Endocarditis Prevention Dropped from Endoscopy Guidelines

By John Gever
OAK BROOK, Ill., 15 may 2008-- Antibiotic prophylaxis to prevent endocarditis is not needed for colonoscopies, sigmoidoscopies, or upper-GI endoscopies, according to practice guidelines just issued by the American Society for Gastrointestinal Endoscopy here.
The society's previous guidelines recommended routine antibiotic prophylaxis for prevention of endocarditis on the basis of some 15 case reports of infection occurring after endoscopy.
The new version, published in the May issue of Gastrointestinal Endoscopy, still recommends routine prophylaxis for other types of infections, such as peristomal infections following percutaneous endoscopic gastrostomy tube placement.
A literature review by the society's practice standards committee turned up no solid connection between endoscopy and cardiac infections, said Todd H. Baron, M.D., of the Mayo Clinic in Rochester, Minn., the committee chairman.
"There are no data that demonstrate a causal link between endoscopic procedures and infectious endocarditis," he said. "Similarly, there are no data that demonstrate that antibiotic prophylaxis before endoscopic procedures protects against infectious endocarditis."
The guideline revision follows a recent similar move by the American Heart Association, which dropped its former recommendation that most patients undergoing dental work should receive antibiotics to prevent endocarditis.
The AHA continues to recommend prophylactic antibiotics for select patients, such as those with prosthetic heart valves or previous endocarditis, although it acknowledged that prophylaxis may not prevent endocarditis even in these patients.
The reported frequency of infectious complications following gastrointestinal endoscopy is one in 1.8 million procedures, according to the ASGE guidelines.
About 14.2 million colonoscopies and 2.8 million flexible sigmoidoscopies, and perhaps as many upper-GI endoscopies, are performed in the U.S. each year, Dr. Baron said.
Procedures where antibiotic prophylaxis is still warranted include:
Endoscopic retrograde cholangiopancreatography (ERCP) with incomplete drainage of bile duct obstruction
ERCP for sterile pancreatic fluid collection
Transmural drainage for sterile pancreatic fluid collection
Endoscopic ultrasound-guided fine needle aspiration for cystic lesions along the GI tract
Insertion of a percutaneous feeding tube
All patients with cirrhosis and acute GI bleeding, regardless of whether endoscopy is used.
For endoscopic ultrasound-guided fine needle aspiration of solid lesions in the lower GI tract, the committee found insufficient data to make a firm recommendation on prophylaxis.
Similarly, they did not make a prophylaxis recommendation for natural orifice transluminal endoscopic surgery. On the other hand, they said prophylaxis "may be beneficial" and suggested that other precautions, such as gas sterilization of endoscopes and decontamination of the gut lumen, may reduce intraperitoneal infections.
The committee also listed several procedures for which prophylaxis is definitely not recommended. These included ERCP with complete drainage as well as any endoscopic procedure involving prosthetic joints or synthetic vascular or other non-valvular cardiovascular grafts. In these sigmoidoscopies, the committee found little or no risk of infection related to endoscopy.
The new guidelines reiterated the importance of general infection control through disinfection and safe handling of equipment, handwashing, use of gloves, and other standard measures.
"Recently reported cases [of endoscope-related infection] are invariably attributable to lapses in currently accepted endoscope reprocessing protocols or to defective equipment," Dr. Baron and colleagues wrote.
No funding information was disclosed. No potential conflicts of interest were disclosed.
Primary source: Gastrointestinal EndoscopySource reference:Banerjee S, et al "Antibiotic prophylaxis for GI endoscopy" Gastrointestinal Endoscopy 2008; 67: 791-98. Additional source: Gastrointestinal EndoscopySource reference: Banerjee S, et al "Infection control during GI endoscopy" Gastrointestinal Endoscopy 2008; 67: 781-90.