Viridans streptococcal bacteremia after esophageal stricture dilation

Approach to Endoscopic Balloon Dilatation in Pediatric Stricturing Crohn Disease: A Position Paper of the Endoscopy Special Interest Group of ESPGHAN

Crohn disease (CD) is often complicated by bowel strictures that can lead to obstructive symptoms, resistant inflammation, and penetrating complications. Endoscopic balloon dilatation of CD strictures has emerged as a safe and effective technique for relieving these strictures, which may obviate the need for surgical intervention in the short and medium term. This technique appears to be underutilized in pediatric CD. This position paper of the Endoscopy Special Interest Group of European Society for Pediatric Gastroenterology, Hepatology and Nutrition describes the potential applications, appropriate evaluation, practical technique, and management of complications of this important procedure. The aim being to better integrate this therapeutic strategy in pediatric CD management.

Staphylococcus lugdunensis Infectious Endocarditis Complicated by Embolic Stroke After Colonoscopy in a 58-Year-Old Female

There are a significant number of colonoscopies and esophagogastroduodenoscopies (EGDs) done in the United States every year and post-endoscopic infections are frequently seen. Data demonstrating causality between endoscopic procedures and infectious endocarditis (IE) or that antibiotic prophylaxis prior to endoscopic procedures protects against IE is still lacking. Here we have presented the case of a patient who underwent diagnostic colonoscopy as part of a malignancy workup and was later found to be septic with Staphylococcus lugdunensis bacteremia and had IE. We hypothesized that the infection was most likely contracted during colonoscopy as a result of bacterial translocation from the perineal region to the bloodstream. This case report highlights the need for further studies investigating the efficacy of prophylactic antibiotics in reducing the risk of IE after colonoscopies.

Endoscopic Management of Refractory Benign Esophageal Strictures

Benign esophageal strictures are commonly encountered in clinical practice. The principal etiologies of benign esophageal strictures include long term acid reflux, caustic injuries, eosinophilic esophagitis, anastomotic strictures or endoscopic therapy. Dysphagia is most prominently present in esophageal strictures along with a variety of other symptoms which depend on the stricture etiology. Benign esophageal strictures can be categorized into two groups: simple or complex depending on their structure. Most strictures can be treated successfully with endoscopic dilation by bougies or balloons dilators. In some cases, treatment is more challenging, involving a higher risk of the patient developing recurrent or refractory strictures. To improve symptoms in these patients, other endoscopic treatments such as steroid injection, incisional therapy and stent placement should be considered. In this manuscript, we provide a comprehensive review of the main treatment options currently available to manage recurrent benign esophageal strictures.

The Endoscopy Patient as a Vector and Victim

Patient and procedural factors can increase the risk of infectious adverse events during endoscopy. Prophylactic antibiotic use must be judicious and individualized in the era of antibiotic resistance. New and emerging procedures require high-quality studies to elucidate appropriate risk profiles.

Obstructive heart failure with Cardiobacterium hominis infective endocarditis

We illustrate the progression of Cardiobacterium hominis infective endocarditis in a patient with a bioprosthetic mitral valve and decompensated heart failure secondary to an obstructive septic vegetation.

Submucosal tunnel endoscopic resection for extraluminal tumors: a novel endoscopic method for en bloc resection of predominant extraluminal growing subepithelial tumors or extra-gastrointestinal tumors (with videos)

BACKGROUND AND AIMS

The management of subepithelial tumors with a predominant extraluminal growth pattern or extra-GI tumors can be challenging and traditionally requires a surgical resection that is not only invasive but may carry a significant risk of morbidity and mortality. We aimed to assess the feasibility, safety, and efficacy of a novel endoscopic technique termed submucosal tunnel endoscopic resection for extraluminal tumors (STER-ET).

METHODS

We prospectively enrolled patients who underwent STER-ET for GI subepithelial tumors with a predominant extraluminal growth pattern or extra-GI tumors located at the level of cardia or the proximal part of the lesser curvature of the stomach seen on cross-sectional imaging between January 2016 and March 2017.

RESULTS

Eight patients underwent STER-ET. The mean (± standard deviation) tumor size was 2.8 ± 0.6 cm and 2.3 ± 0.8 cm in longest and shortest dimension, respectively. The average procedure time was 67 ± 4.4 minutes. The rates of curative en bloc resection and en bloc retrieval was 100% and 87.5%, respectively. On final histology, 6 tumors were GI stromal tumors, 1 was a schwannoma, and 1 was a foregut cyst. Five patients had capnoperitoneum during the procedure and required abdominal decompression. One patient had a small mucosotomy successfully treated with a hemostatic clip. There were no major adverse events or deaths. The median length of hospital stay was 3 days. There was no residual tumor on surveillance imaging after a mean follow-up period of 10.0 ± 2.1 months.

CONCLUSIONS

STER-ET is a novel technique that appears to be safe and effective in achieving a curative resection for GI subepithelial tumors with a predominantly extraluminal growth pattern or extraluminal tumors in a selected group of patients. However, larger studies are required to validate our finding.

A rare complication of esophageal dilatation: Brain abscess

Brain abscess is an uncommon serious disease, which has been reported as a rare complication of repeated esophageal dilations; however, routine periprocedural antibiotic prophylaxis is not currently recommended. Herein, we present a brain abscess that developed after esophageal dilatation for the treatment of induced caustic esophageal strictures. The clinical presentation is non-specific, the most reported signs are high fever and neurologic findings. Cases have been reported in the literature in adult and pediatric patients. Cranial imaging is essential for diagnosis, drainage and antibiotics are essential in its treatment. Clinical improvement was achieved with antibiotic therapy and surgical drainage. This serious complication should be kept in mind when treatment of corrosive strictures though repeated esophageal dilatation is planned and prophylaxis should be considered in selected patients.

Endoscopic treatment of benign esophageal strictures: a literature review

Benign esophageal strictures arise from various etiologies and are frequently encountered. Although endoscopic dilation is still the first-line therapy, recurrent strictures do occur in approximately 10% of the cases and remains a challenge to gastroenterologists. Areas covered: A literature search was performed using PubMed and Google Scholar databases for original and review articles on endoscopic treatment of benign esophageal strictures. This review outlines the main available treatment options and its controversies in the management of refractory benign esophageal strictures. Expert commentary: Adding local steroid injections to dilation can be effective for peptic stenosis and strictures after endoscopic submucosal dissection, but remains uncertain for anastomotic strictures. Intralesional injections of mitomycin-C could be useful in corrosive strictures. Incisional therapy can be a reliable alternative in Schatzki rings and in anastomotic strictures, in experienced hands. By contrast, long-term outcome with endoprosthetic treatment is disappointing, and stent placement should be carefully considered and individualized.

Techniques and principles of endoscopic treatment of benign gastrointestinal strictures

PURPOSE OF REVIEW

The fundamental goal of treating any stenosis is luminal enlargement to ameliorate the underlying obstructive symptoms. Symptoms depend on the etiology and the site of the stricture and may include dysphagia, nausea and vomiting, abdominal pain, obstipation, or frank bowel obstruction. This article compares the various current technologies available for the treatment of gastrointestinal stenoses with regard to ease and site of application, patient tolerance, safety and efficacy data, and cost-benefit ratio.

RECENT FINDINGS

Recent studies indicate that gastrointestinal dilation and stenting have evolved to a point at which in many if not most situations they can be the first line therapy and potentially the final therapy needed to treat the underlying condition.

SUMMARY

Following techniques and principles in the management of gastrointestinal strictures would allow for the well tolerated and effective treatment of most patients with the tools currently available today.

Clinical impact of prophylactic antibiotic treatment for self-expandable metallic stent insertion in patients with malignant colorectal obstruction

Purpose. The aim of this study was to determine the efficacy of prophylactic antibiotics (PA) for reducing the infectious complications and the potential risk factors responsible for the infectious complications after stent insertion for malignant colorectal obstruction. Methods. We performed a retrospective review of 224 patients who underwent self-expandable metallic stent (SEMS) insertion for malignant colorectal obstruction from May 2004 to December 2012. Results. There were 145 patients in the PA group and 79 in non-PA group. The CRP level in PA group was significantly higher than that in non-PA. Abdominal tenderness and mechanical ileus were significantly more frequent in PA group than those in non-PA. The frequency of post-SEMS insertion fever, systemic inflammatory response syndrome (SIRS), and bacteremia was not significantly different between PA and non-PA groups. In multivariate analysis, the CRP level was risk factor related to post-SEMS insertion SIRS. However, in propensity score matching analysis, there was no independent risk factor related to post-SEMS insertion fever, SIRS, and bacteremia. Conclusion. The use of PA in patients with malignant colorectal obstruction may be not effective to prevent the development of infectious complications after SEMS insertion.

Frequent occurrence of fever in patients who have undergone endoscopic submucosal dissection for colorectal tumor, but bacteremia is not a significant cause

BACKGROUND

We examined the incidence of and factors associated with fever, as well as the frequency of bacteremia, in patients who had undergone endoscopic submucosal dissection (ESD) for colorectal tumor.

METHOD

A total of 199 patients (120 male and 79 female) were included. The patients were classified into two groups based on the body temperature on the day after ESD treatment: group A, body temperature <37 °C; and group B, body temperature ≥37 °C. The following factors were analyzed to determine their potential association with post-ESD fever: gender, age, tumor size, form, location, and presence or absence of intraoperative perforation. In addition, blood samples from 50 patients were obtained for blood culture and 16S rRNA gene analysis by polymerase chain reaction.

RESULTS

Group A included 106 patients (70 male and 36 female), with a median age of 63 years. Group B included 93 patients (50 male and 43 female), with a median age of 70 years. The incidence of post-ESD fever in the entire cohort was 46.7%. Univariate analysis based on comparison between groups A and B showed that the following factors were significantly associated with post-ESD fever: age [mean ± standard deviation (SD)], 64.5 ± 9.2 versus 68.5 ± 10.8 years, P = 0.006; and tumor size (mean ± SD) 30.6 ± 10.8 versus 39.1 ± 16.6 mm, P < 0.001. Logistic regression analysis for post-ESD fever also found that age {odds ratio 1.04 (95% CI [1.01-1.07], P = 0.009)} and lesion size {odds ratio 1.05 (95% CI [1.03-1.08], P = 0.0002)} were closely associated with post-ESD fever. Of the 50 patients who had blood samples cultured and 16S rRNA gene analyzed, bacteria in blood culture and the 16S rRNA gene were not detectable in any of the samples from the 50 patients.

CONCLUSIONS

This study indicated that older patients and patients with large tumors were more likely to develop post-ESD fever, but there was a low probability that bacteremia was the cause of fever.

Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy

Flexible endoscopy is a widely used diagnostic and therapeutic procedure. Contaminated endoscopes are the medical devices frequently associated with outbreaks of health care-associated infections. Accurate reprocessing of flexible endoscopes involves cleaning and high-level disinfection followed by rinsing and drying before storage. Most contemporary flexible endoscopes cannot be heat sterilized and are designed with multiple channels, which are difficult to clean and disinfect. The ability of bacteria to form biofilms on the inner channel surfaces can contribute to failure of the decontamination process. Implementation of microbiological surveillance of endoscope reprocessing is appropriate to detect early colonization and biofilm formation in the endoscope and to prevent contamination and infection in patients after endoscopic procedures. This review presents an overview of the infections and cross-contaminations related to flexible gastrointestinal endoscopy and bronchoscopy and illustrates the impact of biofilm on endoscope reprocessing and postendoscopic infection.

Reducing complications in upper gastrointestinal endoscopy

This article reviews the principal aspects related to sedation in endoscopy and to the prevention of adverse events in some of the most frequently performed therapeutic upper gastrointestinal (GI) endoscopic procedures (esophageal dilation and stenting, endoscopic resection of upper GI early neoplasia, hemostasis of upper GI bleeding and percutaneous endoscopic gastrostomy insertion). These procedures have an inherent risk of negative outcomes that cannot be entirely avoided. Endoscopic procedures are best performed by well-trained, competent and thoughtful endoscopists in facilities suited to provide for patient safety. Attention to clinical risk management may effectively reduce the frequency and intensity of adverse events, enhance recognition and early detection, and improve responsiveness.

Dilation of malignant strictures in endoscopic ultrasound staging of esophageal cancer and metastatic spread of disease

Background. Dilation of malignant strictures in endoscopic ultrasound (EUS) staging of esophageal cancer is safe, but no data exists regarding the subsequent development of metastases. Aim. Compare the rates of metastases in esophageal cancer patients undergoing EUS staging who require esophageal dilation in order to pass the echoendoscope versus those who do not. Methods. We reviewed consecutive patients referred for EUS staging of esophageal cancer. We evaluated whether dilation was necessary in order to pass the echoendoscope, and for the subsequent development of metastases after EUS at various time intervals. Results. Among all patients with similar stage (locally advanced disease, defined as T3, N0, M0 or T1-3, N1, M0), there was no difference between the dilated and nondilated groups in the rates of metastases at 3 months (14% versus 10%), P = 1.0, 6 months (28% versus 20%), P = 0.69, 12 months (43% versus 40%), P = 1.0, or ever during a mean followup of 15 months (71% versus 55%), P = 0.48. Conclusions. Dilation of malignant strictures for EUS staging of esophageal cancer does not appear to lead to higher rates of distant metastases.

Low-frequency of bacteremia after endoscopic submucosal dissection of the stomach

BACKGROUND

Mainstream therapy for early gastric cancer in Japan has now shifted from endoscopic mucosal resection (EMR) to endoscopic submucosal dissection (ESD). Although bacteremia is reported as being infrequent and transient in gastric EMR, there are no reports of it being investigated in gastric ESD. This study aimed to determine the frequency of bacteremia in gastric ESD.

PATIENTS AND METHODS

A prospective study, in 46 consecutive patients who underwent gastric ESD, investigated the frequency of bacteremia before and after the procedure.

RESULTS

  The median time for the total ESD procedure was 105min (range 30-400). The median volume of the submucosal injection was 80ml (range 20-260). The mean size of the resected specimen was 40±9.7mm. Blood cultures obtained before ESD were positive in 4.4% (2/45) of cases. Bacillus subtilis and Bacillus spp. were the isolated microorganisms. Blood cultures obtained 10min after ESD were positive in 4.3% (2/46) of cases; with the same microorganisms being isolated. Blood cultures obtained 3h after ESD were all negative. No signs of sepsis were seen in the two patients with a positive blood culture 10min after ESD.

CONCLUSIONS

The frequency of bacteremia after gastric ESD was low and transient. ESD for gastric lesions is thought to have a low risk of infectious complications; therefore, prophylactic administration of antibiotics may not be warranted.

[Gastrointestinal endoscopy and infection]

During a gastrointestinal endoscopy, the device crosses natural cavities with always commensal bacterial flora, sometimes pathogenic flora. In all cases, the device is contaminated after the exam. The lack of effective disinfection exposes to the risks of transmission of germs. The infectious risk depends on the patient, the endoscopic procedure as well as on the technique of disinfection. The bacteraemia is usually not clinically significant. The endoscopic transmission of the germs from a patient to another one is very rare and is mostly due to a defect of disinfection. The procedures for disinfecting equipment should be known, established and controlled.

Low frequency of bacteremia after an endoscopic resection for large colorectal tumors in spite of extensive submucosal exposure

BACKGROUND

During an EMR or endoscopic submucosal dissection (ESD) for colorectal tumors, an injection needle catheter is passed through the contaminated endoscopic channel and may directly inoculate bacteria into the blood stream during submucosal injection. In addition, extensively exposed submucosa, especially with an ESD, directly contacts colonic luminal bacteria after the procedure, which may increase the risk of bacteremia. However, the incidence of bacteremia after an EMR or ESD for colorectal tumors has not been reported.

OBJECTIVE

To evaluate the frequency of bacteremia associated with an EMR or ESD for colon lesions.

DESIGN

A prospective study.

PATIENTS

A total of 40 patients who underwent a conventional EMR (n = 30), an EMR after circumferential pre-cutting (n = 3), or ESD (n = 7) for colorectal tumors.

INTERVENTIONS AND MAIN OUTCOME MEASUREMENTS

Blood cultures were obtained immediately before, 5 minutes after, and 30 minutes after the procedure. Patients were closely monitored for 24 hours after the procedure to detect the development of infectious complications.

RESULTS

Blood cultures at baseline and 5 minutes after the procedure were all negative. However, a blood culture at 30 minutes after the procedure showed a positive result in 1 of 40 patients (2.5%). This patient underwent a conventional EMR, and the isolated microorganism was coagulase-negative Staphylococcus, which might be regarded as a contaminant. None of the 40 patients showed any signs or symptoms associated with infection.

LIMITATION

The small sample size.

CONCLUSIONS

An EMR, or even an ESD, for colon lesions may be considered a low-risk procedure for infectious complications that does not warrant prophylactic administration of antibiotics.

Brain abscess after esophageal dilatation: case report

Brain abscess formation is a serious disease often seen as a complication to other diseases and to procedures. A rare predisposing condition is dilatation therapy of esophageal strictures. A case of brain abscess formation after esophageal dilatations is presented. A 59-year-old woman was admitted with malaise, progressive lethargy, fever, aphasia and hemiparesis. Six days before she had been treated with esophageal dilatation for a stricture caused by accidental ingestion of caustic soda. The brain abscess was treated with surgery and antibiotics. She recovered completely. This clinical case illustrates the possible association between therapeutic esophageal dilatation and the risk of brain abscess formation.

Prospective study of bacteremia and complications With EUS FNA of rectal and perirectal lesions

BACKGROUND & AIMS

Recent studies showed that endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is a low-risk procedure for causing bacteremia and infectious complications when sampling solid lesions of the upper gastrointestinal (GI) tract. As a result, antibiotics are not recommended for prophylaxis against endocarditis. Our aim was to prospectively evaluate the risk of bacteremia and other infectious complications in patients undergoing EUS FNA of lower GI tract lesions.

METHODS

Patients referred for EUS FNA of lower GI tract lesions were considered for enrollment. Patients were excluded if there was an indication for preprocedure antibiotic administration based on American Society for Gastrointestinal Endoscopy guidelines, had taken antibiotics within the prior 7 days, or if they had a cystic lesion. Blood cultures were obtained immediately before the procedure, after flexible sigmoidoscopy/radial EUS, and 15 minutes after EUS FNA.

RESULTS

One hundred patients underwent a total of 471 FNAs (mean, 4.7 FNAs/patient; range, 1-10 FNAs/patient). Blood cultures were positive in 6 patients. Cultures from 4 patients (4.0%, 95% confidence interval, 1.6%-9.8%) grew coagulase-negative Staphylococcus (n = 2), Peptostreptococcus stomatis (n = 1), or Moraxella (n = 1), which were considered contaminants. Two patients (2.0%, 95% confidence interval, 0.6%-7%) developed bacteremia: Bacteroides fragilis (n = 1) and Gemella morbillorum (n = 1). No signs or symptoms of infection developed in any patient.

CONCLUSIONS

EUS FNA of solid lesions in the lower GI tract should be considered a low-risk procedure for infectious complications that does not warrant prophylactic administration of antibiotics for the prevention of bacterial endocarditis.

Minimization of risks of esophageal dilation

Esophageal dilation, along with many other therapeutic endoscopic procedures, carries with it an increased risk of complications, most of which are transient events but some of which may be catastrophic. The author reviews the literature concerning the major and minor complications that one will encounter in a busy and aggressive gastrointestinal endoscopic practice. There are scant prospective data concerning risk minimization and most studies are retrospective case series. Careful identification of groups of patients who have risk factors that may increase the potential for an adverse event is worthwhile and is reviewed. The current literature is discussed and suggestions to provide guidance and pearls in helping to avoiding and diagnosing major complications are given.

Bacteremia after diagnostic conventional laparoscopy and minilaparoscopy: a prospective study in 100 patients

BACKGROUND/GOALS

Diagnostic laparoscopy under sedoanalgesia is a valuable tool in the work-up of liver diseases and is helpful as a staging procedure. The rate of bacteremia caused by this procedure is unknown, in particular when performed as minilaparoscopy.

STUDY

A 100 consecutive patients having undergone diagnostic laparoscopy carried out either conventionally (group I, n=50) or as minilaparoscopy (group II, n=50) were prospectively enrolled in this study. Blood cultures were drawn before and within 5 minutes after the procedure. Risk factors for bacteremia were evaluated.

RESULTS

Bacterial growth occurred in 4 blood cultures drawn immediately after laparoscopy. No patient developed fever or other signs of infection in the follow-up. Risk factors predisposing to bacteremia could not be identified.

CONCLUSIONS

Conventional diagnostic laparoscopy under sedoanalgesia and minilaparoscopy are associated with a low rate of bacteremia as in diagnostic upper endoscopy.

N/A

N/A

Frequency of bacteremia after linear EUS of the upper GI tract with and without FNA

BACKGROUND

Few data are available concerning the frequency of bacteremia after diagnostic EUS or EUS-guided FNA. This study was undertaken to provide these data and to determine whether present guidelines for prophylactic administration of antibiotics to prevent endocarditis during upper endoscopy are applicable to EUS and EUS-guided FNA.

METHODS

A total of 100 patients who were to undergo diagnostic EUS of the upper-GI tract and 50 who were to have upper-GI EUS-guided FNA were enrolled in this prospective study. Blood cultures were obtained before and within 5 minutes after the conclusion of the procedure. In case of bacterial growth, patients were observed for at least 3 days for signs of infection.

RESULTS

After diagnostic EUS, significant bacteremia was found in two patients with esophageal carcinoma (2%: 95% CI[0%, 4.8%]) and after EUS-guided FNA in two patients (4%: 95% CI[0%, 9.6%]). The difference was not statistically significant. None of these patients developed clinical signs of infection. Risk factors predisposing to bacteremia could not be identified.

CONCLUSION

The frequency of bacteremia after EUS, with and without FNA, is within the range of that for diagnostic upper endoscopy. Therefore, the same recommendations for prophylactic administration of antibiotics to prevent endocarditis may be applied in patients undergoing EUS and EUS-guided FNA. The role of esophageal cancer as a predisposing factor to EUS-associated infection remains uncertain.

Guidelines for antibiotic prophylaxis for GI endoscopy

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. 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. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.

Prospective risk assessment of bacteremia and other infectious complications in patients undergoing EUS-guided FNA

BACKGROUND

There are few data regarding the risk of bacteremia with EUS-guided FNA. This study prospectively evaluated the frequency of bacteremia and other infectious complications after EUS-guided FNA.

METHODS

Patients referred for EUS-guided FNA of the upper GI tract lesions were considered for enrollment. Patients were excluded if there was an indication for preprocedure administration of antibiotics based on ASGE guidelines, had taken antibiotics within the prior 7 days, or if they had a pancreatic cystic lesion. Blood cultures were obtained immediately before the procedure, after routine endoscopy/radial EUS, and 15 minutes after EUS-guided FNA.

RESULTS

Fifty-two patients underwent EUS-guided FNA at 74 sites (mean 1.4 sites/patient) totaling 266 passes of the fine needle (mean 5.1 FNA/patient). Coagulase negative Staphylococcus was grown in cultures from 3 patients (5.8%; 95% CI [1%, 15%]) and was considered a contaminant. Three patients (5.8%; 95% CI [1%, 15%]) developed bacteremia: Streptococcus viridans (n = 2), unidentified gram-negative bacillus (n = 1). No signs or symptoms of infection developed in any patient.

CONCLUSION

EUS-guided FNA of solid lesions in the upper GI tract should be considered a low-risk procedure for infectious complications that does not warrant prophylactic administration of antibiotics for prevention of bacterial endocarditis.

Infection control during gastrointestinal endoscopy

Infection-control issues during gastrointestinal endoscopy, which are becoming increasingly important, can generally be divided into three major areas: (1) infectious complications resulting from a patient's own microbial flora (autologous), (2) infections transmitted from patient to patient by way of the endoscope (exogenous), and (3) infections transmitted between the patient and the health-care provider. The mean frequency of postprocedure bacteremia ranges from 0.5% for flexible sigmoidoscopy to 2.2% for colonoscopy, 4.2% for esophagogastroduodenoscopy, 8.9% for variceal ligation, 11% for endoscopic retrograde cholangiopancreatography, 15.4% for variceal sclerotherapy, and 22.8% for esophageal dilation. Although postprocedure bacteremia is not uncommon, it seldom results in infectious complications. Exogenous infections transmitted during endoscopy, which are extremely rare, generally result from failure to follow accepted guidelines for the cleaning and disinfection of gastrointestinal endoscopes, underscoring the importance of meticulous attention to endoscope reprocessing. Finally, although the risk of patient-staff transmission of infection is also rare, standard infection-control recommendations are important in protecting both patients and health-care providers.

Antimicrobial prophylaxis for gastrointestinal procedures: current practices in North American academic pediatric programs

BACKGROUND

Guidelines for the use of antibiotic prophylaxis in children are based on a small number of studies that assess the risk of infection associated with performing endoscopic procedures. The American Heart Association (AHA) and the American Society of Gastroenterological Endoscopy (ASGE) have established guidelines that identify conditions and procedures that place a child at greater risk for infectious complications. Because data on bacteremia and sepsis associated with endoscopy in children are very limited, we reviewed the practices of 15 large academic pediatric gastroenterology services to see if patterns of practice and safety could be determined.

METHODS

A questionnaire was sent to 15 academic gastroenterology centers in the United States and Canada asking about antibiotic prophylaxis for endoscopic procedures for children with six conditions. These included three conditions related to congenital heart disease based on negligible, moderate, and high risk for endocarditis; immune compromise; the presence of a central venous line; and the presence of a ventriculo-peritoneal shunt. Six procedures were evaluated, including esophagogastroduodenoscopy with biopsy, flexible sigmoidoscopy or colonoscopy with biopsy, endoscopic retrograde cholangiopancreatography, esophageal sclerotherapy, esophageal dilation, and percutaneous endoscopic gastrostomy (PEG) tube placement.

RESULTS

The patterns of reported practice generally conform to the AHA and ASGE guidelines. The six conditions and six procedures yielded 36 response categories for the participating centers. The majority of centers reported routine use of antibiotic prophylaxis in about half (17) of the response categories, which represented three distinct situations. These included children with congenital heart disease having moderate or high risk for bacterial endocarditis for almost all procedure categories and children undergoing PEG tube placement regardless of underlying condition. In all other combinations of underlying conditions and procedures, the majority of centers did not use routine prophylaxis. The majority of centers did not use antibiotic prophylaxis for cardiac conditions with a negligible risk of infectious complication or for children with immunocompromise, central venous lines, or ventriculo-peritoneal shunts for any procedure except PEG placement.

CONCLUSIONS

These results indicate that the routine use of antibiotic prophylaxis is limited in pediatric academic centers to a few very specific conditions and procedures. The results also provide indirect evidence that the risk of infectious complications associated with endoscopic procedures appears to be exceedingly low.

A prospective evaluation of the incidence of bacteremia associated with EUS-guided fine-needle aspiration

BACKGROUND

Endoscopic ultrasound (EUS)--guided fine-needle aspiration (FNA) is frequently performed for diagnostic evaluation of lesions in or near the gastrointestinal (GI) tract. Little data exist concerning possible infectious complications associated with EUS-guided FNA. This prospective evaluation was undertaken to determine the frequency of bacteremia and infectious complications associated with EUS-guided FNA.

METHODS

All patients undergoing EUS-guided FNA for any indication were enrolled in this study. Patients who required antibiotic prophylaxis as per the American Heart Association or American Society for Gastrointestinal Endoscopy guidelines were excluded from the study as were patients with cystic lesions, patients with advanced liver disease/ascites and those with human immunodeficiency virus/acquired immune deficiency syndrome. Blood cultures were obtained 30 and 60 minutes after the EUS-FNA. Patients were monitored for evidence of infection after procedure including telephone follow-up of each subject 1 week after procedure.

RESULTS

One hundred patients underwent EUS-FNA of 108 lesions. All blood cultures were negative except in 6 patients in whom 1 of 2 bottles were positive for coagulase negative Staphylococcus, which was considered a contaminant. There were no complications of acute febrile illness, abscess or other infections.

CONCLUSION

EUS-guided FNA was not associated with bacteremia or infectious complications.

Preventing nosocomial infections from gastrointestinal endoscopy

Gastrointestinal procedures have been associated with a wide range of infectious complications, including bacterial endocarditis. Although the rate of bacteremia from the patient's own flora is quite high after some procedures, only a few cases of endocarditis caused by gastrointestinal instrumentation have been reported. Because of the severity of the illness, however, antibiotic prophylaxis has been recommended for patients who are categorized as high risk for some procedures. Bacteremia and other infections, such as colitis, may also originate from a contaminated endoscope. To prevent such an occurrence, high-level disinfection has been recommended for gastrointestinal endoscopes. High-level disinfection includes manual cleaning of the endoscope, flushing of internal channels with a liquid chemical sterilant, and thorough rinsing and drying of internal lumens.

Peptic strictures of the esophagus

Peptic esophageal strictures occur in the context of inadequately treated gastroesophageal reflux, especially in elderly patients. Studies show more pronounced abnormalities of esophageal function resulting in an increased number of prolonged reflux episodes. The diagnosis is best made by a combination of barium esophagram and endoscopy. Patients usually require esophageal dilation to relieve dysphagia followed by adequate medical therapy. Proton pump inhibitors are effective for preventing the recurrence of strictures after dilation. In young patients and patients with strictures that are difficult to dilate or need frequent dilations, surgery may be required; however, results can be disappointing.

The effect of oral decontamination with clindamycin palmitate on the incidence of bacteremia after esophageal dilation: a prospective trial

BACKGROUND

Antibiotic prophylaxis to prevent bacterial endocarditis is recommended in high-risk patients undergoing esophageal dilation, a high-risk procedure. Some studies suggest that the oropharynx is the source of bacteremia. A topical antibiotic mouthwash, which reduces bacterial colonization of the oral flora, might decrease bacteremia rates and would be an attractive alternative to systemic administration of antibiotics.

METHODS

Adults undergoing outpatient bougienage for a benign or malignant esophageal stricture were randomized in a clinician-blinded fashion to either pre-procedure clindamycin mouthwash or no treatment. Subjects were stratified by type of dilator used. Blood cultures were obtained immediately after the first esophageal dilation and 5 minutes after the last dilation.

RESULTS

Fifty-nine patients were enrolled: 30 in the treatment arm and 29 in the no-treatment arm. There were 7 positive blood cultures: 5 in the treatment arm and 2 in the no-treatment arm. The identified organisms were Streptococcus viridans (2), Staphylococcus mucilaginous (2), Lactobacillus (2), and Actinomyces odontolyticus (1). Patients with bacteremia reported greater subjective difficulty with dysphagia (p = 0.01) irrespective of stricture diameter, procurement of biopsies, or dilator type.

CONCLUSIONS

The percentage of cases with bacteremia for all dilations performed in this manner was 12% (95% CI [5.3, 23.6]), much lower than previously cited. All organisms in this study were oral commensals. There appears to be no effect of a clindamycin mouthwash on reducing bacteremia after esophageal dilation.

AGA technical review on treatment of patients with dysphagia caused by benign disorders of the distal esophagus

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Practice Economics Committee. The paper was approved by the committee on September 27, 1998.