Metabolic Brain Disease

, Volume 28, Issue 2, pp 307–312

Antibiotics for the treatment of hepatic encephalopathy

Original Paper

DOI: 10.1007/s11011-013-9383-5

Cite this article as:
Patidar, K.R. & Bajaj, J.S. Metab Brain Dis (2013) 28: 307. doi:10.1007/s11011-013-9383-5


The treatment of hepatic encephalopathy (HE) is complex and therapeutic regimens vary according to the acuity of presentation and the goals of therapy. Most treatments for HE rely on manipulating the intestinal milieu and therefore antibiotics that act on the gut form a key treatment strategy. Prominent antibiotics studied in HE are neomycin, metronidazole, vancomycin and rifaximin. For the management of the acute episode, all antibiotics have been tested. However the limited numbers studied, adverse effects (neomycin oto- and nephrotoxicity, metronidazole neurotoxicity) and potential for resistance emergence (vancomycin-resistant enterococcus) has limited the use of most antibiotics, apart from rifaximin which has the greatest evidence base. Rifaximin has also demonstrated, in conjunction with lactulose, to prevent overt HE recurrence in a multi-center, randomized trial. Despite its cost in the US, rifaximin may prove cost-saving by preventing hospitalizations for overt HE. In minimal/covert HE, rifaximin is the only systematically studied antibiotic. Rifaximin showed improvement in cognition, inflammation, quality-of-life and driving simulator performance but cost-analysis does not favor its use at the current time. Antibiotics, especially rifaximin, have a definite role in the management across the spectrum of HE.


Rifaximin Neomycin Covert hepatic encephalopathy Metronidazole Vancomycin Economics 

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Division of Gastroenterology, Hepatology and NutritionVirginia Commonwealth University and McGuire VA Medical CenterRichmondUSA

Personalised recommendations