Patel V, Lee S, McPhail M, et al. - According to this randomized placebo-controlled double-blind mechanistic study, patients using rifaximin had a lower risk of infection when their overt and covert hepatic encephalopathy (HE) resolved. Rifaximin-α reduced gut oralisation with mucin-degrading species attenuating systemic inflammation. Such findings suggest that rifaximin-α has a function in gut barrier repair as a strategy for reducing bacterial translocation and systemic endotoxemia in cirrhosis.

• Rifaximin-α 550mg (TARGAXAN) twice day (n = 19) or placebo (n = 19) was given for 90 days.

• Patients were well-matched: median MELD [11 rifaximin-α compared with 10 placebo].

• On day 30, rifaximin-α reduced circulating neutrophil TLR-4 expression, which was accompanied by a decrease in plasma tumor necrosis factor-α (TNF-α).

• Rifaximin-α inhibited gut oralisation, lowering the mucin-degrading sialidase-rich species Streptococcus spp, Veillonella atypica and parvula, Akkermansia and Hungatella.

• Rifaximin-α enhanced anti-bacterial responses to invading pathobionts and promoted gut barrier repair by generating a TNF-α and IL-17E enriched intestinal microenvironment.

• Those using rifaximin-α had a lower risk of infection.