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  1. 1. Gastrointestinal Endoscopic Procedures and Antibiotic Prophylaxis Patrick Pfau, M.D. Director of Gastrointestinal Endoscopy Section of Gastroenterology and Hepatology
  2. 2. GI Procedures and Antibiotic Prophylaxis <ul><li>Prevention of endocarditis </li></ul><ul><li>Synthetic vascular grafts </li></ul><ul><li>Prosthetic joint or orthopedic prosthesis </li></ul><ul><li>Patient with cirrhosis/ascites </li></ul><ul><li>Immunocompromised patient </li></ul><ul><li>Peritoneal dialysis </li></ul><ul><li>Goal – Provide adequate prophylaxis to the correct patients without unnecessary use of antibiotics </li></ul>
  3. 3. GI endoscopy and risk of endocarditis <ul><li>Only 15 cases of endocarditis post endoscopy exist in literature </li></ul><ul><li>Need to identify high risk procedures and high risk patients to determine who needs antibiotic prophylaxis </li></ul>
  4. 4. Risk of endocarditis <ul><li>High risk of endocarditis = High risk of bacteremia </li></ul><ul><li>Usually mouth commensals, most commonly strep viridans </li></ul><ul><li>Strep faecalis, Enterococcus, and Klebsiella have been described with colonoscopy </li></ul><ul><li>Bacteremia almost always short lived (<30 minutes) and not of clinical consequence </li></ul>
  5. 5. Risk of Procedure <ul><li>High risk procedures </li></ul><ul><ul><li>Esophageal stricture dilation (12-22 % bacteremia rate) </li></ul></ul><ul><ul><li>Variceal sclerotherapy (up to 30% bacteremia rate) </li></ul></ul><ul><ul><li>Use of Nd: Yag laser </li></ul></ul><ul><ul><li>ERCP with obstructed bile duct </li></ul></ul><ul><li>Low risk procedures </li></ul><ul><ul><li>All other GI procedures (0-4% bacteremia rate) </li></ul></ul>
  6. 7. Endocarditis risk of patient with GI endoscopy <ul><li>High risk patients </li></ul><ul><ul><li>Prosthetic heart valve </li></ul></ul><ul><ul><li>Previous bacterial endocarditis </li></ul></ul><ul><ul><li>Surgical pulmonary shunt </li></ul></ul><ul><ul><li>Cyanotic congenital heart disease </li></ul></ul><ul><ul><ul><li>Transposition of the vessels, tetralogy of Fallot </li></ul></ul></ul>
  7. 8. Endocarditis risk of patient with GI endoscopy <ul><li>Intermediate risk </li></ul><ul><ul><li>Valvular dysfunction </li></ul></ul><ul><ul><li>Hypertrophic cardiomyopathy </li></ul></ul><ul><ul><li>MVP with valve regurgitation/thickened leaflets </li></ul></ul><ul><li>No risk </li></ul><ul><ul><li>Previous CABG </li></ul></ul><ul><ul><li>Pacemakers or defibrillators </li></ul></ul><ul><ul><li>MVP without valve dysfunction </li></ul></ul><ul><ul><li>ASD </li></ul></ul><ul><ul><li>Surgically repaired ASD, VSD, or patent ductus </li></ul></ul><ul><ul><li>Heart murmur </li></ul></ul>
  8. 9. ASGE and AHA recommendations <ul><li>For most GI procedures (EGD, colonoscopy, sigmoidoscopy) </li></ul><ul><ul><li>Antibiotics not recommended for patients with no risk or immediate risk of endocarditis </li></ul></ul><ul><ul><li>Insufficient data on prophylaxis for high risk patients undergoing standard procedures </li></ul></ul><ul><ul><ul><li>Decide case-by-case basis – “We give it” </li></ul></ul></ul>
  9. 10. ASGE and AHA recommendations <ul><li>For high risk procedures (esophageal dilation or sclerotherapy) </li></ul><ul><ul><li>Antibiotic prophylaxis recommended for high risk groups </li></ul></ul><ul><ul><li>Antibiotic prophylaxis not recommended for groups with no risk </li></ul></ul><ul><ul><li>Groups with intermediate risk for endocarditis should be given antibiotics on a case-by-case basis </li></ul></ul>
  10. 11. Endocarditis prophylaxis – what do we give ? <ul><li>Ampicillin 2 G IV 30 minutes prior to the procedure </li></ul><ul><li>Gentamicin 80 mg IV 30 minutes prior to the procedure </li></ul><ul><li>Amoxicillin 1.5 G po 6 hours after procedure </li></ul><ul><li>If PCN allergic , substitute Vancomycin 1G for Ampicillin </li></ul>
  11. 12. Endocarditis prophylaxis – Does it work ? <ul><li>Who Knows ? </li></ul><ul><ul><li>Vandermeer JT Lancet 1992 case control series suggests that antibiotic prophylaxis has little affect on endocarditis rates post medical procedures </li></ul></ul><ul><ul><li>ASGE has graded the level of evidence – there is no data - prospective trial nor observational study that supports endocarditis prophylaxis </li></ul></ul><ul><ul><li>Recommendations solely on basis of expert opinion </li></ul></ul>
  12. 13. Patient with a synthetic vascular graft <ul><li>High risk of infection in grafts that have been in place for less than 12 months </li></ul><ul><li>Infection of graft can result in significant morbidity and even mortality </li></ul><ul><li>Official recommendation – antibiotic prophylaxis for new grafts (< 12 months) in high risk procedures </li></ul><ul><li>In practice we often will provide prophylaxis for all GI procedures and give prophylaxis for all grafts independent of when they were placed </li></ul>
  13. 14. Patients with prosthetic joints <ul><li>One case report of infected joint after an endoscopic procedure </li></ul><ul><li>Official recommendation is antibiotics are not indicated for patients with prosthetic joints </li></ul><ul><li>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 </li></ul><ul><li>Without much evidence antibiotics are often given for “fresh” joint replacements </li></ul>
  14. 15. Ascites/Cirrhosis <ul><li>More susceptible to transient episodes of bacteremia </li></ul><ul><li>High risk procedures (dilation and sclerotherapy) antibiotics should be considered on a case to case basis </li></ul><ul><li>Antibiotics not recommended in general GI endoscopic procedures </li></ul><ul><li>All cirrhotics undergoing GI bleed should receive antibiotics </li></ul>
  15. 16. Immunocompromised patient <ul><li>Neutropenic and bone marrow transplant to be decided on case to case basis </li></ul><ul><ul><li>American societies have no advice however British societies recommend antibiotic prohylaxis for severe neutropenia </li></ul></ul><ul><ul><li>In practice we make decision with hematologists/oncologists </li></ul></ul><ul><li>Not recommended for HIV/AIDS patients </li></ul>
  16. 17. Patients on Peritoneal dialysis <ul><li>Case reports exist of peritonitis after colonoscopy with polypectomy </li></ul><ul><li>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 </li></ul>
  17. 18. Special procedures and antibiotic prophylaxis <ul><li>ERCP and obstructed bile duct </li></ul><ul><ul><li>Antibiotics always given </li></ul></ul><ul><ul><li>Prevents cholangitis and post-procedure sepsis </li></ul></ul><ul><li>Endoscopic ultrasound and Fine Needle Aspiration </li></ul><ul><ul><li>Only required in cystic lesions – prevents cyst infection if contents are not completely evacuated </li></ul></ul><ul><li>PEG placement </li></ul><ul><ul><li>Antibiotics reduce wound infection by 20% </li></ul></ul>
  18. 19. Antibiotic Prophylaxis for Endoscopic Procedures Patient Condition Procedure Contemplated Antibiotic Prophylaxis High risk: Prosthetic Valve Hx Endocarditis Syst-Pulm Shunt Synth Vasc Graft (<1yr old) Complex Cyanotic congenital heart disease Stricture Dilation Variceal Sclerotherapy ERCP/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 abnormalities Acquired valvular dysfunction (eg. Rheumatic heart disease) Hypertrophic Cardiomyopathy Mitral valve prolapse with regurgitation or thickened leaflets Esophageal Stricture Dilation Variceal Sclerotherapy ERCP/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 Dilation Variceal 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)
  19. 20. Summary <ul><li>Little evidence to guide clinician in the need for and effectiveness of antibiotic prophylaxis for GI procedures </li></ul><ul><li>Remember high risk procedures and high risk patients </li></ul><ul><li>In general prophylaxis is implemented on the day of procedure </li></ul><ul><li>Helpful if on endoscopy request list high risk patients are identified – this adds another check to make sure the proper patients receive antibiotics </li></ul>