Antibiotic prophylaxis for gastrointestinal procedures: Who needs it?

Abstract

Two papers in this issue deal with the question of appropriate use of antibiotics in patients undergoing certain gastrointestinal diagnostic procedures. Niederau et al. 1 Niederau C Pohlmann U Lübke H Thomas L Prophylactic antibiotic treatment in therapeutic or complicated diagnostic ERCP: results of a randomized controlled clinical study. Gastrointest Endosc. 1994; 40: 533-537 Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar direct their attention to bacteremia in subjects undergoing ERCP. They apparently believe antibiotics are not needed for patients undergoing diagnostic, noncomplicated ERCP, as they have chosen to study only those patients undergoing therapeutic or complicated diagnostic ERCP. These views are shared in the statements of both the American Heart Association Committee on Rheumatic Fever and Infective Endocarditis (AHA) 2 Dajani A Bisno AL Chung KJ et al. Prevention of bacterial endocarditis recommendations by the American Heart Association. JAMA. 1990; 264: 2919-2922 Crossref PubMed Scopus (493) Google Scholar and the guidelines of the American Society for Gastrointestinal Endoscopy (ASGE). 3 ASGE Infection control during gastrointestinal endoscopy: guidelines for the clinical application. Gastrointest Endosc. 1988; 34: 375-405 Abstract Full Text PDF Google Scholar Niederau et al 1 Niederau C Pohlmann U Lübke H Thomas L Prophylactic antibiotic treatment in therapeutic or complicated diagnostic ERCP: results of a randomized controlled clinical study. Gastrointest Endosc. 1994; 40: 533-537 Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar found bacteremia in 4 subjects (8%) and late sepsis/cholangitis in 4 others (8%) who did not receive cefotaxime (2 gm) IV 15 minutes before the procedure. Subjects receiving cefotaxime prophylaxis developed neither bacteremia nor infectious complications. They appropriately conclude that antibiotics are generally not required in patients without biliary obstruction who undergo ERCP, but are indicated in those with obstructed ducts to prevent systemic or cholangitic infections. The antibiotics should be chosen to provide coverage for those bacteria commonly found in the obstructed biliary tree. Bacteria expected in the obstructed biliary tree include gram-negative rods, 4 Sauter G Grabein B Huber G et al. Antibiotic prophylaxis of infectious complications with endoscopic retrograde cholangiopancreatography. A randomized controlled study. Endoscopy. 1990; 22: 164-167 Crossref PubMed Scopus (92) Google Scholar , 5 Kullman E Borch K Lindström E et al. Bacteremia following diagnostic and therapeutic ERCP. Gastrointest Endosc. 1992; 38: 444-449 Abstract Full Text PDF PubMed Scopus (59) Google Scholar enterococci, 4 Sauter G Grabein B Huber G et al. Antibiotic prophylaxis of infectious complications with endoscopic retrograde cholangiopancreatography. A randomized controlled study. Endoscopy. 1990; 22: 164-167 Crossref PubMed Scopus (92) Google Scholar and α-hemolytic streptococci. 4 Sauter G Grabein B Huber G et al. Antibiotic prophylaxis of infectious complications with endoscopic retrograde cholangiopancreatography. A randomized controlled study. Endoscopy. 1990; 22: 164-167 Crossref PubMed Scopus (92) Google Scholar , 5 Kullman E Borch K Lindström E et al. Bacteremia following diagnostic and therapeutic ERCP. Gastrointest Endosc. 1992; 38: 444-449 Abstract Full Text PDF PubMed Scopus (59) Google Scholar The antibiotics and the dosage schedule recommended by the AHA should give adequate coverage when antibiotics are chosen. 2 Dajani A Bisno AL Chung KJ et al. Prevention of bacterial endocarditis recommendations by the American Heart Association. JAMA. 1990; 264: 2919-2922 Crossref PubMed Scopus (493) Google Scholar I disagree with their conclusion that “as with all gastrointestinal endoscopic procedures, patients at risk for endocarditis should receive antibiotic prophylaxis before undergoing ERCP.” Neither the present authors nor any others have demonstrated an increased risk of endocarditis in patients undergoing routine diagnostic ERCP. Physicians may choose to use antibiotics in those patients with high-risk cardiac lesions (e.g., prior endocarditis, prosthetic heart valves, surgically constructed systemic-pulmonary shunt).