Gastrointestinal Endoscopic Procedures and Antibiotic Prophylaxis

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Gastrointestinal Endoscopic Procedures and
Antibiotic Prophylaxis

• Patrick Pfau, M.D.
• Director of Gastrointestinal Endoscopy
• Section of Gastroenterology and Hepatology

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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

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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

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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 (lt30
  minutes) and not of clinical consequence

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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)

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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

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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

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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

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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

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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

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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

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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 (lt 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

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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

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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

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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

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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

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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

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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