Higher Rate of SBP Recurrence with Secondary SBP Prophylaxis Compared to No Prophylaxis in Two National Cirrhosis Cohorts

Background: Spontaneous bacterial peritonitis (SBP) bacteriology has changed over time. Reappraisal of primary SBP prophylaxis showed an increased rate of resistance in patients on primary prophylaxis with resultant discontinuation of this prophylaxis throughout the VA. We aimed to re-evaluate the risk-benefit ratio of secondary SBP prophylaxis (SecSBPPr). Methods: Using validated ICD 9/10 codes, we utilized the VA Corporate Data Warehouse and the Non-VA National TriNetX database to identify patients in two different large US systems who survived their first SBP diagnosis (with chart review from two VA centers) between 2009-2019. We evaluated the prevalence of SecSBPPr and compared outcomes between those started on SecSBPPr versus not. Results: We identified 4673 Veterans who survived their index SBP episode; 54.3% of whom were prescribed SecSBPPr. Multivariable analysis showed higher SBP recurrence risk in those on vs. off SecSBPPr(HR-1.63[1.40-1.91], p<0.001). This was accompanied by higher fluroquinolone-resistance odds in SecSBPPr patients (OR=4.32[1.36-15.83], p =0.03). In TriNetX we identified 6708 patients who survived their index SBP episode; 48.6% were on SecSBPPr. Multivariable analysis similarly showed SecSBPPr increased SBP recurrence risk (HR-1.68[1.33-1.80], p <0.001). Both datasets showed higher SBP recurrence trends over time in SecSBPPr patients. Results remained consistent at 6-month and 2-year timepoints. Conclusion: In two national data sets of >11,000 patients with SBP we found that SecSBPPr was prescribed in roughly half of patients. When initiated, SecSBPPr, compared to no prophylaxis after SBP, increased the risk of SBP recurrence in multivariable analysis by 63-68%, and this trend worsened over time. SecSBPPr should be reconsidered in cirrhosis.