Division of Pediatric Gastroenterology, Nutrition, and Hepatology, University of California–San Francisco Medical Center, San Francisco, California, U.S.A.
Received December 18, 2001; accepted June 18, 2002.
Address correspondence and reprint requests to Dr. John Snyder, Division of Pediatric Gastroenterology, Nutrition and Hepatology, University of California–San Francisco Medical Center, Box 0136, San Francisco, CA 94143 (e-mail: firstname.lastname@example.org).
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.
When flexible gastrointestinal endoscopic procedures were introduced more than 20 years ago, concern was raised for the development of transient bacteremia leading to serious infections, including endocarditis, cholangitis, central venous line infection, or infection of prostheses or grafts (1–3). However, several types of data indicate that the risk may not be great. Transient bacteremia occurs with many activities and procedures but is usually cleared rapidly by healthy people (4). For example, the frequency of bacteremia associated with chewing hard candy is 17% (5) and with routine rectal examination is 4% (6). The risk of bacteremia for dental procedures is high (30%–90%) (7), but the cumulative burden of bacteremia is as much as 1,000 times greater for mastication than for dental extraction (8). Using case-control methodology, no increased risk of endocarditis has been found in persons with cardiac abnormalities undergoing dental procedures (9). These findings have led some to question the need for antimicrobial treatment for routine dental procedures (8–11).
The frequency of bacteremia associated with upper or lower gastrointestinal endoscopy with or without biopsy is low, ranging from about 2% to 5% (1,2,12). The reported risk of bacteremia with endoscopic retrograde cholangiopancreatography (ERCP) is similar (5%–6%) to that for upper and lower endoscopy unless an obstructed biliary ductal system is present (2,13–15). A substantially higher rate of bacteremia has been reported for variceal sclerotherapy (31%) (16–18) and esophageal dilation (20%–40%) (19–22). However, infections associated with gastrointestinal endosopic procedures are rare, including those performed in children (12); very few published reports exist that document infective endocarditis or other serious infection as a sequela of endoscopy (2,8,23,24). Indeed, the incidence of bacterial endocarditis has not increased despite the estimated millions of flexible endoscopic procedures performed in adults and children each year (2).
Criteria for the use of prophylactic antibiotics have been developed for endoscopic procedures based on the associated risk of developing bacteremia (1,2). Procedures considered to be of low risk include esophagogastroduodenoscopy (EGD) with or without biopsy, flexible sigmoidoscopy and colonoscopy with or without biopsy, and ERCP in the absence of ductal obstruction (1,2). Higher-risk endoscopic procedures include esophageal stricture dilation, esophageal sclerotherapy, and ERCP of an obstructed biliary tree. Prospective, randomized, controlled data support the use of prophylactic antibiotics for the placement of percutaneous endoscopic gastrostomy (PEG) tubes (25).
The indiscriminate use of prophylactic antibiotics is not without risk and can result in excess cost and the potential for complications such as allergic drug reactions and antibiotic-associated colitis (9). In addition, no prospective, controlled studies have documented that the use of prophylactic antibiotics prevents infective endocarditis (2,9).
When the use of antibiotic prophylaxis for endoscopic procedures is considered, the following factors should be evaluated: 1) the degree to which the patient's underlying condition creates a risk of severe infection, 2) the risk of bacteremia associated with the procedure, 3) the potential adverse reactions of the prophylactic antimicrobial agent, and 4) cost–benefit aspects of the prophylaxis (1). The American Heart Association (AHA) divides cardiac disease into high-, moderate-, and negligible-risk conditions based on potential outcome if endocarditis develops (Table 1) (1). Even fewer data are available to assess the risk of infection for conditions such as immunodeficiency or the presence of a foreign body such as a central venous line or ventriculo-peritoneal shunt.
No specific guidelines have been developed for the use of prophylactic antibiotics for endoscopic procedures in children. We surveyed academic pediatric centers in the United States and Canada to determine the current practices of these groups and to compare these practices with the recommendations of the AHA and the American Society of Gastrointestinal Endoscopy (ASGE).
Representatives from 15 pediatric gastroenterology programs at academic centers in the United States and Canada were asked to complete a written questionnaire detailing the antibiotic prophylaxis practices for their group. One representative completed the questionnaire, but the responses often represented a consensus of the practitioners at each center. The centers surveyed included three in Canada (B.C. Children's Hospital, Vancouver; Hospital for Sick Children, Toronto; and Hospital Ste. Justine, Montreal) and 12 from the United States (Children's Hospital and Massachusetts General Hospital, Boston; Children's Hospital of Philadelphia; Miami Children's Hospital; University of Alabama; Children's Hospital, Cincinnati; J. Whitcomb Riley Hospital for Children, Indianapolis; Baylor University; Children's Hospital, Denver; the University of California, Los Angeles; and the University of California, San Francisco). These centers were selected because they have large clinical pediatric gastrointestinal practices that have active endoscopy services and represent a wide geographic cross-section of programs.
The questionnaire sought information on antibiotic prophylaxis for six conditions and six procedures, which yielded 36 categories. The six conditions evaluated included three related to congenital heart disease as well as immune compromise, the presence of a central venous line, and the presence of a ventriculo-peritoneal shunt. Six procedures were evaluated, including EGD with biopsy, flexible sigmoidoscopy or colonoscopy with biopsy, ERCP, esophageal sclerotherapy, esophageal dilation, and PEG tube placement.
Responses were compared with the guidelines for prophylaxis established by the AHA and the ASGE (1,2). The cardiac conditions are grouped into those with high, moderate, and negligible risk of infectious complication (Table 1) (1). For the three noncardiac conditions considered, the AHA has no recommendations, and the ASGE lists recommendations only for immunocompromised patients (2). The ASGE recommendations are influenced more by the nature of the procedure than the condition; because data on infection risk are few, routine prophylaxis is not recommended even for highrisk cardiac conditions if the procedure has a low risk of infection (2).
Procedures considered by the AHA and ASGE to have a low risk of associated infection include EGD with or without biopsy, flexible sigmoidoscopy or colonoscopy with or without biopsy, and ERCP with no evidence of obstruction (Table 1). They recommend no routine antibiotic prophylaxis for lower-risk procedures and feel that evaluation should be performed on a case-by-case basis (1,2). Procedures with a higher risk of infectious complication include esophageal dilation, esophageal sclerotherapy, and placement of a PEG (1,2).
The six conditions and six procedures yielded 36 categories for evaluation; the responses from the 15 pediatric gastroenterology programs are summarized in Tables 2–7. There was no difference in the pattern of response by the country or by the regions within a country of the programs. Most centers indicated that they did not have a written policy and that their responses were often based on a consensus of the endoscopists at their institution.
The responses indicated that the nature of the procedure and the child's condition both were important determinants as to whether prophylactic antibiotics were used. The majority of centers reported routine use of antibiotic prophylaxis in about half (17) of the response categories, which represented three specific situations. The first was cardiac conditions with a high risk of bacterial endocarditis in which the majority of centers used prophylactic antibiotics for all six procedures performed (Tables 2–7). The second was the procedure of PEG placement, in which antibiotic prophylaxis was used by the majority of centers for all six conditions (Table 7). The majority of centers also routinely gave antibiotic prophylaxis to children with cardiac conditions with a moderate risk of bacterial endocarditis for all procedures except for EGD with biopsy, where 9 of the 15 centers do not (Table 2).
In contrast, the majority of responding programs did not use antibiotic prophylaxis for the three low-risk procedures or for the negligible-risk cardiac conditions. The pattern of prophylaxis use for the three higher-risk procedures is found in Tables 5–7. The majority of the centers did not use prophylaxis for dilation or sclerotherapy for the three clinical conditions for which few data on risk are available: patients with immunocompromise, central lines, and ventriculo-peritoneal shunts.
Unanimity of opinion was rarely reported. In only two response categories did all the centers agree on antibiotic prophylaxis: use of antibiotics for ERCP and PEG placement in patients with high cardiac risk for endocarditis.
The results indicate that the majority of these academic pediatric centers follow the guidelines recommended by the AHA and the ASGE and use antibiotic prophylaxis only in selected situations. The specific clinical conditions in which the majority of the centers routinely use antibiotic prophylaxis are for children with cardiac lesions that are at high or moderate risk for bacterial endocarditis. The only procedure in which a majority of the centers use antibiotic prophylaxis for all underlying clinical conditions is PEG placement, which is the only procedure for which randomized, controlled data exist to support its use (25).
From the practices reported by participating centers, only a small proportion of pediatric patients undergoing endoscopy receive prophylaxis. Children who have high- or moderate-risk cardiac conditions and those receiving PEGs represent approximately half of the categories evaluated in this survey, but they represent far fewer patients than those without cardiac disease and those undergoing endoscopy, flexible sigmoidoscopy, or colonoscopy.
The practice of limiting the use of prophylactic antibiotics to high-risk groups is consistent with the current recommendation to limit prophylaxis for dental procedures to those with a high risk of infectious complications when performed in patients with prosthetic valves or previous endocarditis (9–11). Adoption of the practice of limiting antibiotic prophylaxis has the potential to reduce the cost and morbidity of many dental and gastrointestinal procedures and to help reduce the growing problem of antibiotic-resistant organisms.
Few data exist on the need for antibiotic prophylaxis for children with immunocompromise or presence of foreign bodies, including central venous lines and ventriculo-peritoneal shunts. The ASGE does not recommend routine use of antibiotic prophylaxis for immunocompromised patients undergoing endoscopy, flexible sigmoidoscopy or colonoscopy, and ERCP without ductal dilation (2). No recommendations are available for the children with central venous lines or ventriculo-peritoneal shunts. The practices of the participating academic centers indicate that routine antibiotic prophylaxis may not be required for these procedures. The only exception in these populations was the routine use prophylaxis for PEG placement.
Caution should be used in interpreting these results. No data on the rate of infectious complications of endoscopic procedures at the participating centers was reviewed for this study. The responses represent the reported practices of the endoscopists at the institutions, and no quantitation or validation of practices at the centers was sought. However, the fact that large, busy clinical gastrointestinal services often do not report the use of antibiotic prophylaxis for many conditions and procedures indicates that infectious complications are likely to be uncommon.
We conclude that the spirit of the AHA and ASGE guidelines are followed closely by the pediatric gastrointestinal centers in the United States and Canada that participated in this study. Most of these centers use prophylactic antibiotics only in selected cases, which represent a small proportion of all children undergoing endoscopic procedures.
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