Antibiotic Prophylaxis in Gastrointestinal Endoscopy.Pdf

Endoscopy Unit Documentation

The policy of the Endoscopy unit in the Royal Infirmary is to administer antibiotic prophylaxis in gastrointestinal endoscopy according to the guidelines issued by the British Society of Gastroenterology (September 1996). A full .pdf document of these guidelines and other guidelines can be found and downloaded from the web site of the Society at http://www.bsg.org.uk/clinical_prac/guidelines.htm.

The principles of antibiotic prophylaxis are summarised below:

1. Antibiotic prophylaxis is recommended for endoscopic procedures if the patient is at high risk of endocarditis or of symptomatic bacteraemia as a consequence of immunosuppression or neutropenia. In most circumstances parenteral amoxycillin and gentamicin are recommended. The addition of parenteral metronidazole is recommended in patients with neutropenia. Vancomycin or teicoplanin are recommended in patients allergic to penicillin.

2.Antibiotic prophylaxis is recommended for all patients undergoing ERCP with evidence of biliary stasis or pancreatic pseudocyst. Oral ciprofloxacin or parenteral gentamicin (or parenteral quinolone, cephalosporin or ureidopenicillin) are recommended for ERCP.

Table 1: Conditions associated with the risk of endocarditis or symptomatic bacteraemia (BSG Guidelines Sept 1996) Higher risk Moderate, low or theoretical No increased risk risk Prosthetic heart valve Mitral valve prolapse with Mitral valve prolapse Previous endocarditis insufficiency without insufficiency Surgically constructed Rheumatic valvular or Uncomplicated systemic-pulmonary shunt or congenital cardiac lesion secundum atrial septal conduit Hypertrophic cardiomyopathy defect Synthetic vascular graft less Ventriculo peritoneal shunt Cardiac pacemaker than 1 year old Heart transplant Coronary artery bypass Severe neutropenia Moderate neutropenia graft (neutrophils <100x109 /litre) (neutrophils 100-500/109 /litre Implanted defibrillator Peritoneal Dialysis All other patients

Table 2: Approximate incidence of bacteraemia in immunocompetent individuals following various procedures involving the gastrointestinal tract. (BSG guidelines Sept 1996). Procedure Incidence of bacteraemia (%)* UPPER LOWER OTHER Diagnostic upper Rectal digital examination 4 Tooth brushing 25 gastrointestinal endoscopy 4 Proctoscopy 5 Dental extraction 30-60 Oesophageal varices Barium enema 11 band ligation 6 Sigmoidoscopy 6-9 sclerotherapy 10-50** Colonoscopy 2-4 * summary of published Oesophageal dilatation/prosthesis 34-54 data Oesophageal laser therapy 35 ** higher after ERCP (no duct occlusion) 6 emergency than ERCP (duct occluded) 11 elective management

Please Note: The information contained within this document is under Copyright and has been prepared by the Endoscopy Unit for the sole purpose of informing Clinical Staff of the protocols and Guidelines adopted within this unit and should not be freely distributed. Disclaimer The Endoscopy Unit have made all reasonable efforts to ensure the accuracy of the information on this site, but can take no responsibility for your use of it. Nor can the Endoscopy Unit take responsibility for anything contained in other linked sites. The purpose of the site is informational and educational, and it is not a substitute for medical advice. If you are in any doubt as to your medical condition, or if you are in need of advice, you should consult your doctor or other health professional.

Endoscopy Unit Documentation

Table 3: Recommendations for Antibiotic Prophylaxis in Gastrointestinal Endoscopy "Who to give antibiotics to" (BSG Guidelines Sept 1996). Patient Risk Group Antibiotic Prophylaxis All procedures higher risk of endocarditis * + (regimen A1 or A2)# severe neutropenia (neutrophils <100x109 /l)* + (regimen C)# moderate or low risk of endocarditis* - not necessary ERCP higher risk of endocarditis * + (regimen A1 or A2)#

bile stasis pancreatic pseudocyst +(regimen B)# previous cholangitis  NOTE: += prophylaxis * See Table 1 - = no prophylaxis # See Table 4

Table 4: Recommended antibiotics (BSG Guidelines Sept 1996) A1. Patients not allergic to A2. Patients allergic to B. Biliary C.Patients with penicillin and who have not had penicillin or who have had endoscopic severe penicillin more than once in the penicillin more than once procedures neutropaenia previous month. in the previous month. (neutrophils <100x109 /litre) Adults: Adults: Oral Adults: 1 gram amoxycillin Vancomycin 1 gram by ciprofloxacin Add intramuscularly in 2.5ml 1% slow intravenous infusion 750mg 60-90 metronidazole lignocaine hydrochloride plus over 100 minutes minutes be-fore 7.5mg/kg 120mg gentamicin followed by gentamicin procedure, intravenously to intramuscularly just before start 120mg intravenously at OR any of the above of procedure (or 1 gram start of procedure or 15 gentamicin regimes A1, A2 or amoxycillin in 20ml water minutes before the 120mg B. intravenously over 3-4 minutes procedure. intravenously Children under 10 plus 120mg gentamicin i.v.). OR just before the years: Then 500mg amoxycillin orally 6 teicoplanin 400mg procedure, Add hours later. intravenously followed by OR metronidazole Children under 10 years gentamicin 120mg a parenteral 7.5mg/kg Amoxycillin 500mg intravenously at start of quinolone, intravenously to intramuscularly in 2.5ml procedure or 15 minutes cephalosporin any of the above 1% lignocaine hydrochloride plus before the procedure. or regimes A1, A2 or gentamicin 2mg/kg body weight Children under 10 years: ureidopenicillin B. intramuscularly (or 500mg Vancomycin 20mg/kg by given amoxycillin in 10ml water slow intravenous in-fusion intravenously intravenously over 3-4 minutes followed by gentamicin just before the plus gentamicin 2mg/kg body 2mg/kg intravenously. procedure. weight intravenously.) OR Then one oral dose of teicoplanin 6mg/kg amoxycillin 6 hours later. intravenously followed by (Children 5-9 years, 250mg; gentamicin 2mg/kg children 0-4years, 125mg.) intravenously.