1、Gastrointestinal Endoscopic Procedures and Antibiotic Prophylaxis,Patrick Pfau, M.D. Director of Gastrointestinal Endoscopy Section of Gastroenterology and Hepatology,GI Procedures and Antibiotic Prophylaxis,Prevention of endocarditis Synthetic vascular grafts Prosthetic joint or orthopedic prosthes
2、is Patient with cirrhosis/ascites Immunocompromised patient Peritoneal dialysisGoal Provide adequate prophylaxis to the correct patients without unnecessary use of antibiotics,GI endoscopy and risk of endocarditis,Only 15 cases of endocarditis post endoscopy exist in literatureNeed to identify high
3、risk procedures and high risk patients to determine who needs antibiotic prophylaxis,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 Bacte
4、remia almost always short lived (30 minutes) and not of clinical consequence,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 o
5、ther GI procedures (0-4% bacteremia rate),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,Endocarditis risk of patient
6、 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,ASGE and AHA recommen
7、dations,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”,ASGE and AHA recommen
8、dations,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,Endocardit
9、is 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,Endocarditis prophylaxis Does it work ?,Who Knows ? Vander
10、meer 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 solel
11、y on basis of expert opinion,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) i
12、n 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,Patients with prosthetic joints,One case report of infected joint after an endoscopic procedure Official recommendation is antibiotics a
13、re 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 evidenc
14、e antibiotics are often given for “fresh” joint replacements,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 procedur
15、es All cirrhotics undergoing GI bleed should receive antibiotics,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
16、 decision with hematologists/oncologists Not recommended for HIV/AIDS patients,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 pr
17、ior to GI procedures particularly colonoscopy and emptying the abdomen of fluid prior to the procedure,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
18、Only required in cystic lesions prevents cyst infection if contents are not completely evacuated PEG placement Antibiotics reduce wound infection by 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,
