BACKGROUND AND AIMS
Fluoroquinolone (FQ) antibiotics are currently the acceptable therapy for spontaneous bacterial peritonitis (SBP) prophylaxis in selected patients with cirrhosis.1 Based on additional comorbidities and fluid/electrolyte imbalance, these patients may have multiple other risk factors for prolonged corrected QT interval (QTc) beyond low-dose FQ therapy.2 Prolonged QTc can be associated with the risk of a life-threatening ventricular arrhythmia, torsades de pointes, which can lead to syncope, cardiac arrest, or sudden cardiac death.3-7
MATERIALS AND METHODS
Consecutive adult patients with liver cirrhosis hospitalized from June 2022–June 2024 who were on FQ therapy for SBP prophylaxis for at least 72 hours during the inpatient stay (regardless of outpatient therapy) with an available ECG were included in the study. Outcomes, measured retrospectively, included: the incidence of prolonged QTc (>450 ms), the number of cumulative risk factors associated with prolonged QTc in each patient while on FQ therapy, and any documented ventricular arrhythmia.
RESULTS
During the study period, 72 (36% female) patients with liver cirrhosis who met the study criteria were identified (Table 1). The majority of patients were on low dose ciprofloxacin (250 mg once a day). The average duration of FQ prophylactic therapy during hospitalization was 8.3 days (range: 3–30). The median age of patients was 53 years (interquartile range: 37–61). Among these 72 patients, concomitant risk factors for prolonged QTc were renal dysfunction (63%), hypokalemia (14%), hypomagnesemia (32%), azole therapy (2.8%), selective serotonin reuptake inhibitor therapy (9.7%), and diuretic therapy (26%). Cumulative risk factors (besides FQ therapy) for prolonged QTc were: one risk factor (22%), two risk factors(39%), three risk factors (28%), and ≥4 risk factors (11%). Prolonged QTc interval (>450 ms) was seen in 66% of the patients, with none having any evidence of ventricular arrhythmias.
CONCLUSION
Patients with liver cirrhosis are at risk of polypharmacy and organ dysfunction, resulting in multiple risk factors for prolonged QTc. While 66% of patients had evidence of a prolonged QTc on routine ECG and had multiple other concomitant risk factors for prolonged QTc, none of the patients had evidence of any ventricular arrhythmias during their hospitalization. Prolonged QTc alone may not be considered an absolute contraindication for the use of FQs for SBP prophylaxis, when overall benefit is considered to be more than the risk. Active identification and treatment of potentially modifiable risk factors may help prevent any ventricular arrhythmias in patients with liver cirrhosis on FQ prophylaxis
