1. Gastrointestinal Endoscopic Procedures and Antibiotic Prophylaxis Patrick Pfau, M.D. Director of Gastrointestinal Endoscopy Section of Gastroenterology and Hepatology

2. 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

3. 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

4. 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

5. 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)

7. 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

8. 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

9. 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”

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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%

19. Antibiotic Prophylaxis for Endoscopic Procedures Patient ConditionProcedure ContemplatedAntibiotic 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 proceduresNot recommended Obstructed bile ductERCPRecommended Pancreatic cystic lesionERCP, EUS-FNARecommended Cirrhosis acute GI BleedAll endoscopic proceduresRecommended Ascites, Immunocompromised PatientStricture Dilation Variceal Sclerotherapy No Recommendation Other endoscopic procedures including EGD and colonoscopy (with or without biopsy/polypectomy), variceal ligation Not Recommended All patientsPercutaneous endoscopic feeding tube placementRecommended (parenteral cephalosporin or equivalent) Prosthetic jointsAll endoscopic proceduresNot 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)

20. 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