Antibiotic prophylaxis in gastrointestinal endoscopy: a report by a Working Party for the British Society of Gastroenterology Endoscopy Committee

Burdens of Postoperative Infection in Endoscopic Retrograde Cholangiopancreatography Inpatients

Objectives

Our objective in this study is, firstly, to determine postoperative (POI) rates in endoscopic retrograde cholangiopancreatography (ERCP) procedures stratified by patients’ demographic and hospitals’ characteristics in the United States, and secondly, to evaluate the demographic and comorbid risk factors associated with POI in ERCP inpatients, as well as its impact on the length of stay (LOS) and total charges.

Methods

The total sample of 28,525 inpatients with a principal procedure of ERCP from the Nationwide Inpatient Sample (NIS) was included and grouped by co-diagnosis of POI (N=300, 1.05%). We used a logistic regression model and descriptive statistics for the POI rate estimates.

Results

High POI rate was seen in males (1.14%), and adults (36-50 years, 1.25%) with 2.65 times (95% CI 1.69-4.12) higher odds compared to young adults. POI rate in ERCP inpatients varied widely according to geographic region: higher in the West (1.46%) and Northeast (1.20%) and lowest in the Midwest (0.70%). As per the hospital characteristics, inpatients in public (1.26%), urban teaching (1.39%) and small bed-size (1.27%) hospitals had higher POI rates. ERCP inpatients with POI had higher odds of association with comorbid HIV infection (OR 1.55, 95% CI 1.13-2.12) and diabetes (OR 1.43, 95% CI 1.09-1.85). ERCP inpatients with POI had a significantly longer length of stay (LOS) by 5.2 days and higher total charges by USD 53,966 than inpatients without POI.

Conclusions

POI is associated with acute inpatient care, with longer hospitalization stays and higher costs, leading to increased healthcare burdens. The main goal is to identify the risk factors and to prevent POI with prophylactic antibiotics.

Post-ERCP infection and its epidemiological and clinical characteristics in a large Chinese tertiary hospital: a 4-year surveillance study

Background

Endoscopic retrograde cholangiopancreatography (ERCP) is widely performed as a treatment for biliary and pancreatic illness in China; however, there are few data available regarding post-ERCP infections. This study aimed to describe the overall incidence of post-ERCP infections and the epidemiological characteristics of infected patients in a large tertiary-care hospital in China.

Methods

Real-time surveillance was performed from 2012 through 2015 to identify all healthcare-associated infections (HAIs) that occurred after ERCP, using an automatic system. All HAIs (e.g., cholangtitis, bacteremia) were identified by infection control practitioners and doctors. Inpatient data were automatically collected by the surveillance system.

Results

A total of 1743 ERCP operations were included in the study, among these, 132 (7.57%) HAIs were identified. ERCP postoperative infections occurred following different surgical procedures, with infection rates ranging from 3.58 to 13.51%. The most prevalent HAI was biliary tract infection (4.02%), followed by transient bacteremia (1.14%). Overall, 62 cases of bacteremia occurred following ERCP surgery and 34 (54.84%) cases occurred on the day of the operation or 1-day post-surgery. The most prevalent isolates detected during bacteremia were Enterococcus faecium (12/58) and Escherichia coli (11/58). A large proportion (72.73%) of the E. coli isolates and all of the E. faecium isolates were resistant to ciprofloxacin. In addition, only 37.50% of the E. coli isolates were susceptible to ceftriaxone.

Conclusions

The high incidence of post-ERCP infection and the prevalence of drug resistance suggests that employing second generation cephalosporin or ceftriaxone as the antibiotic of choice for prophylaxis before ERCP, as recommended by the Chinese clinical application of antibacterial drugs guidelines, may not be effective.

Brazilian society of hepatology recommendations for the diagnosis and management of autoimmune diseases of the liver

ABSTRACT In order to draw evidence-based recommendations concerning the management of autoimmune diseases of the liver, the Brazilian Society of Hepatology has sponsored a single-topic meeting in October 18th, 2014 at São Paulo. An organizing committee comprised of seven investigators was previously elected by the Governing Board to organize the scientific agenda as well as to select twenty panelists to make a systematic review of the literature and to present topics related to the diagnosis and treatment of autoimmune hepatitis, primary sclerosing cholangitis, primary biliary cirrhosis and their overlap syndromes. After the meeting, all panelists gathered together for the discussion of the topics and the elaboration of those recommendations. The text was subsequently submitted for suggestions and approval of all members of the Brazilian Society of Hepatology through its homepage. The present paper is the final version of the reviewed manuscript organized in topics, followed by the recommendations of the Brazilian Society of Hepatology.

Two case reports of gastroendoscopy-associated Acinetobacter baumannii bacteremia

Two cases of gastroendoscopy-associated Acinetobacter baumannii (A. baumannii) bacteremia were discovered at the study hospital. The first case was a 66-year-old woman who underwent endoscopic retrograde cholangiopancreatography and endoscopic retrograde papillotomy, and then A. baumannii bacteremia occurred. The second case was a 70-year-old female who underwent endoscopic retrograde biliary drainage due to obstruction of intra-hepatic ducts, and bacteremia occurred due to polymicrobes (Escherichia coli, viridans streptococcus, and A. baumannii). After a literature review, we suggest that correct gastroendoscopy technique and skill in drainage procedures, as well as antibiotic prophylaxis, are of paramount importance in minimizing the risk of gastroendoscopy-associated bacteremia.

Antimicrobial prophylaxis in noncardiac prosthetic device recipients

BACKGROUND

Secondary antimicrobial prophylaxis involves the use of ≥ 1 antimicrobial agent just prior to the time when a diagnostic/therapeutic procedure, which may induce infection, is to be performed. In the context of this article, antimicrobial agent(s) are administered to patients with ≥ 1 implanted prosthetic device in order to prevent metastatic seeding of the device(s) during bacteremia induced by a diagnostic/therapeutic procedure. Antimicrobial agents used in this context are only administered periprocedurally. Secondary antimicrobial prophylaxis of endocarditis in recipients of cardiac prosthetic materials (including valves, shunts, conduits, and patches) has been reasonably well established. However, secondary antimicrobial prophylaxis in recipients of other types of prosthetic devices has been the subject of much controversy, with a wide variety of recommendations being made.

OBJECTIVES

The purpose of this article was to conduct a narrative review of the published literature on the topic of secondary antimicrobial prophylaxis in recipients of noncardiac prosthetic devices and make evidence-based recommendations for each type of device, where possible.

METHODS

Medline/PubMed and EMBASE databases were searched for English-language articles published from 1950 to the present (January 2012). Search terms included "prophylaxis," "antibiotics," "antimicrobials," "prosthetic devices," "prosthesis-related infections," "bacteremia," the names of the individual types of prosthetic devices, and the names of the individual procedures potentially inducing bacteremia. Articles dealing with any aspect relevant to this topic were eligible for review. The bibliographies of retrieved articles were also carefully scanned to identify any articles not previously identified.

RESULTS

Based on review of the available literature, secondary antimicrobial prophylaxis is justified in only a few specific circumstances. For recipients of prosthetic vascular grafts/stents, hemodialysis arteriovenous shunts, and ventriculoatrial/ventriculovenous shunts, prophylaxis is warranted during the initial 6 months, initial 6 weeks, and at all times after implantation/revision, respectively, when dental procedures capable of inducing high-level bacteremia are planned. Prosthetic joint recipients should receive prophylaxis in the following 3 circumstances: 1) patient is to undergo dental procedure(s) capable of inducing high-level bacteremia plus either the patient is still within 2 years of device implantation/revision or the patient has ≥ 1 risk factor for hematogenous prosthetic joint infection; 2) patient is to undergo genitourinary tract procedure(s) capable of inducing high-level bacteremia plus the patient has ≥ 1 risk factor for high-risk bacteriuria; and 3) patient is to undergo perforating dermatologic surgery on the oral mucosa or at skin sites at increased risk for surgical site infection plus patient has ≥ 1 risk factor for hematogenous prosthetic joint infection. The data are inadequate to justify secondary antimicrobial prophylaxis for recipients of other types of prosthetic devices. On the basis of 9 surveys of prescriber behavior, it is apparent that there exists, over a wide geographic area, a wide disconnect between clinical practice and the secondary antimicrobial prophylaxis guidelines issued by the professional organizations representing these prescribers. Antimicrobial agent overuse was especially problematic among orthopedic and colorectal surgeons, urologists, and family practitioners. Dentists and maxillofacial surgeons followed guidelines more closely.

CONCLUSION

Device-, procedure-, and patient characteristic-dependent factors elicited over many years have narrowed down the secondary antimicrobial prophylaxis recommendations for noncardiac prosthetic devices to a small number. Despite this, physician prescribers frequently do not follow prophylaxis guidelines established by their own professional organizations. Risk-benefit and cost-effectiveness studies have found that no prophylaxis is actually superior to universal prophylaxis, likely due to known antimicrobial toxicities, such as anaphylactic/anaphylactoid reactions and Clostridium difficile-associated disease. Much work remains in establishing and extending the scientific basis for secondary antimicrobial prophylaxis and transforming this knowledge into appropriate action by the clinician.

Intestinal obstruction associated with chronic peritonitis caused by Sphingomonas paucimobilis

We describe a very rare case of chronic peritonitis with secondary adhesive intestinal obstruction caused by Sphingomonas paucimobilis in a healthy 28-year-old Chinese man. This bacillus has not been described as a cause of spontaneous peritonitis in healthy people. It was an asymptomatic, generalized, and slow-growing peritonitis causing peritoneal adherens and at the end intestinal occlusion that needed surgical adhesiolysis.

Infection after ERCP, and antibiotic prophylaxis: a sequential quality-improvement approach over 11 years

BACKGROUND

Infection is a known complication of ERCP procedures, and the role of antibiotic prophylaxis is uncertain.

OBJECTIVE

To document the incidence of infection after ERCP while changing the policy for antibiotic prophylaxis.

DESIGN

Retrospective analysis of data collected prospectively on infection complications, with progressive reduction in the use of prophylactic antibiotics.

SETTING

Single-center university referral hospital.

PATIENTS

A total of 11,484 ERCP procedures were documented prospectively over a period of 11 years.

INTERVENTIONS

After baseline assessment, the use of prophylactic antibiotics was sequentially reduced and simplified in 3 phases.

MAIN OUTCOME MEASUREMENTS

Incidence of infection, categorized by severity.

RESULTS

The infection rate was low overall and decreased significantly with time, from 0.48% to 0.25%, despite a marked reduction in the proportion of patients given antibiotics (from 95% to 25%). Multivariate analysis also showed that the only category of patients at increased risk for infection (despite antibiotics) was the subgroup undergoing interventions for biliary problems after liver transplantation.

LIMITATIONS

A lack of routine follow-up may mean that some delayed infectious complications were not recorded. The low risk of infection in this series may reflect the high technical success rate for relief of biliary obstruction; thus, our current minimalist antibiotic policy may not be generalizable to community practice.

CONCLUSIONS

Infectious complications of ERCP can be kept to a minimum with a limited use of prophylactic antibiotics.

A new method of biliary sampling for cytopathological examination during endoscopic retrograde cholangiography

OBJECTIVES

Biliary brushing during endoscopic retrograde cholangiography (ERC) may allow the diagnosis of cancer, but this technique is limited by a low (18-57%) sensitivity. We compared the cellular and diagnostic yields of a new sampling method (using stricture dilation and a grasping basket) with those of brushing.

METHODS

Sixty consecutive patients with a suspected malignant obstruction of the common bile duct were included in a consecutive, nonrandomized order. They underwent sampling during ERC using the new method (study patients, N = 30) or a brush (control patients, N = 30). A final diagnosis of cancer was made in 22/30 (73%) study patients and 21/30 (70%) control patients. At the end of the study period, all smears were interpreted at cytopathological examination in a blind and random fashion for cellularity (insufficient, low, moderate, or high) and diagnosis (normal, atypical considered reactive, highly atypical suspicious for cancer, or malignant). "Highly atypical" and "malignant" diagnoses were considered as indicative of cancer.

RESULTS

Compared with biliary brushing, the new method provided a high cellular yield in more cases (19/30 vs 10/30, P= 0.020), a higher sensitivity for the detection of cancer (19/22 [86%] vs 11/21 [52%], P= 0.015), and a higher diagnostic accuracy (27/30 [90%] vs 20/30 [67%], P= 0.028). Specificity for the detection of cancer was 100%. The 30-d complication rate observed with the new method was 3%.

CONCLUSIONS

Significantly higher cellular and diagnostic yields can be obtained at ERC in patients with suspected malignant biliary stricture by combining stricture dilation and a grasping basket compared with brushing.

Biliary candida infections in primary sclerosing cholangitis

BACKGROUND/AIMS

Patients with Primary Sclerosing Cholangitis (PSC) frequently develop dominant stenoses of the bile ducts and bacterial infections represent a major problem in such patients. In the present study, the role of fungal infections of the bile ducts has been evaluated.

METHODS

In a prospective non-randomized trial, in 67 consecutive patients with PSC, 148 bile samples, each taken at one endoscopic examination, were microbiologically analysed.

RESULTS

Candida species were found in 8/67 patients whereas Aspergillus was not detected. Seven patients with biliary Candida had a dominant stenosis and one had a wide papillotomy with chronic ascending cholangitis. Altogether 7/49 of patients with dominant stenosis and 1/18 of patients without dominant stenosis had Candida in their bile. All patients with biliary Candida intermittently had received antibiotics and had advanced disease with cholestasis. Candida disappeared spontaneously in 2/7 patients, cleared after antifungal treatment in 2, and persisted in 3 patients. Patients with biliary Candida had more severe cholangitis with higher CRP and serum bilirubin compared to those without Candida infection.

CONCLUSIONS

This is the first report on the identification of Candida species in the bile of patients with PSC. Apart from bacterial also fungal infection of the bile ducts should be considered in the treatment of such patients.

Recommendations for antibiotic prophylaxis before ERCP: can we come to workable conclusions after review of the literature?

Infectious complications after endoscopic retrograde cholangiopancreatography (ERCP) are rare and can mainly be divided into endocarditis and sepsis/cholangitis. There still remains uncertainty about the indications, antibiotic regimens, and timing for antibiotic prophylaxis. Several guidelines for antibiotic prophylaxis have been published. It is the purpose of the present paper to make an extensive review of the literature and to yield general recommendations on antibiotic prophylaxis before ERCP. Antibiotic prophylaxis is recommended for patients at high risk for endocarditis, as well as for patients with a vascular graft less than 1 year old. For sepsis/cholangitis, prophylaxis is mostly recommended for patients with a bile duct obstruction or with a pancreatic pseudocyst. For other conditions, a case-by-case evaluation by the physician/endoscopist is still inevitable.

The role of dominant stenoses in bacterial infections of bile ducts in primary sclerosing cholangitis

OBJECTIVE

Primary sclerosing cholangitis (PSC) is characterized by progressive fibrotic inflammation and strictures of the biliary system. We studied the role of dominant stenoses in bacterial biliary infections and the effect of routine antibiotic administration with cholangiography.

DESIGN

A prospective clinical trial without blinding or randomization.

SETTING

The endoscopy unit in a university hospital.

PARTICIPANTS

Fifty patients with PSC entered and finished the study.

INTERVENTIONS

A total of 103 endoscopic retrograde cholangiographies (ERC) was performed in 37 PSC patients with dominant stenosis and 13 controls with PSC but no dominant stenosis. After selective cannulation of the bile duct, bile samples were obtained during each procedure. All patients received systemic antibiotic treatment with ciprofloxacin for one week after ERC.

RESULTS

Enteric bacteria were detected in the bile specimens of 15 out of 37 PSC patients (40.5%) with dominant stenosis but never in the absence of dominant stenosis (P=0.004). Positive cultures for enteric bacteria were associated with elevated serum C-reactive protein, high leukocyte counts in bile (P<0.05) and the deterioration of liver function assessed by increasing bilirubin levels during the follow-up period lasting a median of 7 months (P=0.06). Despite the high rate of susceptibility in vitro, ciprofloxacin treatment eradicated enteric bacteria in only two out of 12 cases.

CONCLUSION

Bacterial infection of the bile ducts with dominant stenosis is a frequent finding and may play a role in the progression of PSC. Short-course antibiotic treatment is not very effective in eradicating acteria from the bile ducts.

Bacteremia in cirrhotic patients submitted to endoscopic band ligation of esophageal varices

BACKGROUND

Endoscopic procedures can develop bacteremia. Patients with chronic liver disease are more predisposed to undergo bacteremia and infections because they are immunocompromised.

AIMS

The purpose of this study was to determine the incidence of bacteremia in cirrhotics submitted to endoscopic variceal ligation.

METHODS

Three groups of 40 patients each were studied. One group was made up of patients with cirrhosis who were submitted to ligation, a second group was composed of cirrhotics who underwent esophagogastroduodenoscopy only, and a third group was composed of patients without liver disease who underwent esophagogastroduodenoscopy. Blood was sampled from all patients for culture, both in aerobic and in anaerobic mediums, immediately before endoscopy and at 5 and 30 minutes after its completion.

RESULTS

Blood culture was positive in 6 samples. In 4 of these, the bacteria (Staphylococcus hominis hominis, Staphylococcus auricularis, Acinetobacter lwoffii, and coagulase-negative staphylococcus) were isolated before the endoscopic procedure and thus were considered as contamination. In the ligation group, a streptococcus of the viridans group was isolated 5 minutes after the procedure, and in the cirrhosis without ligation group, a Staphylococcus epidermidis was isolated at 30 minutes. None of the patients showed clinical evidence of infection.

CONCLUSIONS

The bacteremia incidence in cirrhotic patients submitted to variceal ligation was 2.5%, showing no difference from the control groups.

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.

Antibiotic prophylaxis prior to endoscopic retrograde cholangiopancreatography in patients with obstructive jaundice: is it worth the cost?

BACKGROUND

There are few published data concerning the economic impact of antibiotic prophylaxis prior to endoscopic retrograde cholangiopancreatography in the setting of biliary obstruction.

AIM

To perform decision analysis to determine the costs of prophylaxis in patients undergoing endoscopic retrograde cholangiopancreatography for obstructive jaundice.

METHODS

A decision analysis model was constructed. The probability of biliary sepsis, death and endoscopic retrograde cholangiopancreatography complications was obtained from the medical literature and from a retrospective analysis of our own experience. Costs were obtained from Medicare reimbursement at our institution. The strategies evaluated were endoscopic retrograde cholangiopancreatography with and without single-dose antibiotic prophylaxis. We compared the total costs, number of episodes of cholangitis and deaths associated with each strategy.

RESULTS

Based on published data and the results of our retrospective analysis, the strategy of administering single-dose prophylactic antibiotics prior to endoscopic retrograde cholangiopancreatography in patients with obstructive jaundice resulted in lower total costs, fewer episodes of cholangitis and fewer deaths compared to a strategy of not administering antibiotics. The results were sensitive to the rates of cholangitis, cost of antibiotics and the cost of treating an episode of cholangitis.

CONCLUSIONS

Antibiotic prophylaxis prior to endoscopic retrograde cholangiopancreatography results in fewer cases of cholangitis and is cost saving when compared to a strategy of no prophylaxis in patients with obstructive jaundice.

Low frequency of bacteremia after endoscopic mucosal resection

BACKGROUND

Endoscopic mucosal resection has become a popular alternative for the treatment of early-stage neoplasia of the gastrointestinal tract. However, there are still no data on the frequency of bacteremia associated with this form of treatment.

METHODS

We conducted a prospective study of 21 men and 17 women undergoing endoscopic mucosal resection with a cap-fitted panendoscope for upper gastrointestinal lesions. Blood cultures were performed before, 10 minutes after, and 4 hours after the procedure for both aerobic and anaerobic bacteria.

RESULTS

Blood culture at baseline was negative in all the patients. Two of 38 patients (5.3 %) had positive blood culture at 10 minutes after the procedure. The isolated microorganisms were Streptococcus salivarius and Corynebacterium species. All patients had negative blood cultures 4 hours later. None of these 38 patients had any symptoms or signs associated with infection.

CONCLUSIONS

Bacteremia associated with endoscopic mucosal resection is infrequent and transient.

Cost analysis of antibiotic prophylaxis for PEG

BACKGROUND

There are conflicting recommendations regarding the prophylactic use of antibiotics in patients undergoing placement of percutaneous endoscopic gastrostomy tubes. The purpose of this decision analysis was to assess the cost-effectiveness of antibiotic prophylaxis in percutaneous endoscopic gastrostomy.

METHODS

A decision tree was modeled using the data of 7 published prospective placebo-controlled trials. Infectious complications were classified as grade I (requiring local care), grade II (requiring intravenous antibiotics), or grade III (requiring surgery). Medication costs were estimated from the United States average wholesale prices of the 1998 Red Book. Physician and facility costs were estimated based on the 1998 Medicare costs. A one-way sensitivity analysis was performed by varying the probability rates of the complications associated with percutaneous endoscopic gastrostomy and the costs of their treatment.

RESULTS

The average cost of prophylactic antibiotics was $13.10. Antibiotic prophylaxis led to expected cost savings of $76.72 per percutaneous endoscopic gastrostomy. A sensitivity analysis suggested that antibiotic prophylaxis for percutaneous endoscopic gastrostomy was the preferred strategy unless the average probability of grade III complications dropped below an improbably low threshold value of 0.09%.

CONCLUSION

Antibiotic prophylaxis in percutaneous endoscopic gastrostomy is a cost-effective strategy.

Review article: antibiotic prophylaxis for endoscopic retrograde cholangiopancreatography (ERCP)

This review examines the evidence for antibiotic prophylaxis in endoscopic retrograde cholangiopan-creatography (ERCP), and provides detailed advice about suitable antibiotic regimens in appropriate high-risk patients. Ascending cholangitis and infective endocarditis are potential complications of endoscopic ERCP. The pathophysiology of these two complications is quite separate and different sub-groups of patients require prophylaxis with appropriate antibiotic regimens. Ascending cholangitis results from bacterial infection of an obstructed biliary system, usually from enteric Gram-negative microorganisms, resulting in bacteraemia. There is incomplete drainage of the biliary system after ERCP in up to 10% of patients who require stenting. Antibiotics started in these patients will probably reduce the frequency of cholangitis by 80%. If antibiotics are restricted to this group, approximately 90% of all patients having an ERCP will avoid antibiotics, but 80% of cholangitic episodes will be prevented. Infective endocarditis may result from the bacteraemia caused at the time of the ERCP in patients with an abnormal heart valve. Antibiotic prophylaxis, in particular covering alpha-haemolytic streptococci, should be started before the procedure in this defined high-risk group.

Viridans streptococcal bacteremia after esophageal stricture dilation

BACKGROUND

The incidence of bacteremia with organisms that may cause infective endocarditis after esophageal stricture dilation is unknown. There is disagreement among physicians regarding the need for antibiotic prophylaxis for patients with valvular heart disease undergoing dilation. Our aim was to determine the frequency and duration of bacteremia associated with esophageal stricture dilation.

METHODS

Blood cultures were obtained before and after stricture dilation in patients without valvular heart disease and in a control group of patients undergoing upper endoscopy without dilation.

RESULTS

A total of 103 patients undergoing dilation and 50 control patients were studied; 22 of 103 patients (21%) undergoing dilation had at least one post-procedure blood culture positive for viridans streptococcus, compared with 1 of 50 (2%) of control patients (p = 0. 001). Blood cultures obtained 1 minute after stricture dilation were positive for viridans streptococcus in 19 of 81 (23%), in 16 of 96 (17%) 5 minutes post-dilation, and in 3 of 63 (5%) 20 to 30 minutes post-dilation. Of the 19 patients with viridans streptococcus bacteremia 1 minute after dilation, cultures were still positive in 14 of 19 (74%) at 5 minutes and in 2 of 19 (10%) 20 to 30 minutes post-dilation.

CONCLUSIONS

These data support the use of antibiotic prophylaxis before esophageal stricture dilation for patients with valvular heart disease at risk for the development of infective endocarditis.

-Curative and preventive antibiotic therapy in infective endocarditis-

Durack's criteria, including echocardiographic manifestations, are the current standard for the diagnosis of infective endocarditis (IE). The most common microorganisms known to cause IE are streptococci and staphylococci, and therapeutic principles are based on an association of parenteral antibiotics, as far as possible bactericidal and prolonged. Treatment also includes the search for the source of infection and its eradication. IE with negative blood cultures requires special techniques to obtain the causal microorganisms. In about half of the cases, a nosocomial bacteriaemia results in IE in patients with a prosthetic valve. Surgery is mandatory in IE with complications and/or caused by particular microorganisms; surgery is essential in most patients with a prosthetic valve. Although the presence of specific links between some procedures and the occurrence of IE has not been clearly proven, a prevention policy is nevertheless justified, considering the morbidity and mortality. Prophylaxis is indicated in patients with the cardiac conditions at risk for IE. IE prophylaxis prevails over prophylactic antibiotics usually administered for surgery.