Antibiotic Prophylaxis in Colonoscopy and Esophagogastroduodenoscopy (EGD)

Antibiotic Prophylaxis

Are preoperative, perioperative, or peri-procedural antibiotics ever indicated for a colonoscopy procedure, EGD, or upper gastrointestinal endoscopy? The answer to this age old question is ever changing. For example, there are two past indications for which antibiotic prophylaxis is no longer relevant:

1. NON-INDICATION FOR ORTHOPEDIC PROSTHESIS
As of 2008, Antibiotic prophylaxis is not recommended for patients with orthopedic prosthesis who are undergoing GI endoscopic procedures.

2. NON-INDICATION FOR INFECTIVE ENDOCARDITIS
As of 2008, Antibiotic prophylaxis solely to prevent infective endocarditis (IE) is no longer recommended before endoscopic procedures.

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Antibiotic Prophylaxis for Colonoscopy

As of 2008-2012, there are only two known indications for antibiotic prophylaxis before a colonoscopy procedure:

1. Cirrhosis WITH acute GI bleeding
2. Cystic lesions along the GI tract

Other than these two indications, antibiotic prophylaxis is never indicated for a colonoscopy procedure.

Contrary to conventional practice (in some locations), antibiotic prophylaxis for a colonoscopy procedure is not indicated for any orthopedic condition, including artificial joints; or for any cardiac condition, including valvular and nonvalvular cardiovascular devices or synthetic vascular grafts.

The reasoning for this is as follows:
Although bacterial translocation of endogenous microbial flora into the bloodstream may occur during an endoscopy because of mucosal trauma related to the procedure. Endoscopy-related bacteremia carries a small risk of localization of infection in remote tissues i.e., infective endocarditis (IE). As you can see from this chart below, there is a greater risk of bacteremia form flossing teeth or using a toothpick, than there is from an EGD or colonoscopy procedure:

TRANSIENT BACTEREMIA

  • 0% to 25% for Colonoscopy and EGD – Lowest Risk
  • 7% to 51% for just Chewing Food
  • 20% to 40% for using a Toothpick
  • 20% to 68% for Flossing Your Teeth

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Antibiotic Prophylaxis for Upper Endoscopy, Esophagogastroduodenoscopy (EGD)

As of 2008-2012, there are only five known indications for antibiotic prophylaxis before an upper gastrointestinal endoscopy (EGD) procedure:
1. Cirrhosis WITH acute GI bleeding
2. Cystic lesions along the GI tract
3. Bile-duct obstruction WITH cholangitis
4. Sterile pancreatic fluid Collection
5. Percutaneous endoscopic feeding tube placement
Other than these five indications, antibiotic prophylaxis is never indicated for an EGD procedure.

Contrary to conventional practice (in some locations), antibiotic prophylaxis for an EGD procedure is not indicated for any orthopedic condition, including artificial joints; or for any cardiac condition, including valvular and nonvalvular cardiovascular devices or synthetic vascular grafts.

The reasoning for this is as follows:
Although bacterial translocation of endogenous microbial flora into the bloodstream may occur during an endoscopy because of mucosal trauma related to the procedure. Endoscopy-related bacteremia carries a small risk of localization of infection in remote tissues ie, infective endocarditis (IE). As you can see from this chart below, there is a greater risk of bacteremia form flossing teeth or using a toothpick, than there is from an EGD or colonoscopy procedure:

TRANSIENT BACTEREMIA:

  • 0% to 25% for EGD and Colonoscopy – Lowest Risk
  • 7% to 51% for just Chewing Food
  • 20% to 40% for using a Toothpick
  • 20% to 68% for Flossing Your Teeth

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Antibiotics that are Indicated for Use in Specific GI Conditions

CIRRHOSIS WITH GI TRACT BLEEDING
All patients with cirrhosis who are admitted with GI tract bleeding should have antibiotic therapy instituted at admission, preferably with IV ceftriaxone (Grade 1B). In patients allergic to or intolerant of ceftriaxone, oral norfloxacin may be used.

CHOLANGITIS
Antibiotic prophylaxis solely to prevent IE is no longer recommended before endoscopic procedures (Grade1C+). For patients with established GI tract infections in which enterococci may be part of the infecting bacterial flora (such as cholangitis) and with a cardiac condition associated with the highest risk of an adverse outcome from endocarditis, amoxicillin, or ampicillin should be included in the antibiotic regimen for enterococcal coverage (Grade 3). Vancomycin may be substituted for patients allergic to or unable to tolerate amoxicillin or ampicillin. When antibiotic prophylaxis is administered, a fluoroquinolone administered before the procedure and continued for 3 days after the procedure is a reasonable regimen.

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)
Antibiotic prophylaxis should be considered before an ERCP in patients with known or suspected biliary obstruction, in which there is a possibility that complete drainage may not be achieved at the ERCP, such as in patients with a hilar stricture and PSC (Grade 2C). When biliary drainage is incomplete despite an ERCP, continuation of antibiotics after the procedure is recommended (Grade 3). Antibiotics that cover biliary flora, such as enteric gram-negative organisms and enterococci, should be used. When biliary drainage is complete, continuation of antibiotics is not recommended (Grade 3). An exception is patients with posttransplant biliary strictures who are undergoing an ERCP; in these patients, continuation of antibiotics after the procedure may be beneficial (Grade 3), even when drainage is achieved. Antibiotic prophylaxis is not recommended in patients with biliary obstruction when it is likely that an ERCP will accomplish complete biliary drainage (Grade 1C). Antibiotic prophylaxis is not recommended before an ERCP when obstructive biliary-tract disease is not suspected (Grade 1C). Antibiotic prophylaxis is recommended before an ERCP in patients with communicating pancreatic cysts or
pseudocysts and before transpapillary or transmural drainage of pseudocysts (Grade 3).

ENDOSCOPIC ULTRASOUND-GUIDED FINE NEEDLE ASPIRATION EUS-FNA OF CYSTIC LESIONS ALONG THE GI TRACT
Antibiotic prophylaxis is not recommended before a diagnostic EUS or EUS-FNA of solid lesions along the upper-GI tract (Grade 1C). Prophylaxis with an antibiotic such as a fluoroquinolone administered before the procedure is recommended before an EUS-FNA of cystic lesions along the GI tract. Antibiotics may be continued for 3 to 5 days after the procedure (Grade 1C).
There are insufficient data to make recommendations on antibiotic prophylaxis before an EUS-FNA of solid lesions along the lower-GI tract. The endoscopist may consider prophylaxis on a case-by-case basis. When antibiotic prophylaxis is administered, a fluoroquinolone administered before the procedure and continued for 3 days after the procedure is a reasonable regimen.

PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG)
Patients who were undergoing PEG-tube placement are often vulnerable to infection because of age, compromised nutritional intake, immunosuppression, and underlying diseases. An antibiotic that provides optimal coverage of cutaneous organisms, such as cefazolin 1 g IV, should be administered 30 minutes before the procedure.

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REFERENCES

http://www.asge.org/WorkArea/showcontent.aspx?id=4298 Gastrointest Endosc 2008;67:791-798;

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