Definitions for the grades of recommendation (1A to 3) are provided at the end of the "Major Recommendations."
Prevention of Infective Endocarditis
Antibiotic prophylaxis solely to prevent infective endocarditis (IE) is no longer recommended before endoscopic procedures (Grade 1C+). For patients with established gastrointestinal (GI)-tract infections in which enterococci may be part of the infecting bacterial flora (such as cholangitis) and with one of the cardiac conditions associated with the highest risk of an adverse outcome from endocarditis*, amoxicillin, or ampicillin should be included in the antibiotic regimen for enterococcal coverage (Grade 3). Vancomycin may be substituted for patients allergic to or unable to tolerate amoxicillin or ampicillin.
*Note: These conditions include: (1) a prosthetic cardiac valve, (2) a history of previous IE, (3) cardiac transplant recipients who develop cardiac valvulopathy, and (4) patients with congenital heart disease (CHD), including (a) those with unrepaired cyanotic CHD (including palliative shunts and conduits), (b) those with completely repaired CHD with prosthetic material or device, placed surgically or by catheter, for the first 6 months after the procedure, and (c) those with repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or device.
Prevention of Infections Other Than Infective Endocarditis (IE)
Endoscopic Retrograde Cholangiopancreatography (ERCP)
Antibiotic prophylaxis should be considered before an ERCP in patients with known or suspected biliary obstruction, in which there is a possibility that complete drainage may not be achieved at the ERCP, such as in patients with a hilar stricture and primary sclerosing cholangitis (PSC) (Grade 2C). When biliary drainage is incomplete despite an ERCP, continuation of antibiotics after the procedure is recommended (Grade 3). Antibiotics that cover biliary flora, such as enteric gram-negative organisms and enterococci, should be used. When biliary drainage is complete, continuation of antibiotics is not recommended (Grade 3). An exception is patients with posttransplant biliary strictures who are undergoing an ERCP; in these patients, continuation of antibiotics after the procedure may be beneficial (Grade 3), even when drainage is achieved. Antibiotic prophylaxis is not recommended in patients with biliary obstruction when it is likely that an ERCP will accomplish complete biliary drainage (Grade 1C). Antibiotic prophylaxis is not recommended before an ERCP when obstructive biliary-tract disease is not suspected (Grade 1C). Antibiotic prophylaxis is recommended before an ERCP in patients with communicating pancreatic cysts or pseudocysts and before transpapillary or transmural drainage of pseudocysts (Grade 3).
Endoscopic Ultrasound-Guided Fine Needle Aspiration (EUS-FNA)
Antibiotic prophylaxis is not recommended before a diagnostic EUS or EUS-FNA of solid lesions along the upper-GI tract (Grade 1C). Prophylaxis with an antibiotic such as a fluoroquinolone administered before the procedure is recommended before an EUS-FNA of cystic lesions along the GI tract. Antibiotics may be continued for 3 to 5 days after the procedure (Grade 1C). There are insufficient data to make recommendations on antibiotic prophylaxis before an EUS-FNA of solid lesions along the lower-GI tract. The endoscopist may consider prophylaxis on a case-by-case basis. When antibiotic prophylaxis is administered, a fluoroquinolone administered before the procedure and continued for 3 days after the procedure is a reasonable regimen.
Percutaneous Endoscopic Gastrostomy (PEG)
Parenteral cefazolin (or an antibiotic with equivalent coverage) should be administered to all patients 30 minutes before they undergo PEG-tube placement (Grade 1A).
Cirrhosis and GI Bleeding
All patients with cirrhosis who are admitted with GI tract bleeding should have antibiotic therapy instituted at admission, preferably with IV ceftriaxone (Grade 1B). In patients allergic to or intolerant of ceftriaxone, oral norfloxacin may be used.
Synthetic Vascular Graft and other Nonvalvular Cardiovascular Devices
Antibiotic prophylaxis before GI endoscopic procedures is not recommended for patients with synthetic vascular grafts or other nonvalvular cardiovascular devices (Grade 1C+)
Orthopedic Prosthesis
Antibiotic prophylaxis is not recommended for patients with orthopedic prosthesis who are undergoing GI endoscopic procedures (Grade 1C+)
Natural Orifice Transluminal Endoscopic Surgery (NOTES)
There are insufficient data to make recommendations on antibiotic prophylaxis before NOTES. However, at this time, antibiotic prophylaxis seems reasonable.
Definitions:
| Grade of Recommendation |
Clarity of Benefit |
Methodologic Strength Supporting Evidence |
Implications |
| 1A |
Clear |
Randomized trials without important limitations |
Strong recommendation; can be applied to most clinical settings |
| 1B |
Clear |
Randomized trials with important limitations (inconsistent results, nonfatal methodologic flaws) |
Strong recommendation; likely to apply to most practice settings |
| 1C+ |
Clear |
Overwhelming evidence from observational studies |
Strong recommendation; can apply to most practice settings in most situations |
| 1C |
Clear |
Observational studies |
Intermediate-strength recommendation; may change when stronger evidence is available |
| 2A |
Unclear |
Randomized trials without important limitations |
Intermediate-strength recommendation; best action may differ depending on circumstances or patients' or societal values |
| 2B |
Unclear |
Randomized trials with important limitations (inconsistent results, nonfatal methodologic flaws) |
Weak recommendation; alternative approaches may be better under some circumstances |
| 2C |
Unclear |
Observational studies |
Very weak recommendation; alternative approaches likely to be better under some circumstances |
| 3 |
Unclear |
Expert opinion only |
Weak recommendation; likely to change as data become available |
*Adapted from Guyatt G, Sinclair J, Cook D, et al. Moving from evidence to action. Grading recommendations: a qualitative approach. In: Guyatt G, Rennie D, editors. Users' guides to the medical literature. Chicago: AMA Press; 2002. p. 599-608.
