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## Complete Summary

#### GUIDELINE TITLE

Guidelines for antibiotic prophylaxis for gastrointestinal (GI)
endoscopy.

#### BIBLIOGRAPHIC SOURCE(S)

Hirota WK, Petersen K, Baron TH, Goldstein JL, Jacobson BC, Leighton JA,
Mallery JS, Waring JP, Fanelli RD, Wheeler-Harbough J, Faigel DO.
Guidelines for antibiotic prophylaxis for GI endoscopy. Gastrointest
Endosc 2003 Oct;58(4):475-82. \[113 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14520276)

#### GUIDELINE STATUS

**Note**: This guideline has been updated. The National Guideline
Clearinghouse (NGC) is working to update this summary.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Infectious complications of gastrointestinal endoscopy, such as
bacterial endocarditis

#### GUIDELINE CATEGORY

Prevention

#### CLINICAL SPECIALTY

Gastroenterology\
Infectious Diseases

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

-   To provide recommendations for the use of antibiotic prophylaxis for
    gastrointestinal endoscopy

-   To update the 1995 American Society for Gastrointestinal Endoscopy
    guideline on this topic

#### TARGET POPULATION

Individuals with conditions that require gastrointestinal endoscopy

#### INTERVENTIONS AND PRACTICES CONSIDERED

**[Prophylactic Antibiotics]{.underline}**

**Cardiac prophylaxis regimens**

1.  Oral amoxicillin; alternative: intravenous/intramuscular ampicillin

2.  Oral clindamycin (for penicillin-allergic patients); alternatives:
    oral cephalexin or cefadroxil

3.  Intravenous clindamycin (for penicillin-allergic patients unable to
    take oral medication); alternatives: intravenous/intramuscular
    cefazolin or intravenous vancomycin

#### MAJOR OUTCOMES CONSIDERED

Incidence of bacteremia and post-procedural endocarditis

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

In preparing this guideline, a MEDLINE literature search was performed,
and additional references were obtained from the bibliographies of the
identified articles and from recommendations of expert consultants.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review\
Review of Published Meta-Analyses

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Guidelines for appropriate utilization of endoscopy are based on a
critical review of the available data and expert consensus.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Not stated

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not applicable

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Note**: This guideline has been updated. The National Guideline
Clearinghouse (NGC) is working to update this summary. The
recommendations that follow are based on the previous version of the
guideline.

Recommendations are followed by evidence grades (A-C) identifying the
type of supporting evidence. Definitions of the evidence grades are
presented at the end of the \"Major Recommendations\" field.

**[Consensus Statements for Antibiotic Prophylaxis during
Gastrointestinal Endoscopic Procedures]{.underline}**

**Prophylaxis against Infective Endocarditis**

1.  For most endoscopic procedures, including upper endoscopy,
    sigmoidoscopy, and colonoscopy with or without mucosal biopsy,
    polypectomy, and/or nonvariceal hemostasis:

    a.  Antibiotic prophylaxis is not recommended for patients with
        lesions at intermediate risk for the development of
        endocarditis, or those with lesions or conditions at no
        increased risk for endocarditis compared to the general
        population. For example patients with mitral valve prolapse,
        with or without regurgitation do not require prophylaxis for any
        of the above procedures.

    b.  There are insufficient data to recommend routine prophylaxis for
        patients at \"high risk\" for infective endocarditis. The
        endoscopist may consider prophylaxis on a case-by-case basis.

2.  For endoscopic procedures associated with increased rates of
    transient bacteremia, including dilation of an esophageal stricture,
    varix sclerotherapy, and retrograde cholangiography with known or
    suspected bile duct obstruction:

    a.  Prophylaxis is recommended for patients at \"high risk\" for the
        development of endocarditis.

    b.  No prophylaxis is recommended for patients with those cardiac
        lesions and conditions at no increased risk for infective
        endocarditis over the general population. However, it is
        recommended that all patients with suspected or known biliary
        obstruction should receive prophylactic antibiotics prior to
        endoscopic retrograde cholangiopancreatography (ERCP).

    c.  There are insufficient data to recommend routine prophylaxis for
        patients with cardiac lesions or conditions at intermediate risk
        for the development of infective endocarditis. The endoscopist
        may consider prophylaxis on a case-by-case basis.

3.  Regimens (Dajani et al, 1997):

    a.  Standard general prophylaxis: amoxicillin 2.0 g orally (po)
        (adult) or 50 mg/kg po (child), 1 hour prior to the procedure.
        Alternative for those unable to take po is ampicillin 2.0 g
        intravenously or intramuscularly (IV/IM) (adult) or 50 mg/kg
        IV/IM (child), within 30 min before procedure.

    b.  Penicillin-allergic patients: clindamycin 600 mg po (adult) or
        20 mg/kg po (child), 1 hour prior to procedure. Alternatives:
        cephalexin or cefadroxil 2.0 g po (adult) or 50 mg/kg po
        (child), 1 hour prior to the procedure. Azithromycin or
        clarithromycin 500 mg po (adult) or 15 mg/kg po (child), 1 hour
        prior to procedure.

    c.  Penicillin-allergic patients unable to take po: clindamycin 600
        mg IV (adult) or 20 mg/kg IV (child), within 30 min before
        procedure. Alternative: cefazolin 1.0 gm IV/IM (adult) or 25
        mg/kg IV/IM (child) within 30 min before the procedure.
        Vancomycin 1.0 gm IV (adult) or 10-20 mg/kg (child).

**The Patient with a Synthetic Vascular Graft**

For up to the first year after placement of a synthetic vascular graft,
antibiotic prophylaxis is recommended for patients undergoing esophageal
stricture dilation, varix sclerosis, or endoscopic retrograde
cholangiography (ERCP) with known or suspected bile duct obstruction.
For other endoscopic procedures, there are insufficient data to
recommend routine prophylaxis. The endoscopist may consider prophylaxis
on a case-by-case basis.

**The Patient with a Prosthetic Joint or Orthopedic Prosthesis**

There are insufficient data to recommend antibiotic prophylaxis for
patients with prosthetic joints or orthopedic prostheses undergoing
gastrointestinal endoscopic procedures.

**The Patient with Biliary Obstruction, Pancreatic Pseudocyst, or
Pancreatic Cystic Lesion Requiring Fine Needle Aspiration (FNA)**

All patients undergoing ERCP for known or suspected biliary obstruction
or known pancreatic pseudocyst should receive antibiotics along with
adequate drainage of the biliary obstruction or cyst. Endoscopic
transmural drainage of pancreatic pseudocysts similarly may result in
the introduction of infection into the cystic cavity. Additionally, the
endoscopic ultrasound (EUS) guided aspiration of pancreatic cystic
lesions may also result in introduction of infection. Although not
supported by randomized, controlled trials, the use of prophylactic
antibiotics prior to attempted drainage of such pseudocysts and similar
pancreatic lesions is recommended. Antibiotics which cover biliary flora
such as enteric gram-negative organisms, enterococci, and possibly
*Pseudomonas* sp. are recommended. Prophylactic antibiotics do not
appear to be necessary prior to FNA of solid masses.

**The Endoscopic Placement of a Percutaneous Feeding Tube**

All patients undergoing percutaneous endoscopic placement of a feeding
tube should receive prophylaxis to prevent soft tissue infection.
Parenteral cefazolin (or an antibiotic with equivalent coverage) should
be given 30 minutes prior to the procedure. If the patient is already on
an equivalent antibiotic, prophylactic antibiotic administration remains
unnecessary.

**The Patient with Cirrhosis, Ascites, and the Immunocompromised
Patient**

Cirrhotic and otherwise immunocompromised patients are susceptible to
infections from transient bacteremia, which occurs more often in high
risk invasive procedures. The endoscopist should consider prophylaxis on
a case-by-case basis in these high risk procedures such as esophageal
sclerotherapy and stricture dilation. All cirrhotics presenting with
gastrointestinal (GI) bleeding should receive prophylactic antibiotics.

For other endoscopic procedures including prophylactic endoscopic
variceal ligation, routine antibiotic prophylaxis is not recommended.
However, the decision to administer antibiotic prophylaxis should be
made on a case-by-case basis. Cirrhotic patients with ascites appear to
be at a potentially higher risk for infection. Additionally, transplant
patients on high doses of steroids also appear to have increased
susceptibility to infection. The choice of antibiotic should be tailored
to the specific perceived risk.

**Summary**

-   Antibiotic prophylaxis against infective endocarditis is recommended
    when a high risk patient is undergoing an endoscopic procedure
    associated with a high incidence for transient bacteremia (**C**).

-   Patients undergoing high risk endoscopic procedures who have a
    synthetic vascular graft less than one year old should also receive
    antibiotic prophylaxis (**C**).

-   There is no clear benefit or consensus in the use of prophylactic
    antibiotics in patients with a prosthetic joint or an orthopedic
    prosthesis undergoing any endoscopic procedure (**C**).

-   All patients undergoing ERCP for known or suspected biliary
    obstruction or known pancreatic pseudocyst should receive
    antibiotics with adequate drainage of the biliary obstruction
    (**A**) or cyst (**C**).

-   Prophylactic antibiotics are recommended for endoscopic ultrasound
    guided aspiration of pancreatic cystic lesions but not prior to FNA
    of solid masses (**C**).

-   All patients undergoing endoscopic placement of a percutaneous
    feeding tube should receive prophylactic antibiotics to limit the
    risk of soft tissue infection (**A**).

-   All patients with cirrhosis who present with GI bleeding should
    receive prophylactic antibiotics to decrease infectious
    complications and mortality (**A**).

Refer to Table 1 below where antibiotic prophylaxis for endoscopic
procedures is summarized. There are insufficient data to provide
definitive recommendations in certain circumstances. Other factors,
including preferences of patients and referring physicians, must also be
considered. It is strongly recommended that each endoscopy unit or
center develop a policy appropriate for its specific practice. These
recommendations may serve as a template for this process.

  --------------------------------------------------------------------------
  **Antibiotic Prophylaxis for                             
  Endoscopic Procedures**                                  
  --------------------------------- ---------------------- -----------------
  **Patient Condition**             **Procedure            **Antibiotic
                                    Contemplated**         Prophylaxis**

  High risk:\                       Stricture Dilation\    Recommended
  \                                 Variceal               
  Prosthetic Valve\                 Sclerotherapy\         
  Hx Endocarditis\                  ERCP/obstructed        
  Syst-Pulm Shunt\                  biliary tree           
  Synth Vasc Graft (\<1yr old)\                            
  Complex Cyanotic congenital heart                        
  disease                                                  

                                    Other endoscopic       Prophylaxis
                                    procedures including   Optional
                                    EGD and colonoscopy    
                                    (with or without       
                                    biopsy/polypectomy),   
                                    variceal ligation      

  Moderate Risk:\                   Esophageal Stricture   Prophylaxis is
  \                                 Dilation\              optional
  Most other congenital             Variceal               
  abnormalities\                    Sclerotherapy\         
  Acquired valvular dysfunction     ERCP/obstructed        
  (eg. Rheumatic heart disease)\    biliary tree           
  Hypertrophic Cardiomyopathy\                             
  Mitral valve prolapse with                               
  regurgitation or thickened                               
  leaflets                                                 

                                    Other endoscopic       Not recommended
                                    procedures including   
                                    EGD and colonoscopy    
                                    (with or without       
                                    biopsy/polypectomy),   
                                    variceal ligation      

  Low Risk:\                        All endoscopic         Not recommended
  \                                 procedures             
  Other cardiac conditions (CABG,                          
  repaired septal defect or patent                         
  ductus, mitral valve prolapse                            
  without valvular regurg.,                                
  isolated secundum atrial septal                          
  defect,                                                  
  physiologic/functional/innocent                          
  heart murmurs, rheumatic fever                           
  without valvar dysfunction,                              
  pacemakers, implantable                                  
  defibrillators)                                          

  Obstructed bile duct              ERCP                   Recommended

  Pancreatic cystic lesion          ERCP, EUS-FNA          Recommended

  Cirrhosis acute GI Bleed          All endoscopic         Recommended
                                    procedures             

  Ascites, Immunocompromised        Stricture Dilation\    No Recommendation
  Patient                           Variceal Sclerotherapy 

                                    Other endoscopic       Not Recommended
                                    procedures including   
                                    EGD and colonoscopy    
                                    (with or without       
                                    biopsy/polypectomy),   
                                    variceal ligation      

  All patients                      Percutaneous           Recommended
                                    endoscopic feeding     (parenteral
                                    tube placement         cephalosporin or
                                                           equivalent)

  Prosthetic joints                 All endoscopic         Not recommended
                                    procedures             

  Cardiac Prophylaxis Regimens                             
  (oral 1 hour before, IM or IV 30                         
  min before procedure)\                                   
  Amoxicillin PO or Ampicillin IV:                         
  adult 2.0 g, child 50 mg/kg\                             
  Penicillin allergic: Clindamycin                         
  (Adult 600 mg, child 20 mg/kg),                          
  OR Cephalexin OR cefadroxil                              
  (adults 2.0 g, child 50 mg/kg),                          
  OR Azithromycin or clarithromycin                        
  (adult 500 mg, child 15 mg/kg),                          
  OR Cefazolin (adult 1.0 g , child                        
  25 mg/kg IV or IM), OR Vancomycin                        
  (Adult 1.0 g, child 10-20 mg/kg                          
  IV)                                                      
  --------------------------------------------------------------------------

**[Definitions]{.underline}**:

A.  Prospective controlled trials

B.  Observational studies

C.  Expert opinion

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### REFERENCES SUPPORTING THE RECOMMENDATIONS

[References open in a new
window](http://www.guideline.gov/summary/select_ref.aspx?doc_id=4143)

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and classifed for the
recommendations using the following scheme:

A.  Randomized controlled trials

B.  Non-randomized studies

C.  Expert opinion

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Antibiotic prophylaxis in select \"high risk\" patients has been shown
to reduce rates of bacteremia, cholangitis, peristomal wound infection,
as well as rates of peritonitis after sclerotherapy. It also reduced
infectious complications and mortality in cirrhotic patients.

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

The information in this guideline is intended only to provide general
information and not as a definitive basis for diagnosis or treatment in
any particular case. It is very important that patients consult their
doctor about their specific condition.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Hirota WK, Petersen K, Baron TH, Goldstein JL, Jacobson BC, Leighton JA,
Mallery JS, Waring JP, Fanelli RD, Wheeler-Harbough J, Faigel DO.
Guidelines for antibiotic prophylaxis for GI endoscopy. Gastrointest
Endosc 2003 Oct;58(4):475-82. \[113 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14520276)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 Oct

#### GUIDELINE DEVELOPER(S)

American Society for Gastrointestinal Endoscopy - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

American Society for Gastrointestinal Endoscopy

#### GUIDELINE COMMITTEE

Standards of Practice Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee Members*: Douglas O. Faigel, MD (*Chair*); William K. Hirota,
MD; Kathryn Petersen, MD; Todd H. Baron, MD; Jay L. Goldstein, MD; Brian
C. Jacobson, MD; Jonathan A, Leighton, MD; J. Shawn Mallery, MD; J.
Patrick Waring, MD; Robert D. Fanelli (*SAGES Representative*); Jo
Wheeler-Harbough, RN (*SGNA Representative*)

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

**Note**: This guideline has been updated. The National Guideline
Clearinghouse (NGC) is working to update this summary.

#### GUIDELINE AVAILABILITY

Electronic copies of the updated guideline: Available in Portable
Document Format (PDF) from the [American Society for Gastrointestinal
Endoscopy (ASGE) Web
site](http://www.asge.org/PublicationsProductsindex.aspx?id=352).

Print copies: Available from the American Society for Gastrointestinal
Endoscopy, 1520 Kensington Road, Suite 202, Oak Brook, IL 60523

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on April 16, 2004. The
information was verified by the guideline developer on May 12, 2004.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008