Antibiotic prophylaxis for gastrointestinal endoscopic procedures
- George W Meyer, MD, MACP, MACG
George W Meyer, MD, MACP, MACG
- Clinical Professor of Medicine
- University of California Davis, School of Medicine
The value of antibiotic prophylaxis for gastrointestinal (GI) procedures has been debated for many years. Previously, antibiotic prophylaxis was recommended for many GI procedures in patients with high-risk cardiac conditions to protect against infective endocarditis. However, practices have substantially changed, in part due to the low incidence of infective endocarditis following GI procedures and the lack of randomized trials supporting the benefit of antibiotic prophylaxis. Furthermore, the indiscriminate use of antibiotics can be associated with the development of resistant organisms, Clostridium difficile colitis, unnecessary expense, and drug toxicity. (See "Clostridium difficile in adults: Epidemiology, microbiology, and pathophysiology", section on 'Antibiotic use'.)
Recommendations for antibiotic prophylaxis prior to GI procedures will be reviewed here. General issues related to prophylaxis for bacterial endocarditis are discussed separately. (See "Antimicrobial prophylaxis for bacterial endocarditis".)
In 2015, the American Society for Gastrointestinal Endoscopy updated its guideline on antibiotic prophylaxis for GI procedures . Guidelines were also published by the American Heart Association in 2007  and by the British Society of Gastroenterology in 2009 . The discussion that follows is generally consistent with all three guidelines.
Infections following endoscopic procedures are rare and are presumably the result of bacteremia induced during the procedure or, in the case of procedures such as pancreatic cyst aspiration, the result of inoculation with bacteria during the procedure.
Bacteremia results from translocation of endogenous bacteria into the blood stream via mucosal trauma, whereas inoculation of sterile tissues or spaces (eg, cysts) occurs from direct contact with a contaminated endoscope or endoscopic accessory. Contrast injection may also result in bacteria being introduced into a previously sterile space (eg, the biliary tree during endoscopic retrograde cholangiopancreatography).
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- RATES OF BACTEREMIA AND INFECTION
- Routine activities
- High-risk procedures
- Low-risk procedures
- WHEN TO USE ANTIBIOTIC PROPHYLAXIS
- Specific procedures
- - Routine upper endoscopy, colonoscopy, and flexible sigmoidoscopy
- - Endoscopic retrograde cholangiopancreatography (ERCP)
- - Endoscopic ultrasound
- - Percutaneous endoscopic gastrostomy or jejunostomy placement
- Patient factors
- - Cardiac conditions
- - Immunocompromised states
- - Cirrhosis
- - Synthetic vascular grafts
- - Prosthetic joints
- - Peritoneal dialysis
- ANTIBIOTIC REGIMENS
- SUMMARY AND RECOMMENDATIONS