January 21, 2015
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ASGE guideline warns against routine antibiotic prophylaxis before GI endoscopy

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The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy has released an updated guideline on antibiotic prophylaxis for GI endoscopy. Informed by a critical review of data published up to December 2013 and expert consensus, the document provides recommendations for clinical practice regarding endoscopy-related infectious adverse events and periprocedural antibiotic therapy.

Raman Muthusamy

“Antibiotics are often administered somewhat haphazardly without necessarily strong data for their use, but I think what we’ve realized is the risk of adverse events from antibiotic use is probably greater than the risk of having an infectious complication,” Raman Muthusamy, MD, director of interventional endoscopy in the division of digestive diseases at UCLA Health System, and Standards of Practice Committee member, told Healio Gastroenterology. “That’s part of the reason why endocarditis prophylaxis has for the most part been eliminated; so we have very limited indications for the use of antibiotics for GI procedures, primarily because the risk of bacteremia from these procedures is generally quite low.”

Routine antibiotic prophylaxis for IE not recommended

According to the investigators, endoscopy-related bacteremia is associated with a very small risk for localized tissue infection such as infective endocarditis (IE), with only about 25 cases reported of the nearly 20 million procedures performed in the United States each year. No data indicate a causal link between endoscopic procedures and IE or a protective effect with pre-procedure antibiotics. Data on bacteremia rates with newer endoscopic procedures are also lacking.

Procedures with high rates of bacteremia include:

  • esophageal dilation (12% to 22%);
  • variceal sclerotherapy (up to 52%; mean 14.6%); and
  • endoscopic retrograde cholangiopancreatography (ERCP) of obstructed bile ducts (18% compared with 6.4% with nonobstructed bile ducts).

Low-risk procedures include:

  • gastroscopy with or without biopsy (up to 8%; mean 4.4%);
  • colonoscopy (up to 25%; mean 4.4%);
  • therapeutic colon procedures such as colonic stent insertion (6.3%);
  • flexible sigmoidoscopy (<1%);
  • device-assisted enteroscopy (no data; likely small); and
  • endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) of cystic or solid lesions in upper GI tract (4% to 5.8%); of solid rectal and perirectal lesions (2%).

“The frequency and risk of endoscopy-related bacteremia is trivial compared with the frequency of bacteremia encountered with routine daily activity,” the researchers wrote, citing 20% to 68% risk associated with brushing and flossing of teeth, 20% to 40% risk with use of toothpicks and 7% to 51% risk with chewing food. “This provides a strong rationale against routine administration of antibiotic prophylaxis for IE prior to endoscopic procedures.” 

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Antibiotic prophylaxis suggested for high-risk cardiac conditions

The 2007 American Heart Association guidelines for prophylaxis of IE no longer recommend prophylactic antibiotics for the sole prevention of IE for patients undergoing GI endoscopy, but suggest that for patients with high-risk cardiac conditions who have GI infections that may involve enterococci, particularly those undergoing an endoscopic procedure with increased risk for bacteremia, “inclusion of an agent active against enterococci in the concurrent antibiotic regimen may be reasonable.” These conditions include:

  • prosthetic cardiac valve;
  • history of IE;
  • cardiac transplant with cardiac valvulopathy; and
  • congenital heart disease. 

Prevention of other infections

For preventing other endoscopy-related infections, antibiotic prophylaxis may be useful for specific procedures and in specific clinical scenarios.

  • ERCP:
    • not recommended before ERCP without suspected obstructive biliary tract disease or anticipated complete biliary drainage; and
    • recommended before ERCP in patients with liver transplant or known/suspected biliary obstruction where incomplete biliary drainage is possible. If biliary drainage is incomplete antibiotics should be continued after the procedure.
  • EUS and EUS-FNA:
    • not recommended before diagnostic EUS or EUS-FNA of solid lesions of the GI tract; and
    • suggested before EUS-FNA of mediastinal, pancreatic or peripancreatic cysts.
  • Percutaneous endoscopic gastrostomy (PEG) or jejunostomy (PEJ):
    • recommended for all patients before PEG/PEJ tube placement.
  • Cirrhosis with GI bleeding:
    • recommended for all patients with cirrhosis admitted with GI bleeding.
  • Synthetic vascular grafts and other nonvalvular cardiovascular devices:
    • not recommended for these patients.
  • Orthopedic prostheses:
    • not recommended for these patients.
  • Immunocompromised patients and patients with neutropenia:
    • insufficient evidence to recommend for or against.
  • Patients receiving peritoneal dialysis:
    • suggested before endoscopy of the lower GI tract in patients undergoing continuous ambulatory peritoneal dialysis.

Disclosure: Khashab and another investigator are consultants for Boston Scientific, and Khashab also is a consultant for Olympus America and has received research support from Cook Medical.