On-demand and shorter duration versus standard-duration antibiotic prophylaxis in cirrhotic patients with variceal bleeding: a systematic review and meta-analysis

Background The optimal duration of antibiotic prophylaxis in cirrhotic patients with variceal bleeding remains debated. Current guidelines (EASL, AASLD, Baveno VII) recommend 5-7 days of antibiotics, largely based on pre-2010 studies. While ceftriaxone reduces mortality, rebleeding, and infections, prolonged use may increase antimicrobial resistance, hospital length of stay, and costs. We evaluated whether shorter or on-demand antibiotic strategies are comparable to standard prophylaxis. Aim This systematic review and meta-analysis compared standard prophylaxis (5–7 days) with shorter (<5 days) or on-demand strategies. Primary outcomes were rebleeding and bacterial infections. Secondary outcomes included length of stay, infection subtypes, bilirubin at admission, and all-cause mortality. Results Thirteen studies including 2,194 patients were analyzed; ten were RCT's and three were retrospective studies. Heterogeneity was high (I 2 >50%). The pooled OR in favor of standard treatment strategies was 1.22 [95% CI:0.64–2.32] for rebleeding and 1.53 [0.66–3.54] for bacterial infections. Recent studies reported lower risk estimates than earlier studies. Meta-regression showed a downward trend in infection risk over time (p ≤0.0001). Secondary outcomes did not differ significantly. Conclusion Although pooled estimates numerically favored standard prophylaxis, recent evidence suggests that alternative strategies may be as effective. While this generates the hypothesis that current guideline recommendations may no longer reflect modern practice, the prevailing uncertainty emphasizes the need for new and adequately powered randomized trials before clinical practice can be definitively altered.