GUIDELINE Antibiotic prophylaxis for GI endoscopy This is one of a series of statements discussing the use of procedure. Endoscopy-related bacteremia carries a small GI endoscopy in common clinical situations. The Stan- risk of localization of infection in remote tissues (ie, infec- dards of Practice Committee of the American Society for tive endocarditis [IE]). Endoscopy also may result in local Gastrointestinal Endoscopy (ASGE) prepared this docu- infections in which a typically sterile space or tissue is ment, and it updates a previously issued document on breached and contaminated by an endoscopic accessory this topic.1 In preparing this guideline, MEDLINE and or by contrast material injection. This document is an up- PubMed databases were used to search for publications date of the prior ASGE document on antibiotic prophylaxis between January 1975 and December 2013 pertaining for GI endoscopy,1 discusses infectious adverse events to this topic. The search was supplemented by accessing related to endoscopy, and provides recommendations for the “related articles” feature of PubMed, with articles periprocedural antibiotic therapy. identified on MEDLINE and PubMed as the references. Additional references were obtained from the bibliogra- phies of the identified articles and from recommenda- BACTEREMIA ASSOCIATED WITH tions of expert consultants. When few or no data were ENDOSCOPIC PROCEDURES available from well-designed prospective trials, emphasis was given to results from large series and reports from Bacteremia can occur after endoscopic procedures and has been advocated as a surrogate marker for IE risk. How- recognized experts. Weaker recommendations are indi- fi cated by phrases such as “We suggest.” whereas stronger ever, clinically signi cant infections are extremely rare. “ .” Despite an estimated 14.2 million colonoscopies, 2.8 recommendations are stated as We recommend The fl strength of individual recommendations was based on million exible sigmoidoscopies, and perhaps as many up- 2 per endoscopies performed in the United States each both the aggregate evidence quality (Table 1) and an 3 fi year, only approximately 25 cases of IE have been reported assessment of the anticipated bene ts and harms. 4-6 ASGE guidelines for appropriate use of endoscopy are with temporal association to an endoscopic procedure. based on a critical review of the available data and There are no data demonstrating a causal association be- expert consensus at the time that the documents are tween endoscopic procedures and IE or that antibiotic pro- phylaxis prior to endoscopic procedures protects against drafted. Further controlled clinical studies may be fl needed to clarify aspects of this document. This guideline IE. Finally, much of the existing data re ects estimated risk associated with conventional endoscopic techniques. may be revised as necessary to account for changes in fi technology, new data, or other aspects of clinical practice There are no results available that con dently quantify and is solely intended to be an educational device to pro- bacteremia rates with newer endoscopic procedures such vide information that may assist endoscopists in as per oral endoscopic myotomy, endoscopic submucosal providing care to patients. This document is not a rule dissection, or endoscopic mucosal resection. and should not be construed as establishing a legal stan- dard of care or as encouraging, advocating, requiring, Procedures associated with a high risk of or discouraging any particular treatment. Clinical deci- bacteremia sions in any particular case involve a complex analysis The highest rates of bacteremia have been reported of the patient’s condition and available courses of action. with esophageal dilation, sclerotherapy of varices, and Therefore, clinical considerations may lead an endoscop- instrumentation of obstructed bile ducts. The rate of bacteremia following esophageal bougienage was demon- ist to take a course of action that varies from the recom- 7-9 mendations and suggestions proposed in this document. strated to be 12% to 22% in 3 prospective trials. Cultured organisms usually are commensal to the mouth. In 1 study, Streptococcus viridans was the organism isolated in 79% Bacterial translocation of endogenous microbial flora of cases.7 Bacteremia may be more frequent with dilation into the bloodstream may occur during endoscopy of malignant strictures than with benign strictures.8 Bacter- because of mucosal (or deeper) trauma related to the emia also may be more frequent with passage of multiple dilators compared with a single dilation.8 Copyright ª 2015 by the American Society for Gastrointestinal Endoscopy Estimates of bacteremia associated with variceal sclero- 0016-5107/$36.00 therapy have been reported to be as high as 52%, with a 10-13 http://dx.doi.org/10.1016/j.gie.2014.08.008 mean of 14.6%. Endoscopic variceal ligation, which www.giejournal.org Volume 81, No. 1 : 2015 GASTROINTESTINAL ENDOSCOPY 81 Antibiotic prophylaxis for GI endoscopy lesions is associated with a low risk of bacteremia, with 28 TABLE 1. GRADE system for rating the quality of 1 study reporting a risk of 2%. evidence for guidelines2 Bacteremia associated with routine daily Quality of evidence Definition Symbol activity Transient bacteremia occurs frequently during routine High Further research is very unlikely 4444 to change our confidence in the daily activity, often at rates exceeding those associated estimate of effect. with endoscopic procedures. Brushing and flossing of teeth has been associated with rates of bacteremia of Moderate Further research is likely to have 444B an important impact on our 20% to 68%, use of toothpicks with rates of 20% to 40%, confidence in the estimate of and even activity that might be considered entirely physio- effect and may change the logic, such as chewing food, with rates ranging from 7% to estimate. 51%.29 Given the relative rarity with which most individuals Low Further research is very likely to 44BB undergo endoscopic procedures, the frequency and risk of have an important impact on endoscopy-related bacteremia is trivial compared with the our confidence in the estimate frequency of bacteremia encountered with routine daily ac- of effect and is likely to change tivity. This provides a strong rationale against routine the estimate. administration of antibiotic prophylaxis for IE prior to Very low Any estimate of effect is very 4BBB endoscopic procedures. uncertain. ANTIBIOTIC PROPHYLAXIS FOR GI ENDOSCOPIC PROCEDURES has largely replaced sclerotherapy, has been associated The purpose of antibiotic prophylaxis during GI endos- with bacteremia rates of 1% to 25%, with a mean of 14-16 copy is to reduce the risk of iatrogenic infectious adverse 8.8%. events. Recommendations for antibiotic prophylaxis are Whereas ERCP in patients with non-obstructed bile summarized in Tables 2 and 3. ducts has been associated with a low rate of bacteremia of 6.4%, the incidence increases to 18% in the setting of Prevention of IE biliary obstruction because of stones or strictures.17 The 2007 American Heart Association (AHA) guidelines for prophylaxis of IE stated that the administration of Procedures associated with a low risk of prophylactic antibiotics solely to prevent IE was no longer bacteremia recommended for patients undergoing GI endoscopy.29 Gastroscopy with or without biopsy is associated with The AHA based its recommendations on several lines of rates of bacteremia up to 8%, with a mean of 4.4%.18-20 evidence including (1) cases of IE associated with GI pro- The observed bacteremia usually is short lived (!30 min- cedures are anecdotal, (2) no data demonstrate a conclu- utes) and not associated with infectious adverse events. sive link between GI procedures and the development of Rates of bacteremia associated with colonoscopy have IE, (3) there are no data that demonstrate that antibiotic been reported to be as high as 25%, with a mean of prophylaxis prevents IE after GI-tract procedures, (4) IE 4.4%.17 Bacteremia is uncommon (6.3%) even with thera- is more likely to be caused by bacteremia resulting from peutic colon procedures such as colonic stent insertion.21 usual daily activities, and (5) an extremely small number The rate of bacteremia with flexible sigmoidoscopy is ! of cases of IE may be prevented even if antibiotic prophy- 1%.22,23 laxis were 100% effective.29 There are no data on the risk of bacteremia associated The AHA also delineated cardiac conditions associated with device-assisted enteroscopy (eg, single-balloon and with the highest risk of an adverse outcome from IE, double-balloon enteroscopy, spiral enteroscopy), but it is including (1) prosthetic (mechanical or bioprosthetic) car- likely small and comparable to that of routine upper and diac valves, (2) history of previous IE, (3) cardiac transplant lower endoscopic procedures. recipients who develop cardiac valvulopathy, and (4) pa- The frequency of bacteremia after EUS, with or without tients with congenital heart disease (CHD) including those FNA, is within the range of that for diagnostic upper endos- with unrepaired cyanotic CHD including palliative shunts copy. Prospective studies in patients undergoing EUS- and conduits; those with completely repaired CHD with guided FNA (EUS-FNA) of cystic or solid lesions along prosthetic material or devices, placed surgically or by cath- the upper GI tract indicate a low prevalence of eter, for the first 6 months after the procedure; and those procedure-related bacteremia, ranging from 4.0% to with repaired