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Antibiotic Prophylaxis for GI Endoscopy

November 29, 2014 11:22 AM

The American Society for Gastrointestinal Endoscopy (ASGE) updated its guidelines on antibiotic prophylaxis for GI endoscopy in November 2014.

This important topic was summarized by Utah Gastroenterology. For detailed information, please review the excellent guideline paper.

As per the paper “..bacteremia can occur after endoscopic procedures and has been advocated as a surrogate marker for infective endocarditis (IE) risk. However, clinically significant infections are extremely rare. Despite an estimated 14.2 million colonoscopies, 2.8 million flexible sigmoidoscopies, and perhaps as many upper endoscopies performed in the United States each year, only approximately 25 cases of IE have been reported with temporal association to an endoscopic procedure. …. This document is an update of the prior ASGE document on antibiotic prophylaxis for GI endoscopy, discusses infectious adverse events related to endoscopy, and provides recommendations for periprocedural antibiotic therapy..”.

 

ASGE RECOMMENDATIONS

  1. The ASGE recommends against the routine administration of antibiotic prophylaxis solely for prevention of infective endocarditis (IE).
  2. The ASGE suggests that patients with high-risk cardiac conditions and established GI tract infections in which enterococci may be part of the infecting bacterial flora should receive antibiotic coverage.
  3. The ASGE recommends against antibiotic prophylaxis before ERCP when obstructive biliary tract disease is not suspected or complete biliary drainage is anticipated.
  4. The ASGE recommends that antibiotic prophylaxis be administered before ERCP in patients who have had liver transplantation or who have known or suspected biliary obstruction, where there is a possibility of incomplete biliary drainage. Antibiotics that cover biliary flora such as enteric gram-negative organisms and enterococci should be used and continued after the procedure if biliary drainage is incomplete.
  5. The ASGE recommends against antibiotic prophylaxis before diagnostic EUS or EUS-FNA of solid lesions of the GI tract.
  6. The ASGE suggests antibiotic administration prior to EUS-FNA of mediastinal cysts.
  7. The ASGE suggests administration of prophylactic antibiotics before EUS-FNA of pancreatic or peripancreatic cysts.
  8. The ASGE recommends administration of parenteral cefazolin (or an antibiotic with equivalent microbial coverage) to all patients before PEG/PEJ tube placement.
  9. The ASGE recommends that all patients with cirrhosis admitted with GI bleeding should have antibiotic therapy instituted at admission with intravenous ceftriaxone (or an antibiotic with equivalent microbial coverage [eg, oral norfloxacin] in patients allergic to or intolerant of ceftriaxone).
  10. The ASGE recommends against administration of antibiotic prophylaxis before GI endoscopic procedures for patients with synthetic vascular grafts or other nonvalvular cardiovascular devices (eg, implantable electronic devices).
  11. The ASGE recommends against antibiotic prophylaxis for patients with orthopedic prosthesis undergoing any GI endoscopic procedure.
  12. The ASGE suggests administration of antibiotic prophylaxis before endoscopy of the lower GI tract in patients undergoing continuous ambulatory peritoneal dialysis.

 

The 2007 American Heart Association (AHA) guidelines for prophylaxis of IE stated that the administration of prophylactic antibiotics solely to prevent IE was no longer recommended for patients undergoing GI endoscopy. The AHA based its recommendations on several lines of evidence including

  • (1) cases of IE associated with GI procedures are anecdotal
  • (2) no data demonstrate a conclusive link between GI procedures and the development of IE
  • (3) there are no data that demonstrate that antibiotic prophylaxis prevents IE after GI-tract procedures
  • (4) IE is more likely to be caused by bacteremia resulting from usual daily activities, and
  • (5) an extremely small number of cases of IE may be prevented even if antibiotic prophylaxis were 100% effective.

 

The AHA also delineated cardiac conditions associated with the highest risk of an adverse outcome from IE, including

  1. prosthetic (mechanical or bioprosthetic) cardiac valves,
  2. history of previous IE,
  3. cardiac transplant recipients who develop cardiac valvulopathy, and
  4. patients with congenital heart disease (CHD) including those with unrepaired cyanotic CHD including palliative shunts and conduits; those with completely repaired CHD with prosthetic material or devices, placed surgically or by patients with these cardiac conditions who have established infections of the GI tract in which enterococci may be part of the infecting flora (such as cholangitis) and particularly for those who are about to undergo an endoscopic procedure that may increase the risk of bacteremia (such as ERCP), the AHA suggests that inclusion of an agent active against enterococci in the concurrent antibiotic regimen may be reasonable. Although GI tract infections often are polymicrobial, antibiotic coverage for enterococci is recommended, because only enterococci are likely to cause IE. However, the AHA reiterates that no studies have demonstrated that such therapy would prevent enterococcal IE.

 
Therefore the ASGE suggests that patients with high-risk cardiac conditions and established GI tract infections in which enterococci may be part of the infecting bacterial flora should receive antibiotic coverage:

Prevention of infective endocarditis (IE) – Cardiac conditions

1) All cardiac conditions: Antibiotic prophylaxis is not indicated solely to prevent IE.
2) Cardiac conditions associated with the highest risk of an adverse outcome from IE should receive antibiotic coverage:

  • Prosthetic cardiac valve
  • History of IE
  • Cardiac transplant recipients who develop cardiac valvulopathy
  • Patients with congenital heart disease (CHD)
  • Unrepaired cyanotic CHD including palliative shunts and conduits
  • Completely repaired CHD with prosthetic material or device, placed surgically or by catheter, for the first 6 months after the procedure
  • Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or device

For patients with these conditions who have established infections of the GI tract (such as cholangitis) and for those who receive antibiotic therapy to prevent wound infection or sepsis associated with a GI tract procedure, it is recommended that the antibiotic regimen include an antimicrobial agent active against enterococci, such as penicillin, ampicillin, piperacillin, or vancomycin.

Clostridium Difficile Infections

April 27, 2013 8:04 PM

The American College of Gastroenterology published updated guidelines on Clostridium Difficile infection.

Clostridium difficile infection (CDI) is a leading cause of hospital-associated illness and is becoming a more difficult infection to control and treat. Fecal stool transfer is now being discussed and patients are becoming more aware of the difficult issues related to this intestinal infection. The current guidelines are therefore posted to provide our readers with a basis for further discussions with their physicians. It is suggested that patients are treated depending on severity of disease (mild-to-moderate, severe, or complicated disease). Therapy with metronidazole remains the choice for mild to moderate disease but may not be adequate for patients with severe or complicated disease.

Diagnostic tests

  • Only stools from patients with diarrhea should be tested for Clostridium difficile.
  • Repeat testing should be discouraged.
  • Testing for cure should not be done.

Management of mild, moderate, and severe CDI

  • If a patient has strong a pre-test suspicion for CDI, empiric therapy for CDI should be considered regardless of the laboratory testing result.
  • Any inciting antibiotics should be discontinued, if possible.
  • Patients with mild-to-moderate CDI should be treated with metronidazole 500 mg orally three times per day for 10 days.
  • Patients with severe CDI should be treated with vancomycin 125 mg four times daily for 10 days.
  • Failure to respond to metronidazole therapy within 5 – 7 days should prompt consideration of a change in therapy to vancomycin at standard dosing.
  • For mild-to-moderate CDI in patients who are intolerant / allergic to metronidazole and for pregnant / breastfeeding women, vancomycin should be used at standard dosing.
  • In patients in whom oral antibiotics cannot reach a segment of the colon, such as with Hartman’s pouch, ileostomy, or colon diversion, vancomycin therapy delivered via enema should be added to treatments above until the patient improves.
  • The use of anti-peristaltic agents to control diarrhea should be avoided, as they may obscure symptoms and precipitate complicated disease. If used, anti-peristaltic agents must be accompanied by medical therapy for CDI.
  • For complicated disease, supportive care should be offered i.e. iv fluids and electrolyte replacement. In the absence of ileus or significant abdominal distention, oral or enteral feeding should be continued.
  • CT scanning of the abdomen and pelvis is recommended in complicated CDI.
  • Oral vancomycin (125 mg four times per day) plus iv metronidazole (500 mg three times a day) is the treatment of choice in severe and complicated CDI.
  • Vancomycin delivered orally (500 mg four times per day) and per rectum (500 mg in a volume of 500 ml four times a day) plus intravenous metronidazole (500 mg three times a day) is the treatment of choice for patients with complicated CDI with ileus or toxic colon and / or significant abdominal distention.
  • Surgical consultation should be obtained in all patients with complicated disease and considered in patients with any one of the following:
  1. hypotension requiring vasopressor therapy
  2. clinical signs of sepsis and organ dysfunction (renal and pulmonary)
  3. mental status changes
  4. white blood cell count ≥ 50,000 cells / μ l, lactate ≥ 5 mmol / l
  5. failure to improve on medical therapy after 5 days. 

Management of recurrent CDI (RCDI)

Patient face a 30% recurrence risk with the first infection and a 60% recurrence risk if a second infection has occurred.

  • The first recurrence of CDI can be treated with the same regimen as used for the initial episode. If severe, however vancomycin should be used.
  • The second recurrence should be treated with a pulsed vancomycin regimen.
  • If there is a third recurrence after a pulsed vancomycin regimen, fecal microbiota transplant (FMT) should be considered.
  • There is limited evidence for the use of adjunct probiotics to decrease recurrences in patients with RCDI.
  • No effective immunotherapy is currently available.

Management of patients with CDI and co-morbid conditions

  • All IBD patients hospitalized with a disease flare should undergo testing for CDI.
  • IBD patients with diarrhea in the setting of prior quiescent disease, or in the presence of risk factors (i.e. recent hospitalization, antibiotic use) should be tested.
  • Patients with IBD and severe colitis may benefit from empiric therapy against CDI and treatment of an IBD flare while awaiting results of C. difficile testing.