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isks of Infection from Gastrointestinal Endoscopyasma Shaukat, MD, and Douglas B. Nelson, MD, FASGE

The occurrence of bacteremia during gastrointestinal (GI) endoscopic procedures has beenreported in numerous studies, although it is usually transient and clinically significantinfectious complications are uncommon. Although reports of infectious endocarditis (IE)associated with endoscopy are extremely rare, antibiotic prophylaxis has historically beenrecommended for susceptible patients undergoing procedures with a high risk of bactere-mia. Recent guidelines from the American Heart Association no longer recommend the useof prophylactic antibiotics for prevention of IE during GI endoscopy. This article will reviewthe risk of bacteremia associated with various gastrointestinal endoscopic procedures, anddiscuss the rationale for antibiotic prophylaxis recommendations.Tech Gastrointest Endosc 9:225-232 © 2007 Elsevier Inc. All rights reserved.

KEYWORDS endocarditis, bacteremia, infection, prophylaxis, antibiotic

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nfectious complications resulting from bacteremia thatoccurs during routine gastrointestinal (GI) endoscopic

rocedures are uncommon and need to be differentiatedrom transmission of infection because of endoscope con-amination; the latter will discussed in an accompanyingrticle in this issue of the journal. Reported rates of bacte-emia following GI endoscopic procedures range from 0%o 50% and largely depend on individual patient and pro-edure characteristics. Fortunately, such bacteremia rarelyeads to a clinically significant infectious complication,ossibly because of the transient nature of the bacteremiand lack of a critical inoculum of bacteria required toause infection in an otherwise immunocompetent host.he rationale for antibiotic prophylaxis given before a pro-edure is to prevent or reduce the infectious complicationsesulting from bacteremia.

Ideally, one would want to use antibiotic prophylaxis inhigh-risk” patients, ie, individuals with host and endo-copic procedure factors that place them at increased riskor developing an infectious complication; this risk, how-ver, is not always known. Furthermore, antibioticshould have activity against the bacterial species previ-usly implicated in infectious complications from thatpecific endoscopic procedure. In this article, we discusshe risk of infection in two broad categories: infectiousndocarditis (attributed to systemic bacteremia resultingrom instrumentation of the GI tract) and local woundnfections or sepsis caused by specific endoscopic proce-ures. We also discuss patient- and procedure-related fac-

inneapolis VA Medical Center, University of Minnesota Medical School,Minneapolis, MN.

ddress reprint requests to Douglas B. Nelson, MD, FASGE, VA MedicalCenter (111D), One Veterans Drive, Minneapolis, MN 55417. E-mail:

vdouglas.nelson@med.va.gov

096-2883/07/$-see front matter © 2007 Elsevier Inc. All rights reserved.oi:10.1016/j.tgie.2007.08.003

ors and the strength of evidence and rationale for recom-ending antibiotic prophylaxis. Discussion regarding the

ppropriate antimicrobial agent of choice is beyond thecope of this review. The reader should refer to publishednd regularly updated guidelines on this topic from themerican Heart Association (AHA) and the American So-iety for Gastrointestinal Endoscopy (ASGE).1,2

acteremia andnfectious Endocarditis (IE)iagnostic Esophagogastroduodenoscopy

EGD) and Mucosal Biopsy with Control ofleeding

t has been postulated that transient bacteremia occurringfter upper GI endoscopy results from minor mucosal traumaollowing contact with the endoscope, thereby allowing oralnd gastrointestinal flora to gain access to the bloodstream.sing the approach of drawing blood cultures before, at the

ime of, or immediately after upper endoscopy, investigatorsave reported bacteremia rates that range from 0% to 8%.3-10

he rate of bacteremia increases with biopsy and also withontrol of bleeding by epinephrine injection or thermal co-gulation; even this small increase in bacteremia, however, isf no clinical consequence in most individuals. The patho-ens commonly involved in post EGD bacteremia are strep-ococcal species: Streptococcus viridians, Streptococcus pneumo-ia, and Cardiobacterium homonis; other rare organisms, suchs Shewanella spp, also have been reported.11

sophageal Sclerotherapyates of bacteremia following sclerotherapy of esophageal

arices are among the highest of all upper endoscopic proce-

225

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226 A. Shaukat and D.B. Nelson

ures. With upper GI variceal bleeding, the bleeding site is aortal of entry to the vascular system, and additional iatro-enic mucosal breaks are caused by the injection needle dur-ng sclerotherapy. These breaks and the bleeding site allowmple opportunity for organisms of the oropharynx and up-er GI tract to gain access to the bloodstream. In addition,ost factors eg. some degree of immune suppression play an

mportant role, as these patients tend to have advanced liverisease (Childs C cirrhosis) and often have ascites. The rate ofacteremia after endoscopic sclerotherapy that is reported inhe literature ranges from 5% to 55%.12-15 Increasingly, how-ver, this procedure is being supplanted by variceal bandigation, which carries a lower rate of bacteremia, as dis-ussed below.

sophageal Variceal Band Ligation (EVL)VL successfully controls active esophageal variceal bleedingnd is increasingly being used to eradicate varices because,ompared with esophageal injection sclerotherapy (EIS), itequires fewer procedures and is associated with lower ratesf rebleeding, mortality, and complications.16 The reportedates of bacteremia with EVL range from 0% to 25%.17-22

ulkarni and coworkers compared the incidence of bactere-ia after EVL and EIS in 22 cirrhotic patients and found

acteremia in 25% and 40% of the patients, respectively; thencidence was higher in patients with severe liver disease andhen procedures were performed emergently.21 In another

tudy, Lo and coworkers found bacteremia rates of 3.3% and7.2% of 55 patients treated by EVL or sclerotherapy, respec-ively.19 The reported rates of bacteremia were detectedithin the first 24 hours after EVL. The ulcer that forms at theVL site when the strangulated tissue captured by the bandsloughs off in 3 to 5 days creates a subsequent potential portalf entry for bacteria. Thus, the bacteremia rate at 24 hoursctually may underestimate the true rate of bacteremia afterVL. This additional and delayed risk is deserving of furthertudy. Conversely, it has been suggested that the mechanicaltrangulation of varices by the bands may obliterate submu-osal channels, thereby diminishing passage of bacteria in theloodstream.17

sophageal Dilationilation of an esophageal stricture is associated with theighest rates of bacteremia in upper GI endoscopic proce-ures, although the frequency varies widely in publishedeports. Risk of bacteremia historically has been thought toccur because of a breach in mucosal integrity. Such a breakan allow bacteria from the GI tract or the tip of the dilator tonter the circulation.23 Dilation commonly involves the pas-age of one or more dilators across a benign or malignantsophageal stricture. Passage of the initial dilator may createmucosal defect, and subsequent dilators may forcibly inoc-late endogenous bacteria into the newly created defect. Thebnormal tissue architecture and neovasculature of an esoph-geal malignancy also may facilitate entry of bacteria into theloodstream during dilation.Raines and coworkers found a 100% rate of bacteremia

fter dilation of benign and malignant esophageal strictures

n a series of 18 patients.24 Although the organisms cultured a

rom the blood also were recovered from the dilators, theyere not recovered from throat cultures obtained before therocedure. Investigators therefore concluded that the dila-ors were responsible for transmission of the organisms re-overed from the bloodstream. When dilators were sterilizedmmediately before dilation in 8 subsequent patients, no pos-tive blood cultures were obtained. Others have reported lessptimistic results after sterilizing dilators. Stephenson andoworkers studied 11 patients with a mixture of benign andalignant strictures. All dilators were disinfected with glu-

araldehyde immediately before dilation, and bacteremia stillccurred in 45% of procedures. Using routinely disinfectedilators, Nelson and coworkers25 found an overall postdila-ion bacteremia rate of 22%; when bacteremia was observed,t did not result in clinical symptoms and was transient, last-ng less than 30 minutes. The organisms recovered in thelood were not found in cultures taken from dilators be-ore the procedure, arguing against transmission from theilator. Bacteremia was significantly more likely after di-

ation of a malignant stricture or after passage of multipleilators during a single procedure, two risk factors notreviously identified.Hirota and coworkers26 postulated that, by decreasing the

oad of organisms in the oropharynx, one could reduce theisk of bacteremia in patients undergoing esophageal dila-ion. They randomized 59 patients to either clindamycinouthwash 1 hour before procedure or “standard care,” and

hey found an overall rate of bacteremia of 12%, with noifference in rates between the 2 groups. Although the use ofhrough-the-scope balloons for dilation of esophageal stric-ures is increasing, there are few data with respect to thisrocedure in terms of bacteremia rates or infectious compli-ations. One study found that the rate of bacteremia withalloon dilation was significantly less than that for bougien-ge (0 of 14 versus 22 of 89; P � 0.04), although the limitedumber of balloon dilations in the study led the investigatorso question the relevance of their observation.27

iscellaneous Upperndoscopic Proceduresacteremia has been reported with Nd:YAG laser used toblate vascular ectasias and esophageal cancers. Wolf andoworkers28 reported a procedural bacteremia rate of 40% in5 patients undergoing laser ablation of malignant esopha-eal tumors. In all but 1 case, the bacteremia was noted afterndoscope insertion but before laser use, suggesting that itas passage of the endoscope through the narrow lumen of

he tumor, much like a dilator, rather than the laser therapytself, that led to bacteremia. In 5 patients undergoing laserreatment of vascular ectasia, the rate of bacteremia was 0%.ndoscopic mucosal resection (EMR) for early-stage esoph-geal and gastric neoplasia has been used widely, particularlyn Japan. Lee and coworkers29 studied 38 patients undergo-ng EMR for esophageal/gastric malignancy and found tran-ient bacteremia in 5.3% of cases.

ower GI Endoscopyower GI endoscopy encompasses flexible sigmoidoscopy

nd colonoscopy. The reported rates of bacteremia associated

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Risks of infection from GI endoscopy 227

ith flexible sigmoidscopy are between 0% and 1%.30,31

here are numerous reports of bacteremia after colonoscopy,ith a mean rate of bacteremia reported to be approximately%.32 One postulated mechanism is that increased intralu-inal pressure resulting from air insufflation during colonos-

opy leads to increased wall tension, facilitating bacterialranslocation from the colon lumen to the vasculature.33 Theargest studies by Rafoth and coworkers,34 Norfleet and co-orkers,6,35 and Kiss and coworkers36 found bacteremia inone of the 52, 100, and 100 patients, respectively, who hadlood cultures before and at various times after colonoscopysome of the procedures also included biopsy and polypec-omy).

When considering therapeutic lower GI tract procedures,t is likely that, just as with upper GI procedures, the inci-ence of bacteremia varies with the procedure. Adami andoworkers reported bacteremia in 2% of patients undergoingemorrhoidal injection sclerotherapy.37 Kohler and cowork-rs38 reported bacteremia in 34% of patients undergoing laserherapy of stenosing colorectal lesions.

acteremia Leading tonfectious Endocarditis (IE)acterial endocarditis is a potentially catastrophic infectiousomplication of endoscopy; fortunately, it is extremely rare.eview of the English literature reveals only a handful of IEases associated with diagnostic upper endoscopy39-44 andery few reports of IE after sclerotherapy.45,46 Baskin45 re-orted bacterial endocarditis of a prosthetic valve in a patientfter sclerotherapy, despite antibiotic administration. Therere four reported cases of endocarditis associated with dila-ion of an esophageal stricture41,47-49 and no reports of IE withVL, Nd:YAG laser therapy, or EMR.There have been three reported cases of IE after flexible

igmoidoscopy50-52; one additional report was associatedith colonoscopy, but the evidence for causality is weak.39

onsidering the millions of lower GI endoscopies that areerformed annually in the United States, the number of IEases is remarkably low.

ntibiotic Prophylaxisor IE During GI Proceduresistorical Perspective onntibiotic Prophylaxis for IE

E is a life-threatening condition that may result from bacte-emia in a susceptible host, usually with an underlying car-iac abnormality. It is thought that, in individuals with thealvular abnormalities leading to high-velocity jet streams,he endothelium may be damaged, and subsequently plate-ets and fibrin may be deposited and organized into a throm-us; circulating bacteria adhere to these mural lesions, result-

ng in infective vegetations.53-55 Once established, bacterialndocarditis is associated with considerable morbidity andortality, and thus the most effective treatment is thought to

e primary prevention. Although there have been no ran-omized, controlled trials (RCTs) demonstrating the efficacyf antibiotic prophylaxis against IE, the potentially cata-

trophic outcome of infection as well as the relatively low c

isks of antibiotic administration have led to antibioticseing recommended before many invasive procedures. Be-ause numerous studies (discussed previously) have dem-nstrated varying degrees of bacteremia (a necessary pre-ursor for the development of endocarditis) after GIndoscopic procedures, and cases of IE have been associ-ted with endoscopy, antibiotic prophylaxis recommenda-ions has been incorporated into numerous practice guide-ines.

Recommendations for antibiotic prophylaxis of IE haveeen based on an assessment of patient risk (ie, cardiac con-itions that are associated with a higher risk of developingndocarditis, particularly in those patients in whom endocar-itis would be associated with an especially poor prognosis)nd procedural risk (ie, those associated with the highest riskf bacteremia, eg, esophageal sclerotherapy or stricture dila-ion). The following patient populations were considered toe at increased risk by the AHA56:

High risk: Patients with

● Prosthetic heart valves.● History of IE.● Complex cyanotic congenital heart disease, such as sin-

gle-ventricle anatomy, transposition of great arteries,and Tetralogy of Fallot.

● Surgically constructed systemic-pulmonary shunts.

Moderate risk: Patients with

● Congenital cardiac valve malformations, such as bicus-pid aortic valves.

● Acquired valvular dysfunctions, such as rheumatic heartdisease.

● Hypertrophic cardiomyopathy.● Mitral valve prolapse and auscultatory evidence of val-

vular regurgitation.

oth the AHA and the ASGE recommend that antibiotic pro-hylaxis be given for high-risk patients undergoing proce-ures associated with significant rates of bacteremia.2,56 An-ibiotics are not recommended for low-risk patientsndergoing low-risk procedures. For most other combina-ions of patient- and procedural-risk factors, the ASGE con-iders prophylaxis “optional” or has “no recommendation.”2

See most recent American College of CardiologyACC)/AHA guidelines below.)

otential Disadvantages ofrophylactic Antibiotics for IEajor limitations in determining who would most benefit

rom antibiotic prophylaxis for endoscopy-related infectionsre the largely anecdotal nature of reports on incidence andrevalence of these complications, and the lack of evidencerom RCTs on therapeutic efficacy of prophylaxis. Even if theerceived risk of infectious complications was that they wereare, given the potential severity of the complication, oneould reasonably question whether all patients undergoingndoscopy should receive antibiotic prophylaxis. There ismple evidence to counter such reasoning and to suggestntibiotic administration is not without risks, but in certain

ases causes harm, as discussed below.

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228 A. Shaukat and D.B. Nelson

● Antibiotic Adverse Reactions: The risk of allergic reactionto antibiotics is present, even in hosts with no previouslyknown drug allergy, and these risks range from rash andthrombophlebitis to anaphylactic shock and death. It isestimated that 1% to 5% of the population may have anallergic reaction to penicillin, and fatal anaphylactic re-actions can be expected in 15 to 25 individuals per 1million patients who receive 1 dose of penicillin. Manyof those individuals will have had no history of priorallergy to penicillin.57,58 Some authors have suggestedthat the risk of death from penicillin administration out-weighs the risk of infective endocarditis.59 Agha andcoworkers performed a cost-effectiveness analysis of an-tibiotic prophylaxis for IE before dental procedures. Un-der best case assumptions, in 10 million individualswho received antibiotic prophylaxis with amoxicillin,119 cases of IE would be prevented, but at a net loss of181 lives secondary to anaphylaxis.60

● Antibiotic Resistance: Widespread use of antibiotics leadsto the development of resistant organisms, which arethen harder to eradicate. As a relevant example in gas-troenterology, resistance of Helicobacter pylori to nitro-imidazoles (eg, metronidazole) now ranges from 20% to95%.61 Furthermore, treatment of H. pylori has beenshown to result in increased drug resistance of otherindigenous flora, such as enterococcus species.62

● Opportunistic Infections: Widespread use of antibiotics isassociated with increased risk of Clostridium difficile in-fection. This commonly seen infection has had risingincidence rates not just in the hospital setting, but in thecommunity as well. Costs associated with care of peoplewith C. difficile-related disease are substantial. Althoughit generally is held that a treatment course with antimi-crobials is a risk factor for infection with C. difficile, C.difficile-related disease and colitis have been reportedafter single doses of prophylactic antibiotics.63

● Drug–Drug Interactions: These can limit the usefulnessand therapeutic potential of not only the antibiotic, butalso other medications a patient may be taking. For ex-ample, certain antibiotics may decrease the effectivenessof some medications, such as oral contraceptives. More-over, antibiotic administration may alter plasma levelsand lead to toxicity for drugs with a narrow therapeuticpotential, such as warfarin, where the international nor-malized ratio may become supra-therapeutic.

here has also been increased recognition that bacteremiaesulting from activities of daily living (ADL) may represent areater risk for developing IE than intermittent dental, GI, orU tract procedures. It is known that bacteremia occurs dur-

ng ADLs for most individuals, such as brushing or flossingne’s teeth (20-68%), use of wooden toothpicks (20-40%),se of water irrigation devices (7-50%), and chewing food7-51%).1,64-70 It has been estimated that the yearly cumula-ive exposure to bacteremia from these routine daily activitiesay be on the order of millions of times greater than for a

ingle tooth extraction, the dental procedure most likely toause bacteremia.70 By comparison, the reported risk of bac-eremia after GI endoscopy is even lower than that for dentalxtraction.1 Hence, the risk of bacteremia from ADLs far ex-

eeds that from endoscopic procedures. Thus, a person un- a

ergoing a GI endoscopic procedure should not require an-ibiotic use any more than that same individual wouldequire antibiotic prophylaxis before brushing his/her teeth.

It is also apparent that antibiotic prophylaxis is not uni-ormly effective. There are numerous reports of IE after med-cal or dental procedures despite antibiotic prophylaxis.71-73

an der Meer and coworkers evaluated all patients with IEithin 30 days of a procedure for which antibiotic prophy-

actic was given and reported a protective effect in only9% of these cases. Finally, even assuming 100% efficacy,here are several analyses that suggest that the number ofases of IE that are preventable with antibiotic prophylaxiss negligible.73-75

ost Recent ACC/AHA Guidelinesollowing the above lines of reasoning, The AHA has up-ated their guidelines on antibiotic prophylaxis for GI endo-copic procedures.1 The new guidelines do not recommendsing antibiotic prophylaxis for GI tract procedures solely torevent IE, regardless of underlying cardiac risk factors. Theuideline concluded that “no published data demonstrate aonclusive link between procedures of the GI or GU tract andhe development of IE,” and further that “no studies exist thatemonstrate that the administration of antimicrobial prophy-

axis prevents IE in association with procedures performedn the GI or GU tract.”1 This should not be interpreted toean that antibiotics should be withheld in situations where

he efficacy of antibiotic prophylaxis for the prevention ofound infections or other infectious complications resulting

rom endoscopic procedures has been established (such asercutaneous endoscopic gastrostomy placement). This wille discussed in greater detail in the next section. The guide-

ines do suggest, however, that if antibiotics are given torevent wound infection/sepsis resulting from a GI proce-ure, or to treat an existing GI tract infection in a high-riskardiac patient, it would be reasonable to include an antibi-tic with activity against enterococci, the organism from theI tract felt most likely to cause IE.These guidelines simplify existing recommendations and

ractices. Although not yet formally adopted by the ASGE,he new AHA guidelines have already been acknowledged,nd are expected to be incorporated into the next revision ofhe ASGE guidelines.

rocedure-Relatedound and Systemic Infections

he following section discusses GI endoscopic procedures inhich antibiotic prophylaxis is directed toward prevention of

ocal wound infection and sepsis (rather than for IE prophy-axis). Guidelines from the ASGE regarding these proceduresave not changed and are discussed below.

ndoscopic Retrogradeholangiopancreatography (ERCP)

roadly, ERCP is considered a more invasive procedure thanGD and is thought to be associated with higher rates ofacteremia and infectious complications, both because of its

ndications, eg, obstruction of the pancreatico-biliary system,

nd the procedure itself, which involves injection of (non-

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Risks of infection from GI endoscopy 229

terile) contrast medium, sphincterotomy, and instrumenta-ion of the pancreatic and bile ducts. The most common andife-threatening infectious complication after ERCP isholangitis/sepsis. Reported rates of post-ERCP cholangi-is and sepsis generally range from 0.5% to 3%.32,76-79 Thisomplication typically occurs in the setting of an ob-tructed pancreatico-biliary system, when ERCP fails toelieve the obstruction.80

There have been a number of RCTs evaluating the efficacyf antibiotic prophylaxis before ERCP. Although many ofhese studies demonstrated a decrease in bacteremia, a meta-nalysis by Harris and coworkers81 found an overall nonsig-ificant reduction in risk of clinical cholangitis and sepsis (RR.91; 95% CI 0.39-2.15). What may account for the negativendings in these studies, however, is that most of them arenderpowered, and the incidence of cholangitis and sepsis isxtremely low. There is also considerable heterogeneity inhe patient population, indications, choice of antibiotic, andength of treatment. In contrast, a decision analysis byhompson and coworkers, which was limited to cases ofbstructive jaundice, suggested that antibiotic prophylaxisas effective in reducing cholangitis.82 ASGE guidelines cur-

ently recommend antibiotic prophylaxis for ERCP in theetting of biliary tract obstruction and pancreatic cystic le-ions.2

ndoscopic Ultrasound (EUS)n the last two decades, EUS has become an important endo-copic procedure with expanding indications. EUS is graduallyhifting from solely diagnostic to therapeutic applications, espe-ially with introduction of the linear echo-endoscope thatakes fine-needle aspiration (FNA) possible. From the

tandpoint of tissue disruption and the potential for bactere-ia, diagnostic EUS does not differ substantially from diag-ostic EGD, and the rates of bacteremia are assumed to beomparable. EUS-FNA has been shown to be safe when per-ormed by experienced endoscopists, with low rates of bac-eremia between 0% and 5%.83,84 Janssen and coworkers85

eport similar rates of bacteremia of 2% (95% CI 0-4.8) for00 patients undergoing diagnostic EUS and 4% (95% CI-9.6) for 50 patients undergoing EUS-FNA. Levy and co-orkers84 reported bacteremia in 5.8% of 54 patients under-oing EUS-FNA.

The above-mentioned reports of bacteremia did notote any cases of local infection or sepsis. These studiesxcluded high-risk patients, however, such as those withystic lesions of the pancreas or those that met criteria forHA or ASGE guideline recommendations for antibioticrophylaxis. Eloubeidi and coworkers86 reported septicomplications in 2 of 355 (0.5%) patients who underwentUS-FNA of a solid pancreatic mass; both recovered with-ut sequelae. In the largest published series to date, Bour-et and coworkers reported their experience with EUS inurope. There were no infectious complications in 3207iagnostic EUS cases and only 1 case of mediastinal infec-ion out of 224 following EUS-FNA.87 Current ASGEuidelines recommend antibiotic prophylaxis only for

US-FNA of pancreatic cystic lesions.2 t

ercutaneousndoscopic Gastrostomy (PEG)he major concern for infection associated with PEG place-ent is peristomal wound infection. Although aseptic tech-ique is used externally during the procedure, the internalite is nonsterile, and as the PEG tube is pulled/pushed intoosition through the upper GI tract, there is the potential forhe tube-tract or wound to become contaminated with theicrobial flora of the oropharygneal and upper GI tract. Until

he tract has epithelialized, the exposed vascular bed in theract may act as a portal of entry for microorganisms, withotential for local as well as systemic infection.There are several RCTs of antibiotic prophylaxis for PEG.

ates of wound infection in patients who did not receiventibiotics range from 7% to 33%; with antibiotic prophy-axis, rates of 0% to 30% are reported.88-94 A meta-analysishat included 7 RCTs of antibiotic prophylaxis for PEG notedreduction in risk of 73% with antibiotic use.95 There are no

eports of IE after PEG placement. Current ASGE guidelinesecommend prophylactic antibiotics for all patients undergo-ng PEG placement.2

pecial Patient Populationst is intuitive to regard certain susceptible patient populationst increased risk for infectious complications, particularlymmunosuppressed patients. Host factors are thought to ben important determinant of need for prophylactic antibiot-cs; on closer examination, however, the evidence on whicho base such recommendations is scant. The importance ofacteremia and infectious complications in certain vulnera-le populations is discussed below.

irrhotics with Acute GI Bleedingatients with cirrhosis who present with acute GI bleedingre more susceptible to infectious complications and, in par-icular, sepsis. Bernard and coworkers conducted a meta-nalysis of RCTs that evaluated antibiotic prophylaxis in cir-hotic patients with GI bleeding. Five trials comprising 534atients were included. Antibiotic prophylaxis reduced

nfectious complications by 32% and reduced risk ofpontaneous bacterial peritonitis (SBP) by 19%.96 CurrentSGE guidelines recommend prophylactic antibiotics forll cirrhotic patients presenting with GI bleeding.2

one Marrow Transplanthere is some controversy as to whether bone marrow trans-lant recipients are at increased risk of infectious complica-ions after endoscopic procedures. Bianco and coworkersound bacteremia in 19% of the 151 bone marrow transplantecipients who underwent EGD during the first 100 days postransplant. The risk of bacteremia was associated with a di-gnosis of acute GVHD and the use of prednisone; patientseing treated with prednisone were felt to be at particularlyigh risk.97 Another study of 53 patients, however, comparedvariety of endoscopic procedures performed with antibioticrophylaxis with those done without antibiotic prophylaxisnd found no episodes of clinically significant bacteremia inither group.98 Hence, it is not clear whether bone marrow

ransplant recipients (or for that matter, solid organ trans-

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230 A. Shaukat and D.B. Nelson

lants) have a special need for antibiotic prophylaxis. It isurrently recommended that antibiotic prophylaxis be con-idered on a case-by-case basis for high-risk procedures (eg,clerotherapy or stricture dilation).2

lderlyge alone does not seem to be associated with infectiousomplications of endoscopy, although rates of bacteremiaay be higher in the older populations. One study reported

acteremia in 10% of patients older than 60 years of agendergoing upper endoscopy, but no infectious sequelae ofacteremia were documented.99

onclusions● Bacteremia routinely occurs during ADL. Although GI

endoscopic procedures have been associated with bac-teremia, this represents a negligible fraction of the totalexposure experienced by patients over time.

● Bacteremia associated with endoscopic procedures isusually transient and rarely of clinical consequence.

● IE is the most feared infectious complication of endo-scopic procedures, but its incidence is largely unknown,and the utility of antibiotic prophylaxis is poorly estab-lished.

● Recent AHA guidelines no longer recommend the use ofprophylactic antibiotics for prevention of IE for any GIendoscopic procedure.

● The new AHA guidelines do not address antibiotic pro-phylaxis for the prevention of procedure-related woundinfection or sepsis. ASGE guidelines recommend antibi-otic prophylaxis before ERCP in the setting of known orsuspected biliary tract obstruction, before ERCP or EUS-FNA in the setting of pancreatic cystic lesions, beforePEG placement, and in cirrhotic patients presentingwith GI bleeding. Relative benefits and risks should beconsidered when contemplating antibiotic prophylaxisin all other instances.

eferences1. Wilson W, Taubert KA, Gewitz M, et al: Prevention of infective endo-

carditis: guidelines from the American Heart Association. A guidelinefrom the American Heart Association Rheumatic Fever, Endocarditis,and Kawasaki Disease Committee, Council on Cardiovascular Diseasein the Young, and the Council on Clinical Cardiology, Council onCardiovascular Surgery and Anesthesia, and the Quality of Care andOutcomes Research Interdisciplinary Working Group. Available at:http://circ.ahajournals.org/rapidaccess.shtml. Accessed June 5, 2007

2. Hirota WK, Petersen K, Baron TH, et al: Guidelines for antibiotic pro-phylaxis for GI endoscopy. Gastrointest Endosc 58:475-482, 2003

3. Shull HJ Jr, Greene BM, Allen SD, et al: Bacteremia with upper gastro-intestinal endoscopy. Ann Intern Med 83:212-214, 1975

4. Liebermann TR: Bacteremia and fiberoptic endoscopy. Gastrointest En-dosc 23:36-37, 1976

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4. Sauerbruch T, Holl J, Ruckdeschel G, et al: Bacteriaemia associatedwith endoscopic sclerotherapy of oesophageal varices. Endoscopy 17:170-172, 1985

5. Lorgat F, Madden MV, Kew G, et al: Bacteremia after injection of esoph-ageal varices. Surg Endosc 4:18-19, 1990

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