Spontaneous bacterial peritonitis (SBP) is the most common bacterial infection in cirrhotic patients. Historically, the bacterial spectrum was dominated by Gram-negative bacteria. However, recent studies showed that fluoroquinolone (FQ)-based prophylaxis promotes the intestinal overgrowth of Gram-positive bacteria and contributes to the selection of quinolone-resistant Gram-negative bacteria, increasing multidrug-resistant (MDR) organism infections. FQ resistance rates reach up to nearly one-third in community-acquired cases and 50% in hospital-acquired cases, raising concerns about FQ efficacy. Moreover, rare but serious side effects further limit FQ use. Predictive factors of FQ treatment failure have been identified, guiding management strategies. Rifaximin has emerged as a promising alternative for SBP prophylaxis, with encouraging results. This review aims to explore the shifting role of FQ-based SBP prophylaxis, focusing on the emerging concerns, side effects, and alternative strategies. While norfloxacin remains a first-line prophylactic in cirrhotic patients with low ascitic protein levels, its efficacy appears to be reduced in those with advanced liver failure or additional risk factors for MDR organisms. In these subgroups, alternative prophylactics, such as trimethoprim–sulfamethoxazole or rifaximin, may be preferable. We propose a risk-stratification approach to guide treatment selection, with further studies needed to refine these criteria.

Background: Early rebleeding after endoscopic variceal ligation (EVL) represents a serious complication in patients with cirrhosis and is associated with poor short-term outcomes. This study aimed to identify independent predictors of early rebleeding after EVL, with a particular focus on distinguishing factors associated with variceal rebleeding from those related to post-banding ulcer (PBU) bleeding, and to assess predictors of six-week mortality. Methods: We conducted a retrospective cohort study including 217 cirrhotic patients who underwent first emergency EVL for an index episode of esophageal variceal bleeding at a tertiary referral center. Early rebleeding was defined as recurrent upper gastrointestinal bleeding occurring between days 6 and 42 after the index EVL. Results: Early rebleeding occurred in 38/217 patients (17.5%): 27/38 (71.1%) variceal rebleeding and 11/38 (28.9%) PBU rebleeding. In multivariable logistic regression analysis, lower hemoglobin (OR = 0.19, 95% CI: 0.067–0.539, p = 0.002) and a higher albumin–bilirubin (ALBI) grade (OR = 24.94, 95% CI: 1.134–548.342, p = 0.041) were independently associated with increased odds of early variceal rebleeding, whereas a higher number of bands applied during index EVL (OR = 0.52, 95% CI: 0.302–0.896, p = 0.019) was independently associated with reduced odds of rebleeding, with excellent model discrimination (area under the curve [AUC] 0.981; 95% CI: 0.959–1.000). For PBU rebleeding, lower fibrinogen level was the only independent predictor (OR = 0.957, 95% CI: 0.916–1.000, p = 0.047), with strong discriminative performance (AUC 0.945; 95% CI: 0.909–0.982). Model for End-Stage Liver Disease (MELD) score, serum albumin, platelet count, and PBU rebleeding independently predicted six-week mortality. Conclusions: Markers of liver function, along with endoscopic parameters, predict early rebleeding after EVL, emphasizing the importance of the complete assessment of cirrhotic patients for refined risk stratification and tailored post-EVL management.