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Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,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 prosthesis,Patient with cirrhosis/,ascites,Immunocompromised,patient,Peritoneal dialysis,Goal 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 literature,Need to identify high 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,Bacteremia 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 other 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 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 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”,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,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,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,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,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,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,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,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,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%,Antibiotic Prophylaxis for,Endoscopic,Procedures,Patient Condition,Procedure Contemplated,Antibiotic Prophylaxis,High risk:,Prosthetic Valve,Hx EndocarditisSyst,-,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 abnormalitiesAcquired,valvular,dysfunction (,eg,. Rheumatic heart disease),Hypertrophic CardiomyopathyMitral,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),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,
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