PROSPECTIVE ASSESSMENT OF THE RISK OF BACTEREMIA IN CIRRHOTIC PATIENTS AFTER EUS WITH AND WITHOUT FNA Fernández ndez-esparrach G, Gimeno-Garc García a AZ, Pellisé M, Almela M*, Sendino O, Zabalza M, Llach J, Cárdenas C A, Bordas JM, Castells A, Ginès s A. Endoscopy Unit. Institut de Malalties Digestives i Metabòliques. * Microbioloy Department. Hospital Clínic. IDIBAPS. University of Barcelona. Spain.
BACKGROUND The incidence of bacteremia after endoscopic ultrasonography (EUS) or EUS-guided fine-needle aspiration (EUS-FNA) is low (0-6%) and the performance of an EUS-FNA does not increase it. Janssen et al. GIE 2004; Levy et al. GIE 2003; Barawi et al. GIE 2001. Cirrhotic patients undergoing endoscopic procedures present an upper risk of bacteremia and septic complications than the non-cirrhotic patiens. Zuckerman et al. GIE 1994; Cohen et al. GIE 1983 No data exists on the risk of bacteremia and other septic complications on cirrhotic patients that are submitted to an EUS or EUS-FNA.
AIM To prospectively assess the incidence of bacteremia in cirrhotic patients undergoing EUS and EUS-FNA.
PATIENTS Consecutive cirrhotic patients undergoing EUS+/- EUS-FNA Study period: May 2005 June 2006 Exclusion criteria 1) age < 18 years 2) bacterial infection and/or AB treatment within the previous 2 w of EUS 3) GI bleeding or encephalopaty within 2 w of EUS 4) esophageal stricture dilation or sclerotherapy of esophageal varices within 2 w of EUS 5) need for antibiotic prophylaxis according to ASGE 6) lack of informed consent
METHODS EUS technique: -Conscious sedation -EUS: OlympusR GF UM160 -EUS-FNA: OlympusR UCT 140-22 G Wilson Cook needle Microbiologic examination: -Exclusive intravenous line for blood cultures -Blood cultures at: baseline, 5 min and 30 min Clinical Follow-up (Tº, abdominal or thoracic pain): -Physical examination every 12 hours in the first 72 hours -Telephone call at day 7 after EUS
STUDY DESIGN baseline EUS 5 min 30 min Sample 1 Sample 2 Sample 3 Axillary Tº Physical examination Axillary Tº Physical examination Axillary Tº Physical examination 5 min 30 min EUS-FNA Sample 2a Axillary Tº Physical examination Sample 3a Axillary Tº Physical examination
PATIENTS N 41 Age (years) 58 + 11 Gender (male/female) (n) 28/13 Cirrhosis (alcohol, others) (n) 22/18 Ascites (n) 7 Hepatocarcinoma (n) 7 Bilirrubin (mg/dl) 1.7 + 1.9 Prothrombin time (%) 73 + 15 Platelets (x 10 3 ) 135 + 90 Albumin (gr/l) 36 + 10 Creatinine (mg/dl) 1 + 0.5 Child-Pugh (A/B/C) 31/8/2 *Data are expressed as media ± SD RESULTS
RESULTS Indications N (%) Intraabdominal adenopathies Pancreatic lesions Extrahepatic cholestasis Mediastinic adenopathies Esophageal cancer Other 8 (19) 8 (19) 6 (15) 5 (12) 4 (10) 10 (25)
Patient (n = 16) Blood culture sample 1 Blood culture sample 2-2a Blood culture sample 3-3a EUS-1 EUS-2 EUS-3 EUS-4 EUS-5 EUS-6 EUS-7 EUS-8 EUS-9 EUS-10 EUS-11 EUS-12 FNA-1 FNA-2 FNA-3 FNA-4 * Streptococcus mitis Corynebacterium sp. Propionibacterium sp. Peptostreptococcus sp. Staphylococcus aureus Streptococcus viridans Corynebacterium sp. Streptococcus viridans Streptococcus mitis Acinetobacter Lwoffii * : Coagulase negative Staphylococcus
RESULTS Bacteremia incidence (5min + 30 min): 15%. bacteremia after EUS: 12% bacteremia after EUS-FNA: 6% Contamination rate (baseline, 5 min, 30 min): 9%. Clinical signs of infection: 2%.
RESULTS Bacteremia n=6 (15%) No bacteremia n=35 (85%) p Age 62 + 9 58 +12 ns Gender (M/F) 3/3 25/10 ns Ethiology (alcohol/others) 4/2 16/19 ns Ascites 1 6 ns Child-Pugh (A/B/C) 6/0/0 25/8/2 ns Upper endoscopy 1 10 ns Biopsies 0 6 ns Esophageal stricture 1 2 ns
RESULTS Bacteremia n=6 (15%) No bacteremia n=35 (85%) p FNA 1 15 ns Lesions 1 1.4 ns Pases 1 2.4 ns Duration (min) 30 +/- 14 45 +/- 28 ns
CONCLUSIONS 1-. Transient Gram-positive bacteremia develops in cirrhotic patients after EUS (with or without FNA) at a rate higher than that reported in immunocompetent patients. 2-. However, since there is no clinical impact, antibiotic prophylaxis seems not to be necessary except in those patients at high risk for endocarditis.