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Hepatic Encephalopathy — SCE Infectious Diseases MCQ

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EasyAntimicrobial StewardshipHepatic EncephalopathySCE Infectious Diseases

A 55-year-old man with cirrhosis is admitted with hepatic encephalopathy. He has had 3 episodes of hepatic encephalopathy in the past year despite lactulose. His hepatologist starts Rifaximin 550 mg BD as secondary prophylaxis. What is the main advantage of Rifaximin over systemic antibiotics for this indication?

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Correct answer: A — Rifaximin is non-absorbable; it acts locally in the gut with minimal systemic exposure and negligible risk of systemic resistance

Rifaximin is a non-absorbable rifamycin antibiotic that acts locally in the gut lumen. For secondary prophylaxis of hepatic encephalopathy (in combination with lactulose), it reduces recurrence by ~50%. Its non-systemic action means it does not contribute to systemic antimicrobial resistance. The RFHE-3005 trial demonstrated the benefit of Rifaximin in preventing recurrent hepatic encephalopathy. NICE recommends Rifaximin as add-on to lactulose after the second episode of overt HE.

Reference: NICE TA337 2015 – Rifaximin for hepatic encephalopathy; EASL 2024 – Cirrhosis guidelines