What is the role of antibiotics in the treatment of encephalopathy in cirrhosis?

Updated: Oct 15, 2020
  • Author: David C Wolf, MD, FACP, FACG, AGAF, FAASLD; Chief Editor: BS Anand, MD  more...
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Neomycin and other antibiotics (eg, metronidazole, oral vancomycin, paromomycin, oral quinolones) serve as second-line agents. They work by decreasing the colonic concentration of ammoniagenic bacteria. Neomycin dosing is 250-1000 mg orally 2-4 times daily. Treatment with neomycin may be complicated by ototoxicity and nephrotoxicity.

Rifaximin (Xifaxan) is a nonabsorbable antibiotic that received FDA approval in 2004 for the treatment of travelers' diarrhea and was given approval in 2010 for the reduction of recurrent hepatic encephalopathy. This drug was also approved in May 2015 for the treatment of diarrhea-predominant irritable bowel syndrome (IBS-D). Data from Europe suggest that rifaximin can decrease colonic levels of ammoniagenic bacteria, with resulting improvement in the symptoms of hepatic encephalopathy.

A double-blind, placebo-controlled trial, indicated that rifaximin can prevent the occurrence hepatic encephalopathy. In the study, 299 patients whose recurrent hepatic encephalopathy was in remission received either rifaximin 550 mg or placebo twice daily. Each group also received lactulose. Breakthrough episodes of hepatic encephalopathy occurred in 22% of patients treated with rifaximin and in 46% of patients who were given placebo, while hepatic encephalopathy – related hospitalization occurred in 14% of rifaximin patients and in 23% of placebo patients. [44] Rifaximin also appeared to be more effective than lactulose in trials that compared the 2 drugs head-to-head. [45]

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