Antibiotic Prophylaxis in Gastrointestinal System Endoscopy

ESD: Endoscopic submucosal dissection

EMR: Endoscopic mucosal resection

NOTES: Endoscopic surgery through natural openings

POEM: Peroral endoscopic myotomy

Antibiotic prophylaxis in gastrointestinal (GI) endoscopic procedures has been a controversial issue for many years. Which patients are in need? Which procedures require antibiotic prophylaxis? Which antibiotics should be used in which doses? Is it given before or after the procedure? There are many guidelines published by international associations aiming to answer these questions [1,2]. Under normal conditions, occurrence of an infection after an endoscopic procedure is extremely rare. The main purpose of antibiotic prophylaxis is to prevent this rare complication. However, bacterial antibiotic resistance caused by unnecessary use of antibiotics, side effects of antibiotics, allergic reactions and drug costs are prohibitive factors in their use. Antibiotic prophylaxis was recommended for many gastrointestinal endoscopic procedures in previous years, especially in patients with heart valve disease, but this practice has completely changed today [1,3]. 

After endoscopic procedures, infections occur in two ways; the first way is that a microorganism in the body transfers to the blood flow as a result of mucosal trauma, which is called ‘bacterial translocation’ or ‘bacteremia’. Another way is through use of endoscope and/or accessories to a previously known sterile cavity during procedures such as contrast injection, drainage, aspiration or pathological sampling [4].

In this regard, two important points should be considered when evaluating the patient:

Which procedure is going to be performed? Does the planned procedure pose a risk of a new infection or bacteremia?

What are the patient-dependent risk factors? What is the risk to the patient in terms of infectious complications? (Special patient groups such as patients with neutropenia, patients who have cirrhosis, renal failure or history of heart valve replacement).

The risk of transient bacteremia following gastrointestinal endoscopic procedures is lower than that caused by many routine activities in daily life. For example, tooth brushing and flossing (20-68%), using toothpicks (20-40%), consuming chewable foods (7-51%) have a risk of temporary bacteremia [5,6].

Dilatation in esophageal strictures

Multiple dilatations and malignancy-related dilatations have a higher risk [7]. 

Sclerotherapy for esophageal varices

The procedure of injecting a sclerosing agent into or around the varices is reported to have a 15% risk of bacteremia, but band ligation is not considered as a high risk [8]. In a recent study, 60 cirrhotic patients undergoing endoscopic band ligation for variceal bleeding and 112 elective ligation procedures were evaluated. Streptococcus mitis and Staphylococcus epidermidis were found in 3 post-procedural blood cultures. These findings were interpreted as transient bacteremia by the authors [9].

Endoscopic retrograde cholangiopancreatography (ERCP)

If there is a bile flow obstruction, the risk of bacteremia during the procedure as well as risk of post ERCP cholangitis are increased [10]. If biliary drainage is considered to be unsuccessful, antibiotics should be continued until drainage is achieved and cholangitis signs disappear. A review of the gastrointestinal endoscopic performance measures in ERCP and EUS procedures a published by European ESGE in 2018 emphasized the importance of pre-ERCP antibiotic use in patients with appropriate conditions [11].

Fine needle aspiration biopsy during the endoscopic ultrasonography (EUS-FNA)

Although this procedure has a low risk of bacteremia, the overall risk of infection has been found to be high [1]. The most important factor is the structure of the lesion. While the risk is higher with any intervention for cystic lesions, sampling of solid lesions is considered to be practically no risk of infection [12]. Prophylactic antibiotic usage before the puncture of cystic lesions is mentioned as another requirement for higher procedure performance in the ESGE review [11]. When all the results are evaluated, EUS-guided biliary drainage and cyst drainage are considered as high risk for infection and bacteremia [1]. 

Percutaneous endoscopic feeding tube placement (Gastrostomy-PEG- or Jejunostomy-PEJ-)

Studies have shown that pre-procedure antibiotic administration reduces the risk of wound infection at the site of tube insertion [13]. In a recent retrospective study of 781 patients, the rate of peristomal infection was reported to be 21.9%. The risk of peristomal infection was higher in patients receiving chemotherapy or radiotherapy [14]. 

The efficacy of submucosal gentamicin lavage before myotomy was evaluated in 124 POEM cases. This treatment does not reduce the risk of infection but may reduce the systemic inflammatory response [15]. In a prospective randomized controlled study by Lee et al., 100 patients undergoing colorectal ESD were evaluated. Post-ESD electrocoagulation syndrome was significantly low in the prophylactic ampicillin sulbactam group. In addition, C-reactive protein (CRP) elevation and abdominal pain were also observed less frequently in this group [16]. Although there is not much new information about these procedures in the literature, these procedures can be considered as high-risk procedures for bacteremia and de novo infections.

Diagnostic gastroscopy, colonoscopy and flexible rectosigmoidoscopy are considered low risk for infection and bacteremia [4,17]. Although a recent case of Streptococcus Bovis endocarditis has been reported after colonoscopic polypectomy, authors concluded that performing biopsy and polypectomy during the procedure is considered low-risk for infection and bacteremia [18].

Cardiac diseases

Patients who have prosthetic heart valves or history of infective endocarditis are considered to be high-risk cardiac lesions. However, guidelines in both cardiology and gastroenterology do not recommend prophylaxis before the GI endoscopic procedures even in these patients [1,2]. The only exception to this is to give prophylaxis in this group of patients if there is any known GI infection associated with active Enterococci before the procedure. 

Immunocompromised patients

Although there are not enough studies with a high level of evidence, the risk of infection after GI endoscopy is increased in patients with severe neutropenia (3) or advanced hematologic malignancy [19]. Therefore, to give an antibiotic prophylaxis before high-risk procedures is recommended. These patients should be followed up closely after low-risk procedures even if antibiotics are not given. Antibiotic prophylaxis before the endoscopic procedure is not recommended for immunocompromised patients who do not meet these conditions [1].

Cirrhosis

Patients with cirrhosis who present with GI bleeding should be given antibiotics whether endoscopic procedure is planned or not [20]. In addition, since the risk of bacterial translocation is higher in patients with cirrhosis and ascites, prophylaxis before high-risk procedures may be appropriate [21].

Patients with synthetic vascular graft

Prophylaxis is not required for low-risk endoscopic procedures. In high-risk endoscopic procedures, if the endoscopic procedure is elective, it is recommended to wait for 6 months after graft placement. If the patient is unable to wait for that period of time, the antibiotic prophylaxis should be given [2].

Patients with joint prosthesis

Antibiotic prophylaxis prior to GI endoscopic procedures is not recommended in the main guidelines [1,22].

Patients with peritoneal dialysis

Cases of peritonitis have been reported after colonoscopy and especially after polypectomy. In a study retrospectively evaluated 45 peritoneal dialysis patients undergoing endoscopy. The authors found that oral or intravenous prophylactic antibiotic use prior to non-EGD (non-esophagogastroduodenoscopy) examination significantly reduced the endoscopy associated peritonitis rate compared to that without antibiotic use [23]. However, in a recent prospective study showed that there was no significant difference in the rate of peritonitis between pre-procedure intraperitoneal antibiotic (ceftazidime) and non-antibiotic groups. In the same study, it was shown that polypectomy did not change the frequency of peritonitis [24]. Furthermore, The American Society of Gastrointestinal Endoscopy (ASGE) recommends that the peritoneal cavity should be empty and give antibiotic prophylaxis before the colonoscopy [1]. 

Which antibiotic should be given in which dose?

Antibiotics and their dosages according to patient and procedure risk are summarized in the table 1 [1,25,26].
 

EUS: Endoscopic Ultrasonography; FNA: Fine Needle aspiration; ERCP: Endoscopic retrograde Cholangiopacreatography; EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection; MRSA: Meticillin Resistant Staphylococcus aureus; POEM: Peroral endoscopic myotomy

Table 1: Antibiotic doses according to endoscopic procedures and clinical conditions.

Antibiotic prophylaxis in gastrointestinal endoscopic procedures is strongly recommended in two conditions: before the gastrointestinal endoscopic procedures with a high risk of developing new infections or patients whose disease increase susceptibility to infection and who will undergo a high bacteremia risk procedure. These guidelines form a road map based on the information provided by the medical literature. However, in borderline topics like antibiotic prophylaxis, it is necessary to interpret these information within one’s own clinical experience.

None declared

Ali Riza Koksal was supported by funds received from the Akdamar Fellowship Program, Department of Gastroenterology and Hepatology, Tulane University Health Sciences Center.