S2329 Secondary Prophylaxis of SBP in Cirrhosis: Bactrim vs Ciprofloxacin in a Propensity-Matched Real-World Study

Introduction: Spontaneous bacterial peritonitis (SBP) is a common and life-threatening complication in patients with cirrhosis. Secondary prophylaxis with antibiotics such as trimethoprim-sulfamethoxazole (Bactrim) or ciprofloxacin is recommended to prevent recurrence. However, real-world comparative data on the efficacy of these regimens remain limited. This study aimed to evaluate clinical outcomes among cirrhotic patients with prior SBP receiving Bactrim versus Ciprofloxacin for SBP prophylaxis. Methods: Using the TriNetX research network, we identified adult patients with cirrhosis and a documented episode of SBP who were prescribed either Bactrim (n = 11,166) or ciprofloxacin (n = 19,845) for secondary prophylaxis. After 1:1 propensity score matching based on demographics, liver function, Model for End-Stage Liver Disease components, diabetes status, hemoglobin A1c (A1c), and body mass index (BMI); 11,140 matched pairs were analyzed. Outcomes were assessed over a 3-year follow-up period using time-to-event analysis. The primary outcomes were recurrence of SBP and all-cause mortality. Secondary outcomes included all-cause hospitalizations, ascites, hepatic encephalopathy (HE), and variceal bleeding. Results: Patients receiving Bactrim had significantly better outcomes than those receiving Ciprofloxacin across nearly all measured endpoints. SBP recurrence was lower in the Bactrim group (hazard ratio [HR] 0.754, 95% confidence interval [CI] 0.723–0.786; P < 0.0001), as was all-cause mortality (HR 0.838, 95% CI 0.804–0.874; P < 0.0001). Significant reductions were also observed in ascites (HR 0.863, 95% CI 0.835–0.891; P < 0.0001), HE (HR 0.786, 95% CI 0.744–0.830; P < 0.0001), and variceal bleeding (HR 0.813, 95% CI 0.731–0.903; P = 0.0001). There was a decrease in all-cause hospitalizations in the Bactrim group but there was no statistically significant difference. Conclusion: In this large real-world cohort of cirrhotic patients with prior SBP, Bactrim was associated with lower risks of SBP recurrence, mortality, incidence of ascites, HE, and variceal bleeding compared to Ciprofloxacin. While choice of antibiotic prophylaxis needs to be tailored based on individual and local antibiotic resistance profiles, our study showed that Bactrim may be a more effective option for SBP secondary prophylaxis in this population. Further prospective studies are warranted to confirm these observations and guide clinical decision-making.