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Antibiotic prophylaxis in Endoscopy

The module covers:

  1. Current recommendations
  2. Who are at risk of infective endocarditis?
  3. What are the situations we must give antibiotic (and when not!)
  4. ERCP and antibiotics- the current consensus

Current Recommendations

Antibiotic prophylaxis is no longer recommended for the prevention of infective endocarditis in patients with cardiac risk factors who undergo diagnostic or therapeutic endoscopy.  The guidelines from American Heart Association (AHA), American Society of Gastrointestinal Endoscopy (ASGE), British Society of gastroenterology (BSG) and National Institute of Clinical Excellence (NICE) are broadly in agreement.

This change is based on three main considerations:

  • The rarity of infective endocarditis as a complication of endoscopy, and the absence of an exponential increased incidence to parallel the growth of endoscopy
  • The failure in many case reports to demonstrate a causal relationship between infective endocarditis and a preceding endoscopic procedure
  • The risks associated with antibiotic administration, namely allergy, antibiotic resistance and C difficile infection.

What are the cardiac conditions predisposing to risk of infective endocarditis?

  • acquired valvular heart disease with stenosis or regurgitation
  • valve replacement
  • structural congenital heart disease, including surgically corrected or palliated structural conditions, but excluding isolated ASD, fully repaired VSD or fully repaired PDA, and closure devices that are judged to be endothelialised
  • hypertrophic cardiomyopathy
  • Previous infective endocarditis.

Antibiotics are not recommended for any of the above conditions prior to endoscopy.

A word of caution

  1. The possibility of infective endocarditis should be considered in patients with known cardiac risk factors who develop symptoms and signs of infection during the weeks following an endoscopic procedure. Such patients should undergo prompt investigation and appropriate treatment.
  2. Clinical features of infective endocarditis
    • Systemic features: intermittent pyrexia, sweats, chills, rigors,anorexia, weight loss, arthralgia and fatigue. Systemic symptoms may be acute or insidious in onset.
    • Cardiac manifestations: new or worsening cardiac murmurs— typically due to valvular regurgitation; or the development of cardiac failure.
    • Extracardiac manifestations: embolic as well as vasculitic phenomena. All major vessels may be the recipient of infected emboli from valve vegetations. Renal, splenic and neurological complications may be particularly serious

What are the situations we must give antibiotic (and when not!)

Antibiotics are recommended in the following situations for all patients and not just patients at risk of infective endocarditis

PEG

  1. Patients having a percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ) should normally receive a single dose of intravenous co-amoxiclav (1.2gm) during the hour before the procedure.
  2. Patients already receiving broad-spectrum antibiotics do not require additional prophylaxis for PEG.
  3. Teicoplanin (400mg IV) is a logical alternative in penicillin allergic patients

Severe neutropenia (<0.5×109/l) and/or profound immunocompromised (eg, advanced haematological malignancy).

  1. Antibiotic prophylaxis in immunocompromised patients should be considered on an individual basis in patients undergoing GI procedures associated with a high risk of bacteremia ( dilatation, sclerotherapy, ERCP with obstructed system)
  2. Discuss with Microbiologist regarding choice

EUS

  1. Antibiotic prophylaxis is indicated for the fine needle aspiration of cystic lesions in or adjacent to the pancreas, and for endoscopic transgastric or transenteric drainage of pancreatic pseudocysts.
  2. Suggested antibiotic is Co-amoxyclav 1.2g iv before the procedure or ciprofloxacin 750mg orally single pre-procedure dose
  3. Not indicated for diagnostic EUS or FNA of solid organs.

ERCP and antibiotics- the current consensus

1. Routine prophylaxis for ERCP is no longer considered appropriate, but, if it proves impossible to achieve adequate biliary decompression, a full antibiotic course is indicated while arrangements are being made to achieve this goal by repeat ERCP or some other means.

2. There are specific circumstances where antibiotic prophylaxis should be given routinely to cover ERCP. These include:

  • patients with biliary disorders, such as primary sclerosing cholangitis or hilar cholangiocarcinoma, in whom it can be anticipated that complete biliary drainage will be difficult or impossible to achieve during one procedure,
  • patients with a history of liver transplantation,
  • patients with pancreatic pseudocyst,
  • patients with severe neutropenia (<0.5×109/l) and/or
  • advanced haematological malignancy.

3. When prophylaxis for ERCP is given, oral ciprofloxacin (750mg 60-90 minutes before procedure) or intravenous gentamicin (120 mg just before the procedure) is recommended.

4. Additional single-dose ERCP prophylaxis is not normally recommended for those already established on antimicrobial treatment for cholangitis.

Those who are used to get it

  • A group of patients who may turn out to be the most difficult to advise are those who have become accustomed to receiving antibiotic prophylaxis to cover procedures over many years.
  • For such individuals the NICE guidance states ‘‘Treatment and care should take into account patients’ needs and preferences. Patients should have the opportunity to make informed decisions about their care and treatment, in partnership with their healthcare professionals.’’
  • It is expected that the majority of such individuals will accept the changes in guidance, which have arisen with international consensus.
  • It is recognised that some patients will still choose to receive prophylaxis (amoxicillin 2 gms orally an hour before the procedure or ampicillin 2gm iv/im 30 minutes before the procedure. For penicillin allergic patients: options are clarithromycin 500 mg orally an hour before the procedure or vancomycin 1gm iv)

References:

  1. AHA guidelines
  2. BSG guidelines
  3. NICE guidance




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