Patients who require antibiotic prophylaxis for endoscopic procedures

Patient group	Procedures that require prophylaxis	Comments*
Specific patient groups
Patients with cirrhosis and acute GI bleeding	All endoscopic procedures	Patients with cirrhosis and acute GI bleeding require antibiotics as part of their routine treatment, even if they are not undergoing an endoscopic examination.
Cirrhosis with ascites	Procedures that are high risk for infection or bacteremia^¶	Studies supporting using prophylactic antibiotics in patients with cirrhosis and ascites are lacking. We believe it is prudent to provide prophylaxis in this group of patients, given the risk of bacterial translocation.
Severe neutropenia (ANC <500 cells/mm³) Advanced hematologic malignancy	Procedures that are high risk for infection or bacteremia^¶	Studies supporting using prophylactic antibiotics in patients at increased risk for infection are lacking. We believe it is prudent to provide prophylaxis in this group of patients, given their increased risk for infection. Prophylaxis is not recommended for patients who are immunocompromised for other reasons.
Synthetic vascular grafts within six months of graft placement	Procedures that are high risk for infection or bacteremia^¶	When possible, elective procedures should be performed before a synthetic graft is placed or delayed for six months following graft placement. If a procedure is necessary within six months of graft placement, we generally will give antibiotic prophylaxis for high-risk procedures.
Procedure	Patients/conditions that require prophylaxis	Comments*
For patients NOT falling into one of the above mentioned groups
Upper endoscopy
With or without biopsy, polypectomy, esophageal stricture dilation, endoscopic sclerotherapy, or band ligation of varices	None
With PEG/PEJ tube insertion	All patients	The ASGE guidelines recommend pre-procedural screening for MRSA in areas where MRSA is endemic and attempting decontamination before placing the feeding tube.
Colonoscopy or flexible sigmoidoscopy, with or without biopsy or polypectomy	None	Patients undergoing peritoneal dialysis should have the procedure done with the peritoneum empty. However, this recommendation differs from that of the ASGE, which recommends antibiotic prophylaxis for patients undergoing peritoneal dialysis prior to lower GI endoscopy, and the ISPD, which recommends antibiotic prophylaxis for patients undergoing colonoscopy with polypectomy.
ERCP	Cholangitis Biliary obstruction without cholangitis if complete drainage is unlikely (eg, in patients with malignant hilar carcinoma or primary sclerosing cholangitis) Biliary complications following liver transplantation if drainage is unlikely	Patients with cholangitis should receive antibiotics as part of their routine treatment. Additional prophylaxis is not required. If drainage is not successful, antibiotics should be started. Once drainage has been established, antibiotics can be discontinued if there is no cholangitis.
EUS-FNA of cystic lesions	Mediastinal cysts	The ASGE recommends antibiotic prophylaxis for all patients undergoing EUS-FNA of cystic lesions. However, we reserve it for patients with mediastinal cysts since they appear to be at increased risk of infection. We do not provide antibiotic prophylaxis for EUS-FNA of pancreatic cysts because there are insufficient data to support their use in this setting. Antibiotics are typically continued for three to five days after the procedure.
EUS-FNA of solid lesions along the GI tract	None
Interventional EUS procedures^Δ, natural orifice transluminal endoscopic surgery (NOTES)	All patients

NOTE: Refer to other table on antibiotic prophylaxis for endoscopic procedures for specific regimens.

GI: gastrointestinal; ANC: absolute neutrophil count; AHA: American Heart Association; ASGE: American Society for Gastrointestinal Endoscopy; PEG: percutaneous endoscopic gastrostomy; PEJ: percutaneous endoscopic jejunostomy; MRSA: methicillin-resistant Staphylococcus aureus; ISPD: the International Society for Peritoneal Dialysis; ERCP: endoscopic retrograde cholangiopancreatography; EUS: endoscopic ultrasound; FNA: fine-needle aspiration.

* The recommendations in this table are generally consistent with guidelines from the ASGE and AHA except as noted here.

¶ Procedures that are high risk for bacteremia or infection include dilation of esophageal strictures, endoscopic sclerotherapy, ERCP, EUS-FNA, and PEG/PEJ tube placement.

Δ Interventional EUS procedures include drainage of walled-off pancreatic necrosis, biliary drainage, and fine-needle injection of cysts/tumors.

Recommendations summarized from:

ASGE Standards of Practice Committee, Khashab MA, Chithadi KV, et al. Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc 2015; 81:81.
Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143:e72.
Nishimura RA, Carabello BA, Faxon DP, et al. ACC/AHA 2008 guideline update on valvular heart disease: focused update on infective endocarditis: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:887.

Graphic 99536 Version 5.0

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Patients who require antibiotic prophylaxis for endoscopic procedures