Antibiotic regimens: Prophylaxis for endoscopic procedures

Procedure	Condition(s)	Antibiotic and dose*	Interval for intraoperative re-dose for prolonged procedure (timed from initiation of preoperative dose)
High-risk endoscopic procedures needing antibiotic prophylaxis^¶^Δ
PEG/PEJ placement	MRSA risk absent	Cefazolin 2 g for patients weighing <120 kg, 3 g for patients weighing ≥120 kg (pediatric dose 30 mg/kg) IV within 60 minutes before procedure. If penicillin or cephalosporin hypersensitivity: Clindamycin 900 mg (pediatric dose 10 mg/kg) IV within 60 minutes before procedure.	Cefazolin: four hours Clindamycin: six hours
PEG/PEJ placement	MRSA risk present Pre-procedural screening for MRSA and attempted decontamination before feeding tube placement is recommended if practical	Vancomycin 15 mg/kg (maximum 2 g) IV infused over 60 to 90 minutes and beginning within 120 minutes before surgical incision.	Vancomycin: re-dosing is generally not required
ERCP^◊	- Biliary obstruction AND cholangitis - Biliary obstruction unlikely to be successfully drained at ERCP (including malignant hilar obstruction and primary sclerosing cholangitis) - Inadequate biliary drainage following ERCP - Biliary complications following liver transplantation if drainage is unlikely	Ciprofloxacin 500 mg (pediatric dose 15 mg/kg^§) orally given within 60 to 90 minutes prior to procedure or 400 mg (pediatric dose 10 mg/kg^§) IV over 60 minutes beginning within 120 minutes prior to procedure AND/OR	Ciprofloxacin: re-dosing is generally not required
		Amoxicillin-clavulanate 1750 mg (pediatric dose 45 mg/kg) orally within 60 minutes prior to procedure or ampicillin-sulbactam 3 grams (pediatric dose 50 mg/kg ampicillin component) IV within 60 minutes prior to procedure OR	Amoxicillin-clavulanate: two hours
		Ampicillin 2 grams (pediatric dose 50 mg/kg) IV plus gentamicin^¥ 5 mg/kg (pediatric 2.5 mg/kg) IV within 60 minutes before procedure. If penicillin hypersensitivity: Substitute vancomycin 15 mg/kg (maximum 2 g) IV infused over 60 to 90 minutes beginning within 120 minutes before procedure plus gentamicin^¥ 5 mg/kg IV (pediatric 2.5 mg/kg) within 60 minutes before procedure.	Ampicillin: two hours Vancomycin: re-dosing is generally not required Gentamicin: single dose only
		ALL above regimens are discontinued post-procedure when drainage is established absent evidence of cholangitis. For antibiotic dosing post-procedure with incomplete drainage, refer to the individual Lexicomp drug information monograph.
EUS-FNA of cystic lesion(s)^‡	- Mediastinal cysts	Ciprofloxacin 500 mg orally (pediatric dose 15 mg/kg^§) 60 to 90 minutes prior to procedure or 400 mg IV (pediatric dose 10 mg/kg^§) IV given over 60 minutes beginning within 120 minutes prior to procedure. Continue 3 days post-procedure.	Ciprofloxacin: re-dosing is generally not required
Interventional EUS procedures including transmural or transluminal drainage of pancreatic fluid collections	- Mediastinal cysts - Pancreatic cysts - Cysts outside pancreas (excluding solid lesions) - Walled-off pancreatic necrosis	Ciprofloxacin 500 mg orally (pediatric dose 15 mg/kg^§) 60 to 90 minutes prior to procedure or 400 mg IV (pediatric dose 10 mg/kg^§) IV given over 60 minutes beginning within 120 minutes prior to procedure. Continue 3 days post-procedure.	Ciprofloxacin: re-dosing is generally not required
Natural orifice transluminal endoscopic surgery (NOTES)	Insufficient data to make recommendation. Antibiotic prophylaxis seems reasonable.
High-risk patients needing antibiotic prophylaxis^¶
All endoscopic procedures with high risk of bacteremia, including procedures not listed above (eg, routine endoscopy with esophageal stricture dilation or endoscopic sclerotherapy); For procedures in the biliary tree (eg, ERCP with drainage or EUS-FNA of any lesion type) in a patient who is at high risk for infection, refer to antibiotic recommendations listed above	- Immunocompromised patients (eg, severe neutropenia [absolute neutrophil count <500 cells/mm³], advanced hematologic malignancy)^† - Cirrhosis with ascites**	Amoxicillin 2 grams (pediatric dose 50 mg/kg) orally within 60 minutes before procedure OR	Amoxicillin: two hours
		Ampicillin 2 grams (pediatric dose 50 mg/kg) IV or IM within 60 minutes prior to procedure. If penicillin hypersensitivity: Clindamycin 600 mg (pediatric dose 20 mg/kg) orally within 60 minutes before procedure or 900 mg IV (pediatric dose 10 mg/kg IV) within 60 minutes prior to procedure.	Ampicillin: two hours Clindamycin: six hours

The preprocedural antibiotic recommendations presented in this table are generally consistent with those of American Society for Gastrointestinal Endoscopy^[1] and the 2013 guidelines developed jointly by the American Society of Health-System Pharmacists and collaborating organizations^[2]. A 2009 guideline available from the British Society of Gastroenterology^[3] also recommends antibiotic prophylaxis in these conditions, but includes, in some cases, different choices and dosing regimens depending upon specific clinical scenarios. When available, recent culture and sensitivity results should be considered in selecting antibiotic prophylaxis.

PEG: percutaneous endoscopic gastrostomy; MRSA: methicillin-resistant Staphylococcus aureus; ERCP: endoscopic retrograde cholangiopancreatography; EUS-FNA: endoscopic ultrasound-guided fine-needle aspiration; GI: gastrointestinal.
* Pediatric dose should generally not exceed adult dose. Doses shown in table are for patients with normal renal function. Dose modification for renal impairment is needed for some agents.
¶ Antibiotic prophylaxis solely to prevent infective endocarditis is not recommended in patients undergoing endoscopic procedures. For patients with the highest-risk cardiac conditions (eg, prosthetic heart valve, prior endocarditis) who have ongoing GI or genitourinary tract infection or who are undergoing a procedure for which antibiotic therapy to prevent wound infection or sepsis is indicated, the American Society for Gastrointestinal Endoscopy (ASGE) and American Heart Association (AHA) suggest an antibiotic regimen that includes an agent active against enterococci (eg, ampicillin, piperacillin-tazobactam, or vancomycin). Refer to topic review of antimicrobial prophylaxis for bacterial endocarditis section on gastrointestinal tract.
Δ A separate table that summarizes the types of procedures and patients needing antibiotic prophylaxis is available in UpToDate. Low-risk endoscopic procedures that do not need routine antibiotic prophylaxis in most patients (eg, routine upper endoscopy, colonoscopy, flexible sigmoidoscopy, others) are listed in that table.
◊ Patients with cholangitis require antibiotic therapy and additional prophylaxis is not required.
§ While fluoroquinolones have been associated with an increased risk of tendinitis/tendon rupture in all ages, use of these agents for single-dose prophylaxis is generally safe.
¥ Gentamicin use for surgical antibiotic prophylaxis should be limited to a single dose given preoperatively. Dosing is based on the patient's actual body weight. For overweight and obese patients (ie, actual weight is greater than 120% of ideal body weight), a dosing weight should be used. A calculator to determine ideal body weight and dosing weight is available in UpToDate.
‡ While antibiotic prophylaxis is recommended by the ASGE for all patients undergoing EUS-FNA of cystic lesions, we generally reserve antibiotic prophylaxis for patients undergoing EUS-FNA of mediastinal lesions and in those who are at high risk for infection. Antibiotic prophylaxis is not required for patients undergoing EUS-FNA of solid lesions.
† Patients at high risk for postprocedural infections may also include those with decreased gastric acidity and motility resulting from malignancy or acid suppression.
** In patients with cirrhosis and upper gastrointestinal bleeding, antibiotics are indicated even if endoscopy is not planned.

References:

ASGE Standards of Practice Committee, Khashab MA, Chithadi KV, et al. Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc 2015; 81:81.
Bratzler DW, Dellinger EP, Olsen KM, et al. Clinical Practice Guidelines for Antimicrobial Prophylaxis in Surgery. Am J Health Syst Pharm 2013; 70:195.
Allison MC, Sandoe JA, Tighe R, et al. Antibiotic prophylaxis in gastrointestinal endoscopy. Gut 2009; 58:868.

Additional data from:

Red Book: 2012 Report of the Committee on Infectious Diseases, 29th ed, Pickering LK, ed, Elk Grove Village, IL: American Academy of Pediatrics, 2012, p.808.

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Antibiotic regimens: Prophylaxis for endoscopic procedures