Endoscopic Procedures, Antibiotic Prophylaxis (215)

A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.

Recommendations for Antibiotic Prophylaxis in Endoscopic Procedures

Single dose, IV prophylaxis ≤ 60mins prior to skin incision/ intervention.

For gentamicin#
• See appendix 1 for prophylactic dosing
• Doses of up to 400mg gentamicin can be given by slow IV injection over 3 – 5 minutes
• If subsequent treatment using gentamicin is required, measure gentamicin concentration 6-14 hours post theatre gentamicin dose, and follow GGC guidance on staffnet for gentamicin dosing. Calculate the gentamicin dose using the online calculator. Discuss with pharmacy if further advice is required ( or if out of hours, the on call pharmacist)
• Teicoplanin and gentamicin are incompatible when mixed directly and must not be mixed before injection.

Weight > 80 Kg
Increase the dose of antibiotic as below:

	> 100 Kg
Co-amoxiclav	add 1g IV amoxicillin to 1.2g IV co-amoxiclav
	> 80 Kg	> 160 Kg
Metronidazole	1000 mg	1500 mg

Table: Procedure, Antibiotic and Comment

Procedure	Antibiotic and comment
Upper or lower diagnostic GI endoscopy	Not recommended
Endoscopic mucosal resection	Not routinely recommended If severe profound immunosupression (e.g. neutropenia < 0.5 x 109/L and/or advanced haematological malignancy) use: Gentamicin IV (see prophylaxis dosing table) + Metronidazole 500mg IV
ERCP in the following: 1) Biliary disorders where complete biliary drainage will be difficult/ impossible to achieve during one procedure Patients with pancreatic pseudocyst Patients with severe profound immunosupression~ 2) Patients with biliary complications following liver transplant* 3) Ongoing cholangitis or sepsis elsewhere ERCP with anticipated complete drainage and none of the above.**	Gentamicin IV (see prophylaxis dosing table) ~ neutropenia < 0.5 x 109/L and/or advanced haematological malignancy) In liver transplant patients add Amoxicillin 1g IV or if penicillin allergy add Teicoplanin 400mg IV* Ongoing cholangitis /sepsis: Be guided by recent culture results. Patients should already have been established on antibiotics. Seek advice from microbiology. Not routinely recommended** If adequate biliary decompression is not achieved during the procedure antibiotic therapy is required (as per infection management guidelines)
PEG or PEJ tube insertion	Co-trimoxazole 960mg, 10mls oral suspension (480 mg/ 5 ml) administer via the PEG/PEJ tube immediately post insertion. (See Appendix 2 below re administration of co-trimoxazole suspension via PEG/PEJ tube) or in co-trimoxazole allergy Co-amoxiclav 1.2g IV

Administration of Co-trimoxazole Suspension via PEG/PEJ

1. Using an ENfit enteral syringe flush the PEG/PEJ tube with 30mls of sterile water.
2. Measure 10ml (960mg) dose of co-trimoxazole suspension in a medicine cup.
3. Add 10mls of sterile water to the same medicine cup and mix.
4. Draw up and administer the co-trimoxazole suspension using an ENfit enteral syringe (50 or 60ml) via the PEG/PEJ tube.
5. Draw up 30mls of sterile water using the same ENfit enteral syringe
6. Flush the PEG/PEJ tube.
7. Close port on feeding tube

Reference

Adapted from British Society of Gastroenterology Guidance: GUT 2009; 58: 869-880