Do you need to preventively use antibacterial drugs during digestive endoscopy?

It is only for medical professionals to read for reference.
Which situations should be used? What situations should not be used? This article concludes that the diagnosis and treatment of digestive endoscopy is a major breakthrough in the modern medical field, and its clinical application is becoming more and more extensive
.

Digestive endoscopy is an invasive operation.
During the operation, the damage of the mucosa or deeper tissues may cause endogenous bacteria to translocate and cause bacteremia, which may cause the risk of local tissue or distant tissue infection.
Preventive application Antibacterial drugs are an important measure to reduce the risk of infection complications and reduce unnecessary losses and damages
.

However, different endoscopic operations have different risks of infection, so not all endoscopic operations must prevent the use of antibacterial drugs
.

So, under what circumstances do we need preventive application of antibacterial drugs in various digestive endoscopy operations? Under what circumstances should it not be used? The author makes a summary with reference to the readers
.

01 Principles of Preventive Use of Antimicrobial Drugs in Endoscopic Diagnosis and Treatment We know that the basic principles of clinical application of antimicrobial drugs are: first, whether to use antimicrobial drugs with or without indication; second, whether the selected varieties and dosage regimen are correct and reasonable
.

The purpose of preventive medication is to prevent infections caused by specific pathogens or that may occur in specific populations.
The basic principles of preventive medications are: (1) For high-risk populations who have no signs of bacterial infection but are exposed to pathogenic infections
.

(2) The indications for preventive medication and the selection of antibacterial drugs should be based on evidence-based medicine
.

(3) Preventive medication should be taken for one or two of the most likely bacterial infections.
It is not advisable to blindly choose broad-spectrum antibacterials or multi-drug combinations to prevent multiple bacterial infections at multiple sites
.

(4) Should be limited to infections that may occur within a certain period of time, rather than infections that may occur at any time
.

(5) Actively correct the primary disease or underlying conditions that increase the risk of infection
.

For those who can be cured or corrected, preventive medication is of greater value; for those whose primary disease cannot be cured or corrected, the preventive effect of medications is limited, and the pros and cons should be weighed to determine whether to use preventive medications
.

Based on the above principles, antibacterial drugs for the prevention of digestive endoscopy are mainly used to prevent infection of the surgical site and other site infections that may be caused by infection of the surgical site
.

Whether to use antibacterial drugs preventively should be based on different endoscopic operations, the degree of endoscopic surgery trauma, the types of possible contaminating bacteria, the duration of the operation, the chance of infection and the severity of the consequences, the evidence-based medical evidence of the preventive effect of antibacterial drugs, and the treatment of bacteria.
Factors such as the impact of drug resistance and economic evaluation should be considered comprehensively
.

It is not advisable to use antibiotics indiscriminately during digestive endoscopy, to avoid unnecessary costs and potential flora imbalance, bacterial resistance, double infection and other problems
.

In principle, high-risk patients advocate the preventive use of antibacterial drugs; however, the routine use of antibacterial drugs is not recommended for endoscopic operations where the risk of infection is low and bacteremia does not occur frequently
.

02Common endoscopic diagnosis and treatment operations preventive medication recommendations.
Common digestive endoscopy operations in clinical practice include ordinary digestive endoscopy (gastroscopy, colonoscopy), endoscopic polypectomy, endoscopic retrograde cholangiopancreatography (ERCP), and endoscopy Submucosal dissection (ESD), percutaneous endoscopic gastrostomy (PEG) and endoscopic ultrasound (EUS) examinations
.

Although various digestive endoscopy operations may cause damage to the mucosa of the digestive tract, there is a risk of local infection and endoscopic-related bacteremia.
Bacteremia may cause infections in other parts such as infective endocarditis and bacterial peritonitis , Purulent meningitis, etc.
, but different endoscopic procedures are specific to different patients, the risk of infection is different, so whether to use drugs for prevention and medication recommendations are different
.

1 Digestive endoscopy (gastroscopy, colonoscopy) examination.
Endoscopy includes upper gastrointestinal examination (gastroscopy) and lower gastrointestinal examination (colonoscopy).
According to clinical research, the incidence of gastroscopy (with or without biopsy) of bacteremia 0-8%, with an average of 4.
4%, usually short duration (less than 30 minutes), without any infection complications; the incidence of sigmoidoscopy bacteremia is also very low, 0-1%, colonoscopy-related The incidence of bacteremia is 0-25%, with an average of 4.
4%
.

Therefore, the risk of infection in gastroscopy and colonoscopy is low, and there is no need to use antibacterial drugs to prevent infection.
Not only that, during gastroscopy, because some antibiotics may have a greater impact on the detection rate of Helicobacter pylori in the stomach, gastroscopy It is recommended to stop antibiotics for at least a week before the examination
.

2 Endoscopic esophageal varices sclerosing treatment.
Endoscopic esophageal varices sclerosing treatment is an important measure for the treatment of liver cirrhosis combined with esophageal varices bleeding, but it may increase the chance of transient bacteremia, and the incidence of bacteremia is about 11%-16%, there is a risk of complications such as endocarditis, bacterial peritonitis, brain abscess, and sepsis
.

It is recommended to use antibacterial drugs to prevent infection.
The medication time should not exceed 24 hours.
First and second generation cephalosporins can be used.
People with allergies can consider fluoroquinolones
.

3 Endoscopic retrograde cholangiopancreatography (ERCP) has reported in the literature that the incidence of biliary tract infection or acute cholangitis after ERCP is 1%-5%
.

The most important factors for the occurrence of postoperative biliary tract infections are long operation time, high difficulty of operation, repeated access to the bile duct, nipple edema, lax sterilization of instruments, and high bile duct obstruction
.

The incidence of bacteremia of therapeutic and diagnostic ERCP is 15% and 27%, respectively.
Despite this, the Chinese ERCP Guidelines (2018 Edition) believe that it is not necessary to use antibacterial drugs before surgery for all patients who are planning to undergo ERCP, but there are the following situations One should consider preventive application: ① Progressive cholangitis, sepsis with biliary tract infection; ② Hilar bile duct stenosis; ③ Interventional treatment of pancreatic pseudocyst; ④ Organ transplantation/immunosuppressive patients; ⑤ Primary sclerosing cholangitis; ⑥Heart disease (heart valve disease) with moderate to high risk
.

It is generally recommended to take the drug once, and it is recommended to use a broad-spectrum antibacterial drug.
The antibacterial spectrum should cover gram-negative bacteria, enterococci and anaerobic bacteria
.

Preventive use of antibiotics began 1 day before surgery
.

In the choice of antibacterial drugs, quinolones or cephalosporins (second-generation cephalosporins or ceftriaxone) can be considered
.

4 Endoscopic submucosal dissection (ESD) The results of a number of prospective studies have shown that the risk of bacteremia after gastric ESD treatment is low and it is transient.
Therefore, routine preventive use of antibacterial drugs during the perioperative period of gastric ESD is not recommended
.

However, one of the following conditions can use antibacterial drugs as appropriate
.

① preoperative assessment of a large resection; long operation time ②; ③ gastrointestinal perforation high-risk patients; ④ age or with diabetes mellitus, immune function (especially organ transplant recipients), malnutrition in patients with high risk of infection
.

The first and second generation cephalosporins can be used after ESD, and nitroimidazole drugs can be added as appropriate
.
The total time of postoperative medication should generally not exceed 72 hours, but it can be extended as appropriate .

5 Endoscopic resection of gastric and intestinal polyps The risk of bacteremia in endoscopic resection of gastric and intestinal polyps is low, and antibacterial drugs are usually not recommended
.

Use antibacterial drugs when necessary.
If there are the following high-risk factors for infection, the wound after endoscopic treatment of polyps may become a window for bacterial invasion, leading to infection, and antibacterial drugs may be considered
.

①Large resection area (greater than 2cm); ②Long operation time (greater than 120min); ③Patients at high risk of gastrointestinal perforation (intestinal lateral development tumors, large tumors, complex EMR and ESD, hot biopsy forceps, etc.
); ④ poor intestinal preparation; ⑤ other infections risk factors: advanced age (> 70 years), associated with diabetes, immune dysfunction (organ transplantation, agranulocytosis), liver cirrhosis, malnutrition and so on
.

Use second-generation or third-generation cephalosporins, and nitroimidazole drugs can be added
.

The total time of postoperative medication generally does not exceed 72 hours, but it can be extended as appropriate
.

6 Percutaneous endoscopic gastrostomy (PEG) PEG tube placement is not a sterile operation, and patients receiving PEG are often susceptible to infection for various reasons, including advanced age, poor nutritional intake, immunosuppression, and pathogenic factors.
Onset (such as malignant tumors and diabetes, etc.
)
.

During PEG catheterization, the traction tube passes through the nasopharynx and upper gastrointestinal tract.
The colonizing bacteria in it may cause infection around the fistula
.
The frequency of this complication can be as high as 32% when there is no antimicrobial prevention .

It is recommended to use antibacterial drugs to prevent infection.
The most commonly used is intravenous infusion of β-lactams before PEG operation, including compound amoxicillin and clavulanate potassium, cefotaxime, cefoxitin or cefazolin 7 endoscopy ( EUS) examination and EUS-guided puncture.
Ordinary EUS examination does not require routine use of antibiotics to prevent infection.
However, during diagnosis or treatment with EUS-guided puncture, if the puncture site is likely to be infected, such as cysts or cystic lesions near the pancreas.
Endoscopic EUS-guided fine needle aspiration of potentially infected cysts or cystic lesions near the pancreas or pancreatic pseudocysts should be given antibiotics to prevent infection during endoscopic transgastric or intestinal drainage
.

Antibacterial drugs can choose the first and second generation cephalosporins, and add nitroimidazoles as appropriate
.

Reference materials: [1].
Liu Xiaohua, Luo Can.
Comparison of antibacterial drugs used for the prevention of digestive endoscopy in Jiangsu Provincial People's Hospital before and after intervention[J].
Modern Medicine and Clinics, 2015, 30(10): 1280-1284.
[2] .
National Research Center for Clinical Medicine of Digestive System Diseases, Chinese Medical Association Digestive Endoscopy Branch, Chinese Medical Doctor Association Digestive Physician Branch.
Guidelines for the perioperative period of gastroendoscopic submucosal dissection[J].
Chinese Journal of Digestive Endoscopy,2017,34 (12):837-851.
[3].
.
Study on the necessity of prophylactic use of antibiotics during perioperative period of gastrointestinal polyps under endoscopy[J].
Modern Medicine and Health,2018,34(23):3628-3630.
[4].
Digestive Endoscopy Professional Committee of Endoscopy Physician Branch of Chinese Medical Doctor Association, Pancreatic Disease Professional Committee of Chinese Medical Doctor Association, Editorial Department of Chinese Journal of Digestion, etc.
Expert consensus opinions on perioperative medication of ERCP[J].
Chinese Digestive Endoscopy Magazine, 2018, 35(10):704-712.