Bacteremia in children following upper gastrointestinal endoscopy or colonoscopy

Gastrointestinal Endoscopy in the Neonate

Gastrointestinal endoscopy permits direct observation of the alimentary tract, acquisition of mucosal tissue for histopathologic examination, and other diagnostic and therapeutic maneuvers. Endoscopes of appropriate size for many neonates and an expanding array of compatible tools and accessories have broadened what is possible, although few neonatal data exist to guide use. Evaluation and treatment of gastrointestinal bleeding, evaluation and dilation of fibromuscular congenital esophageal stenosis, and the bedside placement of gastrostomy tube have been described. Careful consideration of risks, benefits, and discussions between involved specialties permit patient-specific application of these tools and techniques to augment care of this vulnerable population.

Pediatric Endoscopy and High-risk Patients: A Clinical Report From the NASPGHAN Endoscopy Committee

Pediatric gastrointestinal endoscopy has been established as safe and effective for diagnosis and management of many pediatric gastrointestinal diseases. Nevertheless, certain patient and procedure factors should be recognized that increase the risk of intra- and/or postprocedural adverse events (AEs). AEs associated with endoscopic procedures can broadly be categorized as involving sedation-related physiological changes, bleeding, perforation, and infection. Factors which may increase patient risk for such AEs include but are not limited to, cardiopulmonary diseases, anatomical airway or craniofacial abnormalities, compromised intestinal luminal wall integrity, coagulopathies, and compromised immune systems. Examples of high-risk patients include patients with congenital heart disease, craniofacial abnormalities, connective tissues diseases, inflammatory bowel disease, and children undergoing treatment for cancer. This clinical report is intended to help guide clinicians stratify patient risks and employ clinical practices that may minimize AEs during and after endoscopy. These include use of CO2 insufflation, endoscopic techniques for maneuvers such as biopsies, and endoscope loop-reduction to mitigate the risk of such complications such as bleeding and intestinal perforation. Endoscopic infection risk and guidance regarding periprocedural antibiotics are also discussed.

Obtaining research biopsies during pediatric colonoscopy: Safety and adverse events

AIM: To investigate the safety profile of acquiring additional intestinal biopsies for research purposes in children undergoing a medically indicated colonoscopy.

METHODS: A retrospective review of 122 pediatric patients who underwent colonoscopy over a 9 mo time period was completed. 38/122 participants consented to a research study in which 4 additional biopsies were obtained, in addition to routine biopsies. The outcomes after colonoscopy were measured in the research participants, and compared to 84 control participants who did not consent for the study. Groups were compared with regard to number of biopsies obtained, underlying diagnosis, and both serious and minor adverse outcomes. Data was collected including: age, gender, race, indication, diagnosis, number of biopsies obtained per case and post procedure adverse events. Medical records were reviewed and a questionnaire was completed by each of the ten gastroenterologists who performed procedures during the study. Physicians were asked about individual patient outcomes to ensure that all adverse events, such as perforation, excessive bleeding, infection, and minor gastrointestinal outcomes, were captured and included.

RESULTS: The research group had more biopsies obtained (mean = 13.58 ± 4.21) compared to controls (mean = 9.33 ± 4.40), P≤ 0.0001, however there was no difference in adverse events. Serious outcomes, defined as perforation, bleeding and infection, did not occur, in either group. As such, the relationship between serious adverse events and number of biopsies obtained was not determined. Minor gastrointestinal outcomes, such as abdominal pain, diarrhea or vomiting, were reported in 21 patients (8 research participants and 13 control participants) however the incidence of minor gastrointestinal outcomes between the two groups did not vary significantly, P = 0.45. Additionally, the mean number of biopsies obtained in patients who had a minor outcome (mean = 12.1 ± 0.77), compared to those with no adverse outcome (mean = 10.34 ± 0.5), revealed no statistical difference between the groups (P = 0.12), suggesting that number of biopsies is not associated with incidence of minor adverse events.

CONCLUSION: Patients participating in research requiring acquisition of additional biopsies for research purposes alone, are not at an increased risk of adverse outcomes.

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.

Patient-reported symptoms after pediatric outpatient colonoscopy or flexible sigmoidoscopy under general anesthesia

OBJECTIVES

Endoscopic examination of the colon is indicated in children with diarrhea, hematochezia and suspected inflammatory bowel disease. The aim of this study was to determine the rate of patient-reported symptoms after colonoscopy and flexible sigmoidoscopy under general anesthesia in children.

PATIENTS AND METHODS

This prospective study included patients 18 years of age and younger who underwent colonoscopy or flexible sigmoidoscopy during a 1-year period. At least 30 days after the endoscopy, an interview was conducted regarding symptoms after colonoscopy or flexible sigmoidoscopy.

RESULTS

Eighty-eight children were eligible, and 68 (77%) were available for follow-up. Ten (15%) reported symptoms after their endoscopy. The most common symptoms reported were diarrhea, excessive gas and sore throat. The frequency of reported symptoms was similar between colonoscopy and flexible sigmoidoscopy. The frequency of symptoms was not affected by intubation of terminal ileum, polypectomy or the number of prior colonoscopies or flexible sigmoidoscopies.

CONCLUSIONS

Outpatient colonoscopy and flexible sigmoidoscopy under general anesthesia are well tolerated by children. A minority of children reports mild symptoms that spontaneously resolve.

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.

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.

Prevention of bacterial endocarditis. Recommendations by the American Heart Association

OBJECTIVE

To update recommendations issued by the American Heart Association last published in 1990 for the prevention of bacterial endocarditis in individuals at risk for this disease.

PARTICIPANTS

An ad hoc writing group appointed by the American Heart Association for their expertise in endocarditis and treatment with liaison members representing the American Dental Association, the Infectious Diseases Society of America, the American Academy of Pediatrics, and the American Society for Gastrointestinal Endoscopy.

EVIDENCE

The recommendations in this article reflect analyses of relevant literature regarding procedure-related endocarditis, in vitro susceptibility data of pathogens causing endocarditis, results of prophylactic studies in animal models of endocarditis, and retrospective analyses of human endocarditis cases in terms of antibiotic prophylaxis usage patterns and apparent prophylaxis failures. MEDLINE database searches from 1936 through 1996 were done using the root words endocarditis, bacteremia, and antibiotic prophylaxis. Recommendations in this document fall into evidence level III of the US Preventive Services Task Force categories of evidence.

CONSENSUS PROCESS

The recommendations were formulated by the writing group after specific therapeutic regimens were discussed. The consensus statement was subsequently reviewed by outside experts not affiliated with the writing group and by the Science Advisory and Coordinating Committee of the American Heart Association. These guidelines are meant to aid practitioners but are not intended as the standard of care or as a substitute for clinical judgment.

CONCLUSIONS

Major changes in the updated recommendations include the following: (1) emphasis that most cases of endocarditis are not attributable to an invasive procedure; (2) cardiac conditions are stratified into high-, moderate-, and negligible-risk categories based on potential outcome if endocarditis develops; (3) procedures that may cause bacteremia and for which prophylaxis is recommended are more clearly specified; (4) an algorithm was developed to more clearly define when prophylaxis is recommended for patients with mitral valve prolapse; (5) for oral or dental procedures the initial amoxicillin dose is reduced to 2 g, a follow-up antibiotic dose is no longer recommended, erythromycin is no longer recommended for penicillin-allergic individuals, but clindamycin and other alternatives are offered; and (6) for gastrointestinal or genitourinary procedures, the prophylactic regimens have been simplified. These changes were instituted to more clearly define when prophylaxis is or is not recommended, improve practitioner and patient compliance, reduce cost and potential gastrointestinal adverse effects, and approach more uniform worldwide recommendations.

Absence of bacteremia after gastrointestinal procedures in children

BACKGROUND

Transient bacteremia after certain gastrointestinal endoscopies is well documented in adult patients; however, experience in pediatric patients is very limited. We conducted a prospective study to determine the frequency of bacteremia after common endoscopic procedures in children.

METHODS

A total of 108 endoscopies were performed in 95 patients (age range 8 months to 17 years; mean age 10.2 years). Procedures included 68 esophagogastroduodenoscopies (EGDs), 29 colonoscopies, and 11 flexible sigmoidoscopies. Most procedures (88) were performed with patients under conscious sedation; 20 were under general anesthesia with endotracheal intubation. Biopsy specimens were obtained from all patients. Blood samples for aerobic and anaerobic cultures were obtained prior to, and within 5 minutes of, completion of the procedure. In patients who underwent general anesthesia, a third sample was obtained 5 minutes after endotracheal intubation and before endoscopy.

RESULTS

Four of the pre-endoscopic blood cultures were positive. Two cultures were positive after endotracheal intubation, but were negative after endoscopy. Four cultures were positive after endoscopy. All organisms were skin or environmental flora and were considered contaminants. All patients with positive cultures remained asymptomatic during the 72 hours after the procedure.

CONCLUSION

We conclude that clinically relevant bacteremia is very infrequent following routine endoscopic procedures with biopsies in immunocompetent children.

Diagnostic upper GI endoscopy for hemetemesis in children: experience from a pediatric gastroenterology centre in north India

Upper GI endoscopies were done in 236 children (upto 12 years of age) presenting with history of hemetemesis. Varices were the commonest lesions (in 39.41%) followed by esophagitis (23.73%). Gastritis, gastric ulcer, duodenal ulcer and oesophageal ulcers were identified in 7.20%, 1.27%, 0.42% and 0.42% cases respectively. Cause of bleeding could not be ascertained in 27.54% cases. No significant premedication or procedure related complications were observed. Upper GI endoscopy is thus a safe and useful mode of investigation in cases of hemetemesis in children.

Transesophageal echocardiography: technique, anatomic correlations, implementation, and clinical applications

The introduction of transesophageal echocardiography has provided a new acoustic window to the heart and mediastinum. High-quality images of certain cardiovascular structures [left atrial appendage, thoracic aorta, mitral valvular apparatus, and atrial septum] can be obtained readily (average examination, 15 to 20 minutes). In this article, we discuss the technique of image acquisition, image orientation, and anatomic validation. In addition, we describe our experience with the first 100 awake patients who underwent transesophageal echocardiography at our institution. The procedure was well accepted by the patients and associated with no major complications. The clinical indications for this procedure have included thoracic aortic dissection, prosthetic cardiac valve dysfunction, detection of an intracardiac source of embolism, endocarditis, cardiac and paracardiac masses, and mitral regurgitation. Transesophageal echocardiography also proved to be useful in assessment of critically ill patients in whom standard transthoracic echocardiographic images did not provide complete assessment. In these patients (who had extensive chest trauma, had undergone an operation, or were in an intensive-care unit), rapid assessment of the cardiovascular status at the bedside was possible with transesophageal echocardiography. On the basis of our initial experience, we conclude that transesophageal echocardiography complements standard two-dimensional Doppler and color flow examinations and will considerably improve the care of patients with cardiovascular disorders by providing high-quality unique images.

Endoscopic examination of the colon in infancy and childhood

Flexible fiberoptic colonoscopy is a safe and effective diagnostic procedure in infants and children. It is a sensitive and practical procedure that has made substantial contributions to the diagnosis and treatment of colonic disorders in infants and children. With further refinements in technique, future applications of its use are likely to occur.