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ASGE 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.”
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.
Perspective
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David J. Bjorkman, MD, MSPH
It is helpful to put this guideline in historical perspective. Many years ago, based on animal studies, patients with even minimal valvular heart disease or mitral valve prolapse were recommended to have antibiotic prophylaxis for any minimally invasive procedure, including dental work and endoscopy. Subsequent studies and clinical experience have demonstrated that bacteremia is a frequent occurrence in every day life, and that the risk of infectious endocarditis is very low in most situations.
For several versions of this guideline it has focused on evidence-based stratification of the risk of the endoscopic procedure to cause bacteremia or local infection and conditions that place specific patients at risk for infection. Matching the risk of the procedure with the risk of the patient has limited the recommendations for antibiotics to prevent endocarditis to a handful of specific conditions and procedures. Similarly, initial recommendations for antibiotic use in the setting of artificial joints or vascular grafts have not been supported by evidence and the recommendation eliminated.
There are some situations where good prospective data demonstrate that antibiotic use prevents subsequent infection. Probably the best example is the evidence that pre-procedure antibiotics decrease the incidence of wound infections after percutaneous gastrostomy. Another situation where antibiotics are clearly indicated is in people who have cirrhosis and ascites with GI bleeding. The likelihood of bacterial peritonitis is so high that antibiotic therapy is indicated. Other situations, including placing instruments or injecting contrast into closed spaces, such as undrained bile ducts or cystic lesions also increase the risk of local infection and warrant antibiotic therapy.
The ultimate result is that as more data and experience have accumulated over time, prophylactic antibiotics are indicated in fewer and fewer situations. On the other hand, there are other areas where we have stronger evidence that support the indication of antibiotics to prevent local infections. The overall use of periprocedure antibiotics following these guidelines has been narrowed to those cases where we have good data to support their use. The guideline also provides the reader with the strength of the evidence for each recommendation.
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