Gastrointestinal Endoscopic Procedures and Antibiotic

Prophylaxis

Patrick Pfau, M.D.

Director of Gastrointestinal Endoscopy

Section of Gastroenterology and Hepatology

GI Procedures and Antibiotic Prophylaxis

• Prevention of endocarditis• Synthetic vascular grafts• Prosthetic joint or orthopedic prosthesis• Patient with cirrhosis/ascites• Immunocompromised patient• Peritoneal dialysis

• Goal – Provide adequate prophylaxis to the correct patients without unnecessary use of antibiotics

GI endoscopy and risk of endocarditis

• Only 15 cases of endocarditis post endoscopy exist in literature

• Need to identify high risk procedures and high risk patients to determine who needs antibiotic prophylaxis

Risk of endocarditis

• High risk of endocarditis = High risk of bacteremia

• Usually mouth commensals, most commonly strep viridans

• Strep faecalis, Enterococcus, and Klebsiella have been described with colonoscopy

• Bacteremia almost always short lived (<30 minutes) and not of clinical consequence

Risk of Procedure

• High risk procedures– Esophageal stricture dilation (12-22 % bacteremia rate)– Variceal sclerotherapy (up to 30% bacteremia rate)– Use of Nd: Yag laser– ERCP with obstructed bile duct

• Low risk procedures– All other GI procedures (0-4% bacteremia rate)

Endocarditis risk of patient with GI endoscopy

• High risk patients– Prosthetic heart valve– Previous bacterial endocarditis– Surgical pulmonary shunt– Cyanotic congenital heart disease

• Transposition of the vessels, tetralogy of Fallot

Endocarditis risk of patient with GI endoscopy

• Intermediate risk– Valvular dysfunction– Hypertrophic cardiomyopathy– MVP with valve regurgitation/thickened leaflets

• No risk– Previous CABG– Pacemakers or defibrillators– MVP without valve dysfunction– ASD– Surgically repaired ASD, VSD, or patent ductus– Heart murmur

ASGE and AHA recommendations

• For most GI procedures (EGD, colonoscopy, sigmoidoscopy)– Antibiotics not recommended for patients with

no risk or immediate risk of endocarditis– Insufficient data on prophylaxis for high risk

patients undergoing standard procedures• Decide case-by-case basis – “We give it”

ASGE and AHA recommendations

• For high risk procedures (esophageal dilation or sclerotherapy)– Antibiotic prophylaxis recommended for high

risk groups– Antibiotic prophylaxis not recommended for

groups with no risk– Groups with intermediate risk for endocarditis

should be given antibiotics on a case-by-case basis

Endocarditis prophylaxis – what do we give ?

• Ampicillin 2 G IV 30 minutes prior to the procedure

• Gentamicin 80 mg IV 30 minutes prior to the procedure

• Amoxicillin 1.5 G po 6 hours after procedure

• If PCN allergic , substitute Vancomycin 1G for Ampicillin

Endocarditis prophylaxis –Does it work ?

• Who Knows ?– Vandermeer JT Lancet 1992 case control series

suggests that antibiotic prophylaxis has little affect on endocarditis rates post medical procedures

– ASGE has graded the level of evidence – there is no data - prospective trial nor observational study that supports endocarditis prophylaxis

– Recommendations solely on basis of expert opinion

Patient with a synthetic vascular graft

• High risk of infection in grafts that have been in place for less than 12 months

• Infection of graft can result in significant morbidity and even mortality

• Official recommendation – antibiotic prophylaxis for new grafts (< 12 months) in high risk procedures

• In practice we often will provide prophylaxis for all GI procedures and give prophylaxis for all grafts independent of when they were placed

Patients with prosthetic joints

• One case report of infected joint after an endoscopic procedure

• Official recommendation is antibiotics are not indicated for patients with prosthetic joints

• Meyer G Am J Gastro, 1997 surveyed ID specialists. Most recommended not giving antibiotics for general procedures but 50% would give antibiotics for colonoscopy with polypectomy in artificial joints placed in the last 6 months

• Without much evidence antibiotics are often given for “fresh” joint replacements

Ascites/Cirrhosis

• More susceptible to transient episodes of bacteremia

• High risk procedures (dilation and sclerotherapy) antibiotics should be considered on a case to case basis

• Antibiotics not recommended in general GI endoscopic procedures

• All cirrhotics undergoing GI bleed should receive antibiotics

Immunocompromised patient

• Neutropenic and bone marrow transplant to be decided on case to case basis– American societies have no advice however

British societies recommend antibiotic prohylaxis for severe neutropenia

– In practice we make decision with hematologists/oncologists

• Not recommended for HIV/AIDS patients

Patients on Peritoneal dialysis

• Case reports exist of peritonitis after colonoscopy with polypectomy

• No recommendations per GI societies but the International Society for Peritoneal Dialysis has recommended antibiotics prior to GI procedures particularly colonoscopy and emptying the abdomen of fluid prior to the procedure

Special procedures and antibiotic prophylaxis

• ERCP and obstructed bile duct– Antibiotics always given

– Prevents cholangitis and post-procedure sepsis

• Endoscopic ultrasound and Fine Needle Aspiration– Only required in cystic lesions – prevents cyst infection

if contents are not completely evacuated

• PEG placement– Antibiotics reduce wound infection by 20%

Antibiotic Prophylaxis for Endoscopic Procedures

Patient Condition Procedure Contemplated Antibiotic Prophylaxis

High risk:Prosthetic ValveHx EndocarditisSyst-Pulm ShuntSynth Vasc Graft (<1yr old)Complex Cyanotic congenital heart disease

Stricture DilationVariceal SclerotherapyERCP/obstructed biliary tree

Recommended

Other endoscopic procedures including EGD and colonoscopy (with or without biopsy/polypectomy), variceal ligation

Prophylaxis Optional

Moderate Risk:Most other congenital abnormalitiesAcquired valvular dysfunction (eg. Rheumatic heart disease)Hypertrophic CardiomyopathyMitral valve prolapse with regurgitation or thickened leaflets

Esophageal Stricture Dilation Variceal SclerotherapyERCP/obstructed biliary tree

Prophylaxis is optional

Other endoscopic procedures including EGD and colonoscopy (with or without biopsy/polypectomy), variceal ligation

Not recommended

Low Risk:Other cardiac conditions (CABG, repaired septal defect or patent ductus, mitral valve prolapse without valvular regurg., isolated secundum atrial septal defect, physiologic/functional/innocent heart murmurs, rheumatic fever without valvar dysfunction, pacemakers, implantable defibrillators)

All endoscopic procedures Not recommended

Obstructed bile duct ERCP Recommended

Pancreatic cystic lesion ERCP, EUS-FNA Recommended

Cirrhosis acute GI Bleed All endoscopic procedures Recommended

Ascites, Immunocompromised Patient Stricture DilationVariceal Sclerotherapy

No Recommendation

Other endoscopic procedures including EGD and colonoscopy (with or without biopsy/polypectomy), variceal ligation

Not Recommended

All patients Percutaneous endoscopic feeding tube placement Recommended (parenteral

cephalosporin or equivalent)

Prosthetic joints All endoscopic procedures Not recommended

Cardiac Prophylaxis Regimens (oral 1 hour before, IM or IV 30 min before procedure)Amoxicillin PO or Ampicillin IV: adult 2.0 g, child 50 mg/kg Penicillin allergic: Clindamycin (Adult 600 mg, child 20 mg/kg), OR Cephalexin OR cefadroxil (adults 2.0 g, child 50 mg/kg), OR Azithromycin or clarithromycin (adult 500 mg, child 15 mg/kg), OR Cefazolin (adult 1.0 g , child 25 mg/kg IV or IM), OR Vancomycin (Adult 1.0 g, child 10-20 mg/kg IV)

Summary

• Little evidence to guide clinician in the need for and effectiveness of antibiotic prophylaxis for GI procedures

• Remember high risk procedures and high risk patients

• In general prophylaxis is implemented on the day of procedure

• Helpful if on endoscopy request list high risk patients are identified – this adds another check to make sure the proper patients receive antibiotics