Gastroenterological Endoscopy. Группа авторов

and/or known or suspected biliary obstruction, where there is a possibility that complete biliary drainage may not be achieved.²⁵ Antibiotics should also be continued postprocedure when biliary drainage is incomplete.

      There are no studies that have assessed the value of antibiotic prophylaxis in patients undergoing ERCP who have pancreatic cystic lesions that communicate with the main pancreatic duct. However, the incidence of infectious complications in this setting seems to be uncommon given that ERCP is commonly performed in patients with such cystic lesions (e.g., intraductal papillary mucinous neoplasms, pseudocysts) without reports of cyst infections.

      Acute cholecystitis may result from placement of biliary self-expandable metallic stents (SEMSs) and is believed to be due to cystic duct obstruction. This occurs in 2 to 12% of cases.⁴² In two meta-analyses, the incidence of cholecystitis was similar between covered and uncovered SEMSs.^43,44 The majority of reported cases of cholecystitis after biliary SMES placement occurred in patients with malignant biliary obstruction,⁴² and tumor involvement of the cystic duct orifice is an independent risk factor for acute cholecystitis after SEMS insertion.⁴⁵ The role of prophylactic antibiotics has not been studied, but may help prevent this complication, especially since surgery is frequently needed to manage this untoward event.

      8.4 EUS-FNA

      Two large series encompassing 672 patients undergoing EUS-FNA of a variety of solid lesions reported sepsis as a complication in only 3 patients.^46,47 Therefore, prophylactic antibiotics are not recommended prior to EUS-FNA of solid lesions.²⁵

      Periprocedural administration of antibiotics has been recommended for EUS-FNA of cystic lesions in order to prevent cyst infection.²⁹ The benefit of this practice has not been evaluated in prospective randomized studies. Reports of infected cystic lesions following FNA are scarce. One comparative retrospective trial that included 253 patients studied the effect of prophylactic antibiotics during EUS-FNA of pancreatic cysts.⁴⁸ The incidence of infectious complications was very low (one cyst infection in the antibiotic group and one fever episode in the nonantibiotic group), and antibiotics did not confer a protective effect against infections. Infections and antibiotic-related complications occurred more commonly in the group of patients who received prophylactic antibiotics (4.4 vs. 0.6%, p = 0.04).⁴⁸ Infectious complications after EUS-FNA of mediastinal cysts seem to occur more commonly. Multiple case reports and case series with limited numbers of patients reported infection of mediastinal cysts and mediastinitis following EUS-FNA, some occurring despite the use of appropriate intravenous antibiotic prophylaxis.^49,50 The ASGE suggests administration of prophylactic antibiotics in patients undergoing EUS-FNA of cystic lesions, although the benefit of this practice has not been proven.²⁵

      The risk of bacteremia and infectious complications after EUS-FNA in the lower GI was studied in one prospective trial which assessed complications of EUS-FNA of solid rectal and perirectal lesions in 100 patients.¹² Two patients developed bacteremia, but without signs or symptoms of infection. Based on these findings, the ASGE recommends against antibiotic prophylaxis prior to diagnostic EUS or EUS-FNA of solid lesions in the lower GI tract.²⁵

      The role of prophylactic antibiotics in patients undergoing interventional EUS procedures (e.g., pseudocyst drainage, biliary drainage, fine needle injection of cysts/tumors, fiducial placement) has not been studied. Most interventional EUS studies have included patients who received periprocedural antibiotics and a short course of antibiotics thereafter,^{51,52,53,54,55,56} and post-procedural infections are infrequent using this practice.

      8.5 Percutaneous Endoscopic Gastrostomy/Jejunostomy

      Patients undergoing placement of PEG tubes are frequently susceptible to infectious complications because of age, compromised nutritional intake, immunosuppression, and comorbid conditions. A systematic review of randomized studies evaluating the use of prophylactic antibiotics for PEG placement included 12 trials and 1,271 patients.⁵⁷ A pooled analysis demonstrated that administration of prophylactic antibiotics resulted in a statistically significant reduction in the incidence of peristomal infection (odds ratio [OR], 0.36; 95% confidence interval [CI], 0.26–0.50).⁵⁷ An antibiotic that provides adequate coverage of cutaneous organisms such as cefazolin 1 g intravenously should be given 30 minutes prior to the procedure.^25,58

      The role of prophylactic antibiotics before percutaneous endoscopic jejunostomy (PEJ) placement has not been studied. However, administration of antibiotics should offer similar protection against peristomal infections observed in patients who undergo PEG placement, especially when it is considered that complications, including local infections, seem to be more common with PEJ.^59,60

      8.6 Cirrhosis with GI Bleeding

      A Cochrane meta-analysis of 12 randomized controlled trials that comprised 1,241 patients showed that antibiotic administration in cirrhotic patients with GI bleeding was associated with significantly lower overall mortality, mortality from bacterial infections, incidence of bacterial infections, rebleeding, and length of hospital stay.⁶¹ Antibiotic therapy should therefore be commenced at presentation in such patients. Intravenous ceftriaxone seems to be the optimal choice and has been shown to be superior to oral norfloxacin in one randomized controlled trial.⁶²

      8.7 Synthetic Vascular Grafts and Other Nonvalvular Cardiovascular Devices

      There are no reported cases of vascular graft infection related to GI endoscopic procedures. The AHA does not recommend antibiotic prophylaxis following vascular graft or other nonvalvular cardiovascular device (pacemakers, defibrillators, coronary artery stents, peripheral vascular stents, and vena cava filters) in patients undergoing endoscopy.⁶³

      8.8 Orthopaedic Prostheses

      There exist scant case reports of pyogenic arthritis which followed endoscopic procedures, and thus it is believed that infection of prosthetic joints related to endoscopy is exceptionally rare.⁶⁴ Although the American Association of Orthopedic Surgeons (AAOS) initially recommended antibiotic prophylaxis for patients with total joint replacement before invasive procedure that may cause bacteremia, this recommendation was subsequently withdrawn since it was not based on clinical evidence.

      8.9 Patients Receiving Peritoneal Dialysis

      Patients on continuous ambulatory peritoneal dialysis can develop peritonitis due to translocation of microorganisms across the bowel wall.⁶⁵ Endoscopic procedures in these patients can result in peritonitis. A retrospective study found that peritonitis developed in 6.3% of patients after colonoscopy without antibiotic prophylaxis and did not occur in patients who received prophylactic antibiotics.⁶⁶ The International Society for Peritoneal Dialysis (ISPD) recommended administration of antibiotics such as ampicillin (1 g) plus a single dose of an aminoglycoside, with or without metronidazole, given intravenously immediately before endoscopic procedures.⁶⁷ An alternative suitable strategy is the administration of prophylactic antibiotics by the intraperitoneal route the night before the endoscopic procedure. The ISPD recommended that the abdomen be emptied of fluid prior to the procedure.⁶⁷

      References

      [1] Sekino Y, Fujisawa N, Suzuki K, et al. A case of recurrent infective endocarditis following colonoscopy. Endoscopy. 2010; 42(Suppl 2):E217

      [2] Yu-Hsien L, Te-Li C, Chien-Pei C, Chen-Chi T. Nosocomial acinetobacter genomic species 13 TU endocarditis following an endoscopic procedure. Intern Med. 2008; 47(8):799–802

      [3] Malani AN, Aronoff DM, Bradley