December 1991

BACTEREMIA IN SCLEROTHERAPY 1643

view Board, and informed consent was obtained before patients entered the study. A total of 72 patients (58 men and 14 women) were enrolled. There were three groups of patients: the emergency endoscopy group and the two sclerotherapy groups [Table 1). The emergency endoscopy group (36 patients] included all patients admitted to the hospital who had emergency endoscopy within 24 hours of admission to evaluate UGI bleeding, in whom sources other than esophageal varices were found. None of them received any endoscopic therapy, because multipolar electrocoagulation, heater probe, and laser therapy were not available. No patient underwent endoscopy more than once. The sclerotherapy groups (36 patients) included the following patients. 1. The emergency EVS group consisted of all patients with UGI bleeding in whom variceal bleeding sources were found by endoscopy and in whom EVS was performed either in an attempt to control the acute esophageal variceal bleeding (27%) or to prevent rebleeding (73%). Most patients (93%) underwent endoscopy within 24 hours of admission and the rest either within 48 hours (2%) or within 24 hours of rebleeding in hospital (5%). 2. The elective EVS group consisted of all patients who had elective EVS. It was standard practice at our institution to admit all patients for elective EVS to the hospital for “23-hour” (overnight observation) stays. None of the elective EVS patients had acute UGI bleeding at the time of admission, and most of them (79%) also had previous emergency EVS during the study. Of the 36 emergency EVS patients, 11 went on to have elective EVS, and the additional 3 patients in the elective EVS group had emergency EVS at our hospital before initiation of the study. The schedule for elective EVS was approximately every 3 weeks until eradication or repeat emergency EVS if patients rebled. All sclerotherapy patients had either biopsy-proven cirrhosis or a clinical picture, with abnormal liver-spleen scan with colloid shift, consistent with cirrhosis. The severity of liver disease at presentation was graded according to Pugh’s modification of Child’s criteria (19). Endoscopy

Patients were premeditated with IV diazepam or midazolam and at times meperidine. Endoscopy was perTable 1. Patient Profile No. of

No. of

Group

patients

sessions

Emergency endoscopy Elective EVS

36 14 36

37 33 56

Emergency EVS

Age

[yr: mean

Sex

(range11

(Ml

51(31-77) 49 (33-63) 49 (28-78)

30/6 10/4 2818

NOTE. A total of 126 endoscopies were performed in 72 patients; 36 were in the emergency endoscopy control group and 36 in the sclerotherapy groups.

formed with an Olympus GIF-Q flexible endoscope (Olympus, Lake Success, NY) (M.Z.). Sclerotherapy was performed with a 25-gauge 4-mm disposable flexible injector (Flexitip Retractable Sclerotherapy Needle no. 198; American Endoscopy Inc., Mentor, OH) and sodium tetradecyl sulfate 1.5% (Elkins-Sinn Inc., Cherry Hill, NJ] in D50W sclerosant. Injections were administered intravariceally with an average of 2 mL of sclerosant (range, l-3 mL) per injection.

Blood Cultures

Blood cultures were drawn via separate venous punctures of the forearm before endoscopy (BCXl), at 5 minutes (BCXB), and at 30 minutes (BCX3) after the procedure. The blood cultures were taken by endoscopy unit nurses or intensive care unit nurses after the patient’s forearm was cleansed with povido.ne-iodine and 70% isopropyl alcohol. Blood, 5 mL, was inoculated into each Trypticase Soy Broth bottle (Becton Dickinson, Towson, MD) for both aerobic and anaerobic cultures. Bacterial growth was monitored radiometrically for 7 days with the Bactec 360 Microscan system (Baxter, West Sacramento, CA).

Data Analysis

All descriptive statistical analyses, Fischer’s Exact Test, and Student’s t tests were performed with the Statview 512+ (Bram Power Inc., Calabasas, CA). To make the interpretation of positive blood cultures more meaningful and clinically relevant, positive blood cultures were categorized into the following two groups, based on previous studies (20-24) Significant bacteremia group included (a) any positive blood culture in which the isolated microorganism is one of the following: coliform bacteria (including Escherichia coli and Proteus), Bacteroides, Hemophilus, group A Streptococcus, and Streptococcus pneumoniae or (b) more than one blood culture, drawn at different times, positive for the same organism. Patients were not necessarily symptomatic. Nonsignificant bacteremia group included (a) a single positive blood culture in which the isolated microorganism is one of the following: Staphylococcus coagulase negative (including S. epidermidis and S. warneri), Corynebacterium, Propionibacterium, and Bacillus species, unless the patient has a prosthetic valve, graft, or shunt or (b) a single positive blood culture for Clostridia (including C. perji-ingens and C. sordelli) without clinical correlation of active infection. Results Of the 72 patients enrolled in the study, patients were in the emergency endoscopy group 36 patients in the sclerotherapy groups. A total of endoscopies were performed, 37 sessions (36 tients) of endoscopy alone and 89 of endoscopy EVS (36 patients). In the EVS groups, 56 sessions

36 and 126 paand (36

GASTROENTEROLOGY Vol. 101, No. 6

1644 HO ET AL.

patients) were performed on an emergency basis and 33 sessions (14 patients) were for elective EVS. The emergency endoscopy and sclerotherapy groups were comparable in age and sex distribution (Table 1). The sources of UGI bleeding in the emergency endoscopy group were duodenal ulcer, 15 patients (40.5%); acute gastritis, 8(21.6%); gastric ulcer, 5(13.5%); Mallory-Weiss tear, 5(13.5%); esophagitis, 2(5.4%); duodenitis, 1(2.7%);and anastomotic erosion, 1(2.7%). The modified Child’s class status of patients in the 56 emergency EVS sessions were Child’s A, 18 patients (32.1%); Child’s B, 23(41.4%); andChild’s C, 15(26.8%). In the 33 elective sessions they were Child’s A, 21 patients (63.6%); Child’s B, 10(30.3%); and Child’s C, 2(6.1%). Therefore, the majority (68%) of emergency EVS patients were either Child’s B or C, whereas the majority (64%) of elective EVS patients were Child’s A. Alcohol was the etiology of the underlying liver disease in more than 90% of patients in the sclerotherapy groups. The average duration of endoscopy was 10 minutes in the emergency endoscopy group, 15 minutes in the elective EVS group, and 17 minutes in the emergency EVS group. There was an average of nine injections and 15 mL of sclerosant per patient in the emergency EVS group compared with eight injections (P = 0.25) and 13 mL of sclerosant (P = 0.08) in the elective EVS group. Results of Blood Cultures Positive blood culture results were found from 30 of 378 cultures obtained (7.9%) (Table 2). Of them, 11 blood cultures from eight sessions were considered to be potentially significant. The organisms isolated from each positive blood culture obtained either before or after endoscopy are listed in Table 3. Emergency

Endoscopy

Group Blood Cultures

There were five positive blood culture results. None of the blood culture results drawn before endoscopy were positive. Only one patient (number 5) received antibiotics during hospitalization, and no patient experienced any sign of persistent bacteremia or sepsis during admission. The incidence of endoscopy-related bacteremia was 11% (4/36), with a predominance of oral or skin flora. Esophageal Variceal Sclerotherapy Blood Cultures

Group

Elective esophageal variceal sclerotherapy. There were eight positive blood culture results. Three (9%) drawn before endoscopy were positive, compared with five (15%) post-EVS blood culture results.

Table 2. Number of Sessions With Positive Blood Culture Results Before and After Endoscopy BCXl (%)

Group Emergency endoscopy Elective EVS (33) Emereencv EVS (56)

(37)

BCX2 (%)

BCX3 (%)

6 (6) 2 (5) 3 (6) 3 (6) 1 (3) 4 (11) 7 (131 5 191 5 (91

Total after endoscopy” 5 (13) 5 (15) 8 (141

NOTE. Statistical analysis of positive blood culture results includes the following. Preendoscopic groups: emergency EVS vs. emergency endoscopy (P = 0.02), emergency EVS vs. elective EVS (P = 0.45), and elective EVS vs. emergency endoscopy (P = 0.10); postendoscopic groups: emergency EVS vs. emergency endoscopy (P= 0.58), emergency EVS vs. elective EVS (P= 0.57), and elective and within groups (postEVS vs. emergency endoscopy (P = 0.56); endoscopic vs. preendoscopic): emergency endoscopy (P = 0.03), elective EVS (P = 0.35), and emergency EVS (P = 0.30). Statistical analysis of significant bacteremia (see Table 3) includes the following. Preendoscopic groups: emergency EVS vs. emergency endoscopy(P = 0.121, emergency EVS vs. elective EVS (P = 0.15), and elective EVS vs. emergency endoscopy (P = NA); postendoscopic groups: emergency EVS vs. emergency endoscopy (P = 0.07), emergency EVS vs. elective EVS (P = 0.09), and elective EVS vs. emergency endoscopy (P = 0.52); and comparison of postendoscopic to preendoscopic within emergency EVS group (P= 0.50). 'Number of patients with either BCX2 or BCX3, or both, positive. BCX, blood culture.

No significant bacteremia was observed, and no patient had signs or symptoms of infection. Emergency esophageal variceal sclerotherapy. There were 17 positive blood culture results. Seven (13%) drawn before endoscopy were positive. Four (7.1%) sessions had significant preendoscopic blood cultures, and five (8.9%) sessions had six significant postendoscopic blood cultures with 8 of 17 (47%) testing positive for E. coli, Campylobacter coli, Pseudomonas jluorescens, Bacteroides fragilis, or they were polymicrobial with Clostridium. The other 9 of 17 (53%) positive blood culture results were with oral and skin flora. Two patients apparently developed empyemas as a complication of sclerotherapy. New bilateral pleural effusions were found on post-EVS chest radiograph in both patients. The microorganisms isolated in both the pleural fluid and blood cultures were identical. One additional patient had fever and leukocytosis associated with postendoscopic bacteremia and responded to antibiotic therapy. If patients were culture positive after emergency EVS, conversion to negative culture was not documented, because the patients were either asymptomatic or were treated with antibiotics (Table 3). In the emergency EVS group, there were positive post-EVS blood culture results in 14% (8/56) sessions. Excluding patients who had the same microorganisms identified before and after the procedure, the emergency EVS-related bacteremia was 11% (6/56) sessions. Significant bacteremia potentially caused by the procedure was present in 5.4% (3/56).

December

BACTEREMIA

1993

Table 3.

Bacteria

Isolated

BCXZ

BCXl

BCX3

Comment

group

-

-

Bacillus Bacillus

Diphtheroid Clostridium -

0 (0%)

E. coli 1(2.70/o)

0 (0%)

Diphtheroid Diphtheroid Bacillus -

-

a

0 (0%)

Total significant Emergency 1”

1645

From Blood Cultures Before and After Endoscopy

Patient Emergency endoscopy 1 2 3 4 5 Total significant Elective EVS 1 2 3 4 5 fi 7

IN SCLEROTHERAPY

P\J before endoscopy,

treated

S13 tube, leukocytosis,

treated

Diphtheroid Diphtheroid Propionibacterium 0 (0%)

S. warneri S. epidermidis 0 (0%)

EVS Diphtheroid

-

2

3” 4” 5” 8” 7

S. epidermidis S. epidermidis -

Clostridium S. epidermidis Bacillus Bacillus

10 11 12 Total significant

4 (7.1%)

S. epidermidis S. epidermidis

S. epidermidis

Asymptomatic

Propionibacterium

Bacillus B. fragilis E. coli C. coli -

a 9

Clostridium S. epidermidis

P. jluorescens 3 (5.4%)

C. coli E. coli

Differences

in

bacteremia

between

groups.

leukocytosis, treated endoscopy, treated endoscopy, treated treated treated

3 (5.4%)

NOTE. Of 378 blood cultures obtained, 30 were positive. There were 11 potentially significant and the other positive blood cultures represented probable contaminants. Underlined organisms PN, pyelonephritis; SB, Sengstaken-Blakemore; SBP, spontaneous bacterial peritonitis. “Patients actively bleeding ai emergency EVS.

There was a higher frequency of preendoscopic bacteremia in emergency EVS (13%) than in emergency endoscopy alone (0%) (P = 0.02), but not in elective EVS (9%) [Table 2). Frequencies of postendoscopic bacteremia were similar. There were more total sessions with significant positive blood cultures (7/56) (13%) in the emergency EVS group than in the elective EVS group (O/33) (P = 0.03). Differences in bacteremia within groups. In interpreting the meaning of postemergency EVS blood cultures in patients with positive preprocedure culture results, it was assumed that if the same organism was present, then this was not procedure related: if a different organism or no organism was present afterwards, then the original bacteremia was probably transient or intermittent. The finding of only one positive postendoscopic blood culture result in emergency EVS patient 10 may have been caused by the organism being fastidious. There was no difference in postendoscopic bacteremia compared with preendo-

Fever and PN before SBP before Empyema, Empyema,

positive blood cultures from eight sessions, were considered to be significant.

scopic bacteremia in emergency endoscopy alone (P = 0.06 excluding patient 5), and there were also no differences in elective EVS or emergency EVS. The presence of active bleeding at the time of emergency EVS was not associated with a Idifference in frequency of bacteremia. Discussion

The findings from prospective studies of the incidence of bacteremia after UGI endoscopy range from 0% to 8% (25-32), which is similar to the reported incidence of bacterelmia in healthy adults (21,33). Most of these studies were performed on a selected group of patients who did not have acute GI bleeding, IV catheterization, fever, or leukocytosis; therefore, the results may not be applicable to the situation that exists in emergency endoscopy for UGI bleeding. The current study examined the frequency of bacteremia in three settings. both before and after endoscopy. Both the emergency endoscopy without

1646

GASTROENTEROLOGY

HO ET AL.

Table 4. Summary

Vol. 101, No. 6

of Prospective Studies of Bacteremia Ajler Sclerotherapy

Timing Study Cohen et al., 1983 (12)

Endoscope

Needle length

NS

6-8 mm

Sclerosant Thrombin and SM

Technique I

of blood cultures

Control Olympus, GIF-IT

4mm

SM

I

Olympus, GIF-IT

4 mm (?)

STS

NS

Olympus GIF-K2

NS

Polidocanol

I and P

NS

3-4 mm

Thrombin and SM or STS

0 (01

14 (50)

Elective EVS, 14 Elective EGD, varices, 7

28

Emergency and elective, 18 None

40

0 (0)

2 (5)

Emergency EVS, 11 None

25

0 (01

0 (0)

Elective EVS, 24 None

40

1 (31

21 (53)

Elective EVS,

43

-

4 (9)

7

0 (01

0 (0)

Before, during, 5 min. 30 min, 3h24h

Sclerotherapy Control Snady et al., 1985 (16)

(%)

Before, during, 30 min”

Sclerotherapy Control Sauerbruch et. al., 1985 (15)

(%)

Before, 5 min, 30 min, 24 h

Sclerotherapy Control Brayko et al., 1985 (14)

No. of sessions

No. of positive BCX after

Before, 5 min, 4 h, 24 h

Sclerotherapy

Camara et al., 1983 (13)

No. of patients

No. of positive BCX before

5 min*

Sclerotherapy

21

Control Low et al., 1986 (17)

None NS

5mm

Ethanolamine and Evans blue

Before, 5 min, 10 min Mostly elective, 38 None

Sclerotherapy Control Hegnhoj et al., 1988 (18)

Olympus GIF-K2,Q

4mm

Polidocanol

Control

Sclerotherapy Control

Olympus, GIF-Q

4mm

STS

2 (21

9 (9)

Elective EVS, 19 Elective EGD, varices, 11

31

4 (13)

7 (23)

16

0 (0)

1 (6)

Emergency EVS, 36 Elective EVS,

56

7 (13)

6 (14)

33

3 (9)

5 (15)

Before, 5 min, 2h”

Sclerotherapy

Ho et al., (current study)

104

Before, 5 min, 30 min

14

Emergency EGD, no variates, 36

37

0 (0)

5 (131

NOTE. The number of patients with positive blood culture results before and during/after endoscopy are listed; some patients may have had more than one postendoscopic culture positive. EGD, esophagogastroduodenoscopy; NS, not stated; SM, sodium morrhuate; STS, sodium tetradecyl sulfate; I, intravariceal; P, paravariceal. “Transient bacteremia in initial sessions was caused by contaminated water. *Additional BCX at 4 and 24 hours in 10 at 43 sessions. “Additional BCX at 20 hours for sclerotherapy patients.

December

1991

EVS group and the emergency EVS groups were performed on an emergency basis in an intensive care unit setting, whereas the elective EVS group had the procedure performed in more controlled circumstances. Compared with endoscopy alone, both the emergency and elective EVS groups had an additional potential source of bacteremia as a result of the introduction of microorganisms via the sclerotherapy needle or solution. Although a control group of patients undergoing emergency endoscopy for bleeding caused by varices that were not sclerosed would have provided additional relevant data, sclerotherapy is the standard therapy for variceal bleeding at our institution. Inherent in all studies using positive blood cultures is the difficulty of determining true bacteremia from contaminants (20-24); consequently, results in the current study are reported for both all positive blood cultures, as well as results specifically for significant positive blood cultures. The remaining positive cultures may have been caused by transient bacteremia, especially in the emergency settings in which patients had multiple IV catheterizations for fluid and blood replacement before endoscopy; however, one cannot rule out the possibility of contaminants. The studies of the incidence of bacteremia after upper endoscopy with sclerotherapy are conflicting, with reports ranging from 0% to 50% (12-18) (Table 4). Most previous data on bacteremia after sclerotherapy have been obtained from patients undergoing elective EVS. The microorganisms frequently isolated were alpha-hemolytic Streptococcus, Staphylococcus epidermis, and diphtheroids. The length of the needle injector (16) and a contaminated water supply (14) have been shown to be important in the incidence of EVS-associated bacteremia. In our study, finding of preendoscopic bacteremia in the sclerotherapy groups is consistent with the previously observed tendency of alcoholic cirrhotics to develop bacteremia (34-377, probably caused by multiple factors, including decreased reticuloendothelial system function, impaired neutrophil chemotaxis, low levels of serum complement, and impaired cellmediated immunity. No significant bacteremia caused by scierotherapy was observed in the elective EVS group, and no patients subsequently had infectious complications. Retrospective studies (38,39) of emergency EVS report a high incidence of bacteremia and infectious complications, but it is difficult to analyze the contribution of sclerotherapy to the incidence of infection. In our prospective study, the frequency of bacteremia after emergency EVS was similar to elective EVS, but there did seem to be infectious complications. Recommendations for antibiotic prophylaxis before endoscopy vary (40-44), and some consider prophy-

BACTEREMIA

IN SCLEROTHERAPY

164 7

laxis before endoscopy with. EVS to be routinely indicated. Most authorities recommend prophylaxis specifically for all patients with prosthetic valves or previous endocarditis; however, sclerotherapy patients usually do not have these risk factors. Based on our data, routine antibiotic prophylaxis for elective EVS is not justified. Routine prophylaxis for emergency endoscopy with possible EVS is not recommended, but physicians should be aware that a low risk of bacteremia does exist in this setting. It is essential to pay strict attention to routine equipment cleaning and disinfection to avoid contamination of endoscopes and the water supply. In conclusion, the present prospective controlled study provides data that there js a higher frequency of preendoscopic bacteremia in patients requiring emergency EVS than in patients who have emergency endoscopy alone for nonvariceal bleeding. However, we found no significant difference between the incidences of postendoscopic bacteremia in the emergency EVS group, the elective EVS group, and the emergency endoscopy without EVS group. The patients who had emergency EVS had more total episodes of significant bacteremia than patients who had elective EVS. The incidence of clinically significant postendoscopic bacteremia was l3%, but only 5.4% were potentially caused by emergency EVS. Although there was some postendoscopm bacteremia attributable to emergency EVS, there was none associated with elective EVS and none attributable to emergency endoscopy in patients with UC1 bleeding caused by nonvariceal sources.

References 1. Sivak MV. Esophageal varices. In: Sivak MV, ed. Gastroenterologic endoscopy. Philadelphia: Saunders, 1987:342-372. 2. Standards of Training and Practice Committee of the American Society for Gastrointestinal Endoscopy. The role of endoscopic sclerotherapy in the management of variceal bleeding: guidelines for clinical application. Gastrointest Endosc 1989;35:600601. 3. Terblanche J, Burroughs AK, Hobbs KEF. Controversies in the management of bleeding esophageal varices. N Engl J Med 1989;320:1393-1398,1469-1475. 4. Schuman BM, Beckman JW, Tedesco FJ, Griffin JW Jr, Assad RT. Complications of endoscopic injection sclerotherapy: a review. Am J Gastroenterol 1987;82:823-830. 5. Sanowski RA, Waring JP. Endoscopic techniques and complications in variceal sclerotherapy. J Clin Gastroenterol1987;9:504513. 6. Cohen FL, Koerner RS, Taub SJ. Solitary brain abscess following endoscopic injection sclerosis aof esophageal varices. Gastrointest Endosc1985;31:331-333. 7. Ritchie MT, Lightdale CJ, Botet JF’. Bilateral perinephric abscesses: a complication of endoscopic injection sclerotherapy. Am J Gastroenterol 1987;82:670-673. 8. Lai KH, Tsai YT, Lee SD. Spontaneous bacterial peritonitis after endoscopic variceal sclerotherapy (lett]. Gastrointest Endose 1986;32:303.

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9. Barn&t JL, Elta G. Bacterial peritonitis following endoscopic variceal sclerotherapy. Gastrointest Endosc 1987;33:316-317. 10. Tam F, Chow H, Prindiville T, Cornish II, Haulk T, Trudeau W, Hoeprich P. Bacterial peritonitis following esophageal injection sclerotherapy for variceal hemorrhage. Gastrointest Endose 1990;36:131-133. 11. Baskin G. Prosthetic endocarditis after endoscopic variceal sclerotherapy: a failure of antibiotic prophylaxis. Am J Gastroenter01 1989;84:311-312. 12. Cohen LB, Korsten MA, Scherl EJ, Velez ME, Fisse RD, Arons EJ. Bacteremia after endoscopic injection sclerosis. Gastrointest Endosc 1983;29:198-200. 13. Camara DS, Gruber M, Barde CJ, Montes M, Carvana JA Jr, Chung RS. Arch Intern Med 1983;143:1350-1352. 14. Brayko CM, Kozarek RA, Sanowski RA, Testa AW. Bacteremia during esophageal variceal sclerotherapy: its cause and prevention. Gastrointest Endosc 1985;31:10-12. 15. Sauerbruch T, Ho11 J, Ruckdeschel G, Forstl J, Weinzierl M. Bacteremia associated with endoscopic sclerotherapy of oesophageal varices. Endoscopy 1985;17:170-172. 16. Snady H, Korsten MA, Waye JD. The relationship of bacteremia to the length of injection needle in endoscopic variceal sclerotherapy. Gastrointest Endosc 1985;31:243-246. 17. Low DE, Shoenut JP, Kennedy JK, Harding GKM, Den Boer B, Micflikier AB. Infectious complications of endoscopic injection sclerotherapy. Arch Intern Med 1986;146:569-571. 18. Hegnhoj J, Andersen JR, Jarlov JO, Bendtsen F, Rasmussen HS. Bacteremia after injection sclerotherapy of oesophageal varices. Liver 1988;8:167-171. 19. Pugh RHN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 1973;60:646-649. 20. MacGregor RR, Beaty HN. Evaluation of positive blood cultures. Arch Intern Med 1972;130:84-87. 21. Wilson WR, Van Scoy RE, Washington JA II. Incidence of bacteremia in adults without infection. J Clin Microbial 1975;2: 94-95. 22. Weinstein MP, Reller LB, Murphy JR, Lichtenstein KA. The clinical significance of positive blood cultures: a comprehensive analysis of 500 episodes of bacteremia and fungemia in adults. I. Laboratory and epidemiologic observations. Rev Infect Dis 1983;5:35-53. 23. Allen SD. Clostridium. In: Lennett EH, Ballows H, Havoler WJ, Shadomy HJ, eds. Manual of clinical microbiology. Washington, D.C.: American Society for Microbiology, 1985:434-444. 24. Aronson MD, Bor DH. Blood cultures. Ann Intern Med 1987;106: 246-253. 25. Shull HJ Jr, Greene BM, Allen SD, Dunn GD, Schenker S. Bacteremia with upper gastrointestinal endoscopy. Ann Intern Med 1975;83:212-214. 26. Mellow MH, Lewis RL. Endoscopy-related bacteremia. Incidence of positive blood cultures after endoscopy of upper gastrointestinal tract. Arch Intern Med 1976;136:667-669. 27. Baltch AL, Buhac I, Agrawal A, O’Connor P, Bram M, Malatino E. Bacteremia after upper gastrointestinal endoscopy. Arch Intern Med 1977;137:594-597. 28. Stray N, Midtvedt T, Valnes K, Rosseland A, Pytte R, Hoivik B. Endoscopy-related bacteremia. Stand J Gastroenterol 1978;13: 345-347.

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29. O’Connor HJ, Hamilton I, Lincoln C, Maxwell S, Axon ATR. Bacteremia with upper gastrointestinal endoscopy-a reappraisal. Endoscopy 1983;15:21-23. 30. Liebermann TR. Bacteremia and fiberoptic endoscopy. Gastrointest Endosc 1976;23:36-37. 31. Kirk A, Graham-Brown R, Perinpanayagam RM, Smith RG, Barnard0 DE. Bacteremia and upper gastrointestinal fibreendoscopy. J R Sot Med 1979;72:409-411. 32. Norfleet RG, Mitchell PD, Mulholland DD, Philo J. Does bacteremia follow upper gastrointestinal endoscopy? Am J Gastroenterol 1981;76:420-422. 33. Zierdt CH. Evidence for transient Staphylococcus epidermidis bacteremia in patients and healthy humans. J Clin Microbial 1983;17:628-630. 34. Rimola A, Soto R, Bory F, Arroyo V, Piera C, Rodes J. Reticuloendothelial system phyagocytic activity in cirrhosis and its relation to bacterial infections and prognosis. Hepatology 1984;4:53-58. 35. Graudal N, Milman N, Kirkegaard E, Korner B, Thomsen AC. Bacteremia in cirrhosis of the liver. Liver 1986;6:297-301. 36. Wyke RJ. Problems of bacterial infection in patients with liver disease. Gut 1987;28:623-641. 37. Barnes PF, Arevalo C, Chan LS, Wong SF, Reynolds TB. A prospective evaluation of bacteremic patients with chronic liver disease. Hepatology 1988;8:1099-1103. 38. Gerhartz HH, Sauerbruch T, Weinzierl M, Ruckdeschel G. Nosocomial septicemia in patients undergoing sclerotherapy for variceal hemorrhage. Endoscopy 1984;16:129-130. 39. Crotty B, Wood LJ, Willet IR, Colman J, McCarthy P, Dudley FJ. The management of acutely bleeding varices by injection sclerotherapy. Med J Aust 1986;145:130-133. 40. Shulman ST, Amren DP, Bisno AL, Dajani AS, Durack DT, Gerber MA, Kaplan EL, Millard HD, Sanders WE, Schwartz RH, Watanakunakorn C. Prevention of bacterial endocarditis, a statement for health professionals by the Committee on Rheumatic Fever and Infective Endocarditis of the Council on Cardiovascular Disease in the Young. Circulation 1984;70: 1123A-1127A. 41. Standards of Training and Practice Committee of the American Society for Gastrointestinal Endoscopy. Infection control during endoscopy: guidelines for clinical application. Gastrointest Endosc 1988:34:373-40s. 42. Neu HC. Recommendations for antibiotic prophylaxis before endoscopy. Am J Gastroenterol1989;84:1488-1489. 43. Fleischer D. Recommendations for antibiotic prophylaxis before endoscopy. Am J Gastroenterol1989;84:1489-1491. 44. Meyer GW. Endocarditis prophylaxis and gastrointestinal procedures (editorial). Am J Gastroenterol1989;84:1492-1493.

Received August 16,199O. Accepted March 22,199l. Address requests for reprints to: Hoi Ho, M.D., Department

of Medicine, Texas Tech University Health Sciences Center, 4800 Alberta Avenue, El Paso, Texas 79905. The authors thank Dr. Stuart M. Polly for his advice, Guadalupe Rivera and Phyllis Chrestman for their contributions to the study, and Monica S. Gonzalez for her excellent secretarial assistance.