Digestive endoscopy is a highly dynamic medical discipline, with the recent adoption of new endoscopic procedures. However, comprehensive guidelines on the role of antibiotic prophylaxis in these new procedures have been lacking for many years. The Guidelines Commission of the French Society of Digestive Endoscopy (SFED) convened in 2023 to establish guidelines on antibiotic prophylaxis in digestive endoscopy for all digestive endoscopic procedures, based on literature data up to September 1, 2023. This article summarizes these new guidelines and describes the literature review that fed into them.

Current guidelines suggest antibiotics prophylaxis is not necessary for patients with orthopedic prosthetics undergoing gastrointestinal endoscopy. Clinical evidence to support this recommendation is lacking.

To analyze the association between inpatient gastrointestinal endoscopy and prosthetic joint infection (PJI) in patients with a recent arthroplasty.

We included patients admitted from July to October of each calendar year (index admissions) who had an arthroplasty in the same calendar year prior to the index admission. We followed the occurrence of PJI for 60 days after the index admission. Only admissions from July to October were chosen as index admissions, and the follow-up period was limited to 60 days because the database structure prohibits the analysis of events in different calendar years. We compared the rate of 60-day PJI between those who had gastrointestinal endoscopy on index admissions to those who had not. We excluded patients aged less than 18 years, who died on index admission, or had any infection in the same calendar year before or during the index admission.

Of 1,831,218 patients with arthroplasty, 88,345 met the inclusion criteria, out of which 5,855 had gastrointestinal endoscopy. The rate of 60-day PJI in those who had endoscopy was 0.23%, and in those who had not was 0.52% (P < 0.001). EGD without excision (adjusted odds ratio [95% confidence interval]: 0.20 [0.03-1.42], P = 0.107), EGD with excision (0.58 [0.21-1.60], P = 0.295), colonoscopy without excision (0.43 [0.11-1.72], P = 0.233), colonoscopy with excision (0.31 [0.04-2.21], P = 0.241), and PEG/PEJ (0.38 [0.05-2.71], P = 0.337) were not associated with risk of 60-day PJI. We found no PJI cases in patients underwent esophageal dilation, ERCP, and EUS with FNA.

Gastrointestinal endoscopy in hospitalized patients with a recent previous arthroplasty is not associated with an increased risk of 60-day prosthetic joint infection.

Liver cirrhosis is a well-known risk factor of sepsis after emergent gastrointestinal (GI) endoscopy. Elective GI endoscopy before living donor liver transplantation (LDLT), however, may also carry the septic risk among these patients.

This retrospective study reviewed the medical records of 642 cirrhotic recipients who underwent GI endoscopy from 2008 to 2016. We analyzed the incidence and risk factors of post-endoscopy sepsis during 2008-2012 (experience cohort). Our protocol changed after 2013 (validation cohort) to include antibiotic prophylaxis.

In experience cohort, 36 cases (10.5%) of the 342 LDLT candidates experienced sepsis within 48 h after endoscopy. The sepsis rate was significantly higher in patients with hepatic decompensation than patients without (22.2% vs. 9.6% vs. 2.6% in Child C/B/A groups respectively; ×2 = 20.97, P < 0.001). Using multivariate logistic regression analysis, the factors related to post-endoscopy sepsis were the Child score (OR 1.46; 95% CI 1.24-1.71), Child classes B and C (OR 3.80 and 14.13; 95% CI 1.04-13.95 and 3.97-50.23, respectively), hepatic hydrothorax (OR 4.85; 95% CI 1.37-17.20), and use of antibiotic prophylaxis (OR 0.08; 95% CI 0.01-0.64). In validation cohort, antibiotics were given routinely, and all cases of hepatic hydrothorax (n = 10) were drained. Consequently, 4 (1.3%) episodes of sepsis occurred among 300 LDLT candidates, and the incidence was significantly lower than before (1.3% vs. 10.5%, P < 0.001).

Patients with decompensated cirrhosis and hepatic hydrothorax have higher risk of sepsis following endoscopy. In advanced cirrhotic patients, antibiotic prophylaxis and drainage of hydrothorax may be required to prevent sepsis before elective GI endoscopy.

To investigate the effect of prophylaxis with antibiotics on clinical adverse events in patients who underwent endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) for colorectal lesions.

From June 2011 to December 2013, a total of 428 patients were enrolled into the study, of which 214 patients admitted to hospital underwent EMR or ESD procedures. These patients were randomized to an antibiotic group, in which patients were given cefuroxime 1.5 g iv half an hour before and 6 h after surgery respectively, and a control group, in which patients were not given any antibiotic. A further 214 outpatients with small polyps treated by polypectomy were compared with controls that were matched by age and gender, and operations were performed as outpatient surgery. Recorded patient parameters were demographics, characteristics of lesions and treatment modality, and the size of the wound area. The primary outcome measures were clinical adverse events, including abdominal pain, diarrhea, hemotachezia, and fever. Secondary outcome measures were white blood cell count, C-reactive protein and blood culture. Additionlly, the relationship between the size of the wound area and clinical adverse events was analyzed.

A total of 409 patients were enrolled in this study, with 107 patients in the control group, 107 patients in the antibiotic group, and another 195 cases in the follow-up outpatient group. The patients' demographic characteristics, including age, gender, characteristics of lesions, treatment modality, and the size of the wound area were similar between the 2 groups. The rates of adverse events in the antibiotic group were significantly lower than in the control group: abdominal pain (2.8% vs 14.9%, P < 0.01), diarrhea (2.0% vs 9.3%, P < 0.05), and fever (0.9% vs 8.4%, P < 0.05) respectively. The levels of inflammatory markers also decreased significantly in the antibiotic group compared with the control group: leukocytosis (2.0% vs 11.2%, P < 0.01), and C-reactive protein (2.0% vs 10.7%, P < 0.05). Additionally, clinical adverse events were related to the size of the surgical wound area. When the surgical wound area was larger than 10 mm × 10 mm, there were more clinical adverse events.

Clinical adverse events are not uncommon after EMR or ESD procedures. Prophylactic antibiotics can reduce the incidence of clinical adverse events. This should be further explored.

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.

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.

Gastrointestinal complications are important causes of morbidity and mortality in patients with acute leukaemia. However, no adequate reports exist regarding safety and usefulness of endoscopies. We present a retrospective series of consecutive patients in whom upper or lower gastrointestinal endoscopies or ERCP were performed after 117 of 1640 cycles of myelosuppressive chemotherapy. The most frequent findings of upper endoscopies were: Oesophagitis (50.9%), gastric erosions (30.2%), hiatus hernia (24.5%) and gastritis (22.6%). Upper endoscopies had therapeutic consequences in 55%. Endoscopy could be performed relatively safely but the percentage of patients in whom endoscopic haemostasis was applicable and effective was low.

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

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

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.

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.

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

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.

Patients who have prosthetic heart valves, previous history of endocarditis, and surgically constructed systemic-pulmonary shunts or conduits should receive prophylactic antibiotics before colonoscopy. The usefulness of this approach in cirrhotic patients remains unknown. The present study prospectively assesses the incidence of bacteremia in these patients.

Lower intestinal endoscopy was performed in 58 cirrhotic patients. Two blood samples were obtained from every patient (just before endoscopy and within 5 minutes of withdrawal of the endoscope) and were incubated for 7 days and examined daily for growth of bacteria. Patients were closely monitored for 72 hours after endoscopy to detect the development of infectious complications.

Only 6 cultures from 6 patients were positive. Four were obtained post-endoscopy and the remaining 2 before colonoscopy but the corresponding post-endoscopy samples were negative. All organisms recovered were normal skin flora. All patients, including those with positive cultures, remained asymptomatic during the 72 hours after the procedure.

Our findings indicate that lower intestinal endoscopy does not induce bacteremia in cirrhotic patients with or without ascites in the absence of gastrointestinal bleeding and do not support the routine use of prophylactic antibiotics in these patients.

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.

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.

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.

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

The risk of endocarditis associated with transesophageal echocardiography was studied in 101 patients. To evaluate possible bacteremia, blood cultures were performed on samples from consecutive patients who did not have clinical or laboratory evidence of infection. The broth blood culture Signal system was used in all patients, and additionally, the lysis-centrifugation technique was performed in a subgroup of 40 patients to further ameliorate recovery of rapidly phagocytosed germs. Comprehensive criteria for differentiation between true bacteremia and possible contamination were provided by means of simultaneous blood sampling from two separate venipuncture sites and skin specimens from the venipuncture area. Oropharyngeal specimens were cultured for evaluation of possible association of oropharyngeal flora with positive blood culture findings. They revealed facultative pathogenic isolates, as well as physiologic residental flora, in 15 patients. All blood isolates that were recovered simultaneously 6 minutes after the procedure were found to be sterile. Correspondingly, clinical follow-up for 2 weeks was uneventful with regard to episodes of infection. These results indicate that the risk of bacteremia associated with transesophageal echocardiography is extremely low. Thus endocarditis prophylaxis is not required for this procedure.

The occurrence of bacteremia in association with diagnostic or therapeutic ERCP was studied in 180 patients undergoing a total of 194 examinations. Nineteen (15%) of 126 diagnostic procedures and 18 (27%) of 68 therapeutic procedures were associated with bacteremia (p less than 0.1). Nine patients had polymicrobial bacteremia and a total of 16 species were detected. Different streptococci, mainly alpha-hemolytic, were the most common bacteria which were identified in 38% of the bacteremic patients. There were no significant differences with regard to the occurrence of fever, pancreatitis, or septic complications between the diagnostic and therapeutic groups of patients. Neither did the complication rate in patients with bacteremia differ from that in patients without bacteremia, whether the procedure was diagnostic or therapeutic. Complication rates did not differ between patients with and patients without pancreaticobiliary obstruction. However, the majority of patients with biliary stasis had drainage with relief of the obstruction at the time of the diagnostic ERCP. We conclude that general routine antibiotic prophylaxis is not indicated in patients undergoing diagnostic or therapeutic ERCP. The question whether such prophylaxis should be given with certain diagnoses or treatments, or in patients with valvular heart disease, remains to be answered in controlled randomized studies.

Infection is one of the major hazards of endoscopic procedures and is the commonest complication of endoscopic retrograde cholangio-pancreatography (ERCP) causing death. Prevention of endoscopy-associated infections is based on adequate cleaning and disinfection regimens. Scrupulous mechanical cleaning is fundamental; even prolonged chemical disinfection will be ineffective if cleaning has not been adequate. Special measures are required to prevent ERCP-related infections. It is important to recognize various special circumstances that increase a patient's susceptibility to infection and to administer antibiotic prophylaxis when appropriate.

One hundred four patients with ovarian cancer underwent intestinal reconstruction as part of a cytoreductive effort or for relief of intestinal obstruction from July 1980 to June 1990. Twenty-four percent of patients were obstructed preoperatively, while the remaining seventy-six percent had bowel resections performed in concert with a debulking procedure. The overall infectious complication rate was 14.4%. No statistical association was found between the presence of ascites at the time of laparotomy and infectious morbidity (P = 0.58). The use of a preoperative mechanical bowel preparation was associated with a significant reduction in infectious morbidity (P = 0.01). Additionally, patients considered in adequate nutritional condition experienced significantly less infectious complications than those patients in poor nutritional condition (P = 0.03). Intestinal procedures involving the large bowel were marginally associated with increased infectious complications (P = 0.13). Neither preoperative radiotherapy, the presence of preoperative obstruction, disease presence, extent of debulking, number of intestinal procedures, or hand versus stapled anastomosis was found to be significantly associated with infectious complications. It is concluded that the presence of ascites does not increase the infectious complication rate in ovarian cancer patients who undergo small or large bowel reconstructive procedures. Additionally, patients with preoperative bowel obstruction or previous abdominal radiation therapy were not found to experience a significant increase in the infectious complication rate in the current series.

Reported incidences of bacteremia after endoscopy with esophageal variceal sclerotherapy are conflicting. A prospective controlled study was conducted to determine the frequency of bacteremia after emergency endoscopy with esophageal variceal sclerotherapy compared with frequency after elective esophageal variceal sclerotherapy and after emergency endoscopy in patients with upper gastrointestinal bleeding from nonvariceal sources. A total of 126 endoscopies were studied in 72 patients. Groups consisted of (a) emergency endoscopy without esophageal variceal sclerotherapy, 37 sessions with 36 patients; (b) elective esophageal variceal sclerotherapy, 33 sessions with 14 patients; and (c) emergency esophageal variceal sclerotherapy, 56 sessions with 36 patients. Blood cultures were obtained before and 5 and 30 minutes after endoscopy. There was a higher frequency of preendoscopic bacteremia in emergency esophageal variceal sclerotherapy (13%) than in emergency endoscopy alone (0%) (P = 0.02). Clinically significant bacteremia in emergency esophageal variceal sclerotherapy was observed in 7 of 56 (13%) sessions, compared with 0 of 33 in elective esophageal variceal sclerotherapy (P = 0.03) and 1 of 36 (3%) in emergency endoscopy alone (P = 0.45). Of these cases, 3 (5.4%) were potentially caused by emergency esophageal variceal sclerotherapy, but not clinically significant postendoscopic bacteremia was attributable to the procedure in the other groups.

Thirty consecutive alcoholic patients with biopsy-proven cirrhosis of the liver and oesophageal varices underwent a total of 47 upper intestinal endoscopies. During 31 of the endoscopies paravariceal sclerotherapy of oesophageal varices was performed. Blood cultures were drawn before and after the procedures. Bacteriaemia after endoscopy was detected on seven occasions: six after sclerotherapy and one after endoscopy without sclerotherapy. This difference did not reach statistical significance. The microorganisms cultured belonged to the normal flora of the skin or the oropharynx. Bacteriaemia was transient and had no clinical consequences.

The authors have reviewed 40 prospective studies of bacteremia with gastrointestinal procedures. Endoscopic procedures with a low mean frequency of bacteremia were esophagogastroduodenoscopy (4.2%), endoscopic retrograde cholangiopancreatography (5.6%), colonoscopy (2.2%), and sigmoidoscopy (4.9%). A higher mean frequency of bacteremia was encountered with esophageal dilation (45%) and variceal sclerotherapy (31%), although the number of patients studied was small. Potentially pathogenic organisms, such as Streptococcus viridans, Staphylococcus aureus, and Staphylococcus epidermidis have been isolated. Recommendations for antibiotic prophylaxis are reviewed. Less cumbersome regimens encourage compliance and are preferred.

The authors evaluated whether depth of needle insertion as determined by needle length is an important factor in sclerotherapy-associated bacteremia. In 18 consecutive sclerotherapy sessions in which sodium morrhuate was used, blood cultures were positive in 11% when using an injector with only 3 to 4 mm of needle protruding beyond the sheath, compared with the 39% incidence of bacteremia previously observed when an injector was used which permitted 6 to 8 mm of needle to protrude (0.01 less than p less than 0.05). Twenty-five additional sclerotherapy sessions in which the shorter needle was used were performed with a different sclerosant, 1% sodium tetradecyl sulfate; only 8% of blood cultures were positive. No correlation was found between fever and bacteremia. The authors conclude that the exposed needle length of the injector must be specified in any report of endoscopic variceal sclerotherapy with the flexible endoscope since this length is critical in the incidence of associated bacteremia and possibly other complications.

The incidence of bacteremia associated with endoscopy varies widely for different endoscopic procedures. This study prospectively evaluates the incidence of bacteremia in patients undergoing elective endoscopic laser therapy for two diseases of the upper gastrointestinal tract. In five patients (eight treatment sessions) with arteriovenous malformations, no bacteremia developed. In 15 patients (26 treatment sessions) with esophagogastric carcinoma, bacteremia developed at some time during the procedure in six (40%). However, bacteremia appeared to be associated with the endoscopic insertion through the tumor rather than the laser treatment per se. These findings lead us to conclude that for patients undergoing endoscopy and laser therapy for esophagogastric malignancy, but not for those being treated for arteriovenous malformations, antibiotic prophylaxis to prevent endocarditis may be indicated.

Prevention of infective endocarditis continues to concern health care providers in many specialties. The well-known lack of primary clinical trials in this area is not expected to change. Therefore, the evolution of recommendations and practice must be based on theoretic considerations and continuing assessment of secondary sources of information. Recent developments include a report of 52 cases in which antibiotic prophylaxis for infective endocarditis was attempted but appeared to fail. Most of these patients had undergone dental procedures after oral penicillin prophylaxis, with subsequent development of streptococcal endocarditis. In two thirds, the organism was sensitive to the antibiotic used. Notably, the most common underlying cardiac lesion among these patients was mitral valve prolapse. However, two recent independent analyses have concluded that providing endocarditis prophylaxis for all patients with mitral valve prolapse during procedures that might cause bacteremia would not be cost-effective. This is primarily because mitral valve prolapse is common and endocarditis is relatively rare, resulting in an adverse risk-benefit ratio. Parenteral prophylaxis for mitral valve prolapse might even cause a net loss of life from anaphylaxis. On the other hand, for the individual patient or physician, the reassurance provided by attempted prophylaxis with oral penicillin can be purchased at low cost and low risk. Very few cases of infective endocarditis have been reported after gastrointestinal and other endoscopic procedures; most of these do not need antibiotic coverage. Prophylactic antibiotics should be restricted to those situations in which both the procedure and the underlying cardiac condition seem to pose significant risk, for example, endoscopic sclerotherapy of esophageal varices in patients with prosthetic heart valves. Newly revised recommendations have been issued by the Medical Letter, the American Heart Association, and the American Dental Association. These regimens are shorter and simpler than earlier versions.

In a 6 week period, three of 50 patients developed Pseudomonas aeruginosa septicaemia following Endoscopic Retrograde Cholangiopancreatography (ERCP). Pseudomonas aeruginosa serotype 10 was isolated from each of the patients and from the endoscope. The outbreak was related to inadequate disinfection of the air and water channel of the endoscope. Following the introduction of a modified decontamination technique, which involved rinsing the air and water channel with glutaraldehyde, no further cases of pseudomonas infection occurred, and the organism could not be isolated from the instrument. Obstruction of the biliary tract was a predisposing factor in the development of infection; and administration of antibiotics immediately following the procedure failed to prevent it. This may have been due to inadequate dosage. We suggest that patients presenting for ERCP, in whom obstruction of the biliary tract is suspected, should come prepared for immediate drainage of the obstructed system at the time of the procedure.