placebo-controlled clinical trial of nadolol in the prophylaxis of growth of small esophageal varices in cirrhosis. Gastroenterology. 2004; 127(2): 476-84. doi: 10.1053/j.gastro.2004.05.004 pmid: 15300580
19	Liu CL, Wu CK, Shi HY, Tai WC, Liang CM, Yang SC, et al. Medical expenses in treating acute esophageal variceal bleeding: a 15-year nationwide population-based cohort study. Medicine (Baltimore). 2016; 95(28): e4215. doi: 10.1097/MD.0000000000004215
20	Quan S. Upper-gastrointestinal bleeding secondary to peptic ulcer disease: incidence and outcomes. World J Gastroenterol. 2014; 20(46): 17568. doi: 10.3748/wjg.v20.i46.17568
21	Enestvedt BK, Gralnek IM, Mattek N, Lieberman DA, Eisen G. An evaluation of endoscopic indications and findings related to nonvariceal upper-GI hemorrhage in a large multicenter consortium. Gastrointest Endosc. 2008; 67(3): 422-9. doi: 10.1016/j.gie.2007.09.024 pmid: 18206878
22	Eckburg PB, Bik EM, Bernstein CN, Purdom E, Dethlefsen L, Sargent M, et al. Diversity of the human intestinal microbial flora. Science. 2005; 308(5728): 1635-8.
23	Chen Y, Yang F, Lu H, Wang B, Chen Y, Lei D, et al. Characterization of fecal microbial communities in patients with liver cirrhosis. Hepatology. 2011; 54(2): 562-72. doi: 10.1002/hep.24423 pmid: 21574172
24	Mitchell H, Katelaris P. Epidemiology, clinical impacts and current clinical management of Helicobacter pylori infection. Med J Aust. 2016; 204(10): 376-80. pmid: 27256648
25	Chaudhuri D, Bishay K, Tandon P, Trivedi V, James PD, Kelly EM, et al. Prophylactic endotracheal intubation in critically ill patients with upper gastrointestinal bleed: a systematic review and meta-analysis. JGH Open. 2020; 4(1): 22-8. doi: 10.1002/jgh3.12195 pmid: 32055693

Variables	Antibiotics (n=281)	Non-antibiotics (n=111)	P-value
Age
≥65 years	14/126 (11.11%)	14/50 (28%)	0.006
<65 years	4/155 (2.58%)	5/61 (8.20%)	0.074
Endotracheal intubation
Yes	8/45 (17.78%)	12/23 (52.17%)	0.003
No	10/236 (4.24%)	7/88 (7.95%)	0.182
Endoscopic treatment
Yes	9/228 (3.95%)	11/82 (13.41%)	0.003
No	9/53 (16.98%)	8/29 (27.59%)	0.257
Etiology
Variceal	6/104 (5.77%)	10/52 (19.23%)	0.009
Non-variceal	12/177 (6.78%)	9/59 (15.25%)	0.063

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