Bacteremia and fiberoptic endoscopy Thomas R. Liebermann, MD Temple, Texas
Blood samples for cultures were obtained before and at 10, 15, 20, and 30 minutes after instrumentation of the upper or lower gastrointestinal tract in 64 consecutive patients. Of 44 patients undergoing upper gastrointestinal endoscopy, only 1, with a narrowed gastric antrum, had a positive blood culture (at 10 minutes). Three blood cultures were positive from 20 patients undergoing colonoscopy (15%); bacteremia occurred with alpha-hemolytic streptococci. Upper gastrointestinal endoscopy does not carry an undue risk of bacteremia. Colonoscopy appears to carry a somewhat greater hazard.* It is recommended that patients receiving! immunosuppressant therapy ori who have valvular heart disease be protected by appropriate antibiotic therapy.
That transient bacteremia can be caused by instrumentation is well recognized. Such bacteremia has been described after urologic instrumentation,' dental extractions/,J and gum massage;' more recently, it has been reported after routine proctosigmoidoscopy with a frequency of 9%,57 and after barium enema with a frequency of 11.4%.8 The possibility of bacteremia in patients undergoing various fiberoptic endoscopic procedures leads to the question of antibiotic prophylaxis in some circumstances, such as in patients with valvular heart disease or in those receiving immunosuppressant therapy. Pseudomonas bacteremia in leukemic patients has been recently described 9 and was thought to be related to contaminated esophagoscopes. The present study was undertaken to determine the frequency of bacteremia during fiberoptic endoscopy. MATERIALS AND METHODS Sixty-four consecutive patients referred to the endoscopy service of the Scott and White Clinic were informed of the purpose of the study and their consent was obtained. After preparation ofthe skin with soap, alcohol, povidone-iodine (Betadine), and alcohol, blood samples for aerobic and anaerobic cultures lO were obtained at 0, 10, 15, 20, and 30 minutes; a late blood sample for culture also was obtained at 6 hours for outpatients and 24 hours for inpatients. Each set of blood samples was obtained by way of separate punctures. Before the blood (1 to 2 ml) was transferred to the culture tube (Becton-Dickinson, peptone yeast extract under 2% C02), the original needle was replaced with a new one, and the top of the tube was cleansed with povidone-iodine. One tube was vented; the other was not. The cultures were incubated at 37°C for 10 days. At 38 hours, each tube was recultured. At 10 days, Gram-stained smears were made from all apparently negative tubes. Positive cultures were identified and also Gram-stained. None of the patients was receiving antibiotics at the time of endoscopy or during the 72 hours before the procedure. Our routine procedure for cleansing the endoscope is as follows. The insertion tube is wiped with sterile gauze pads. The control section light guide tube plug and camera are wiped with gauze lightly dampened with 70% alcohol. The
rubber hood is removed, and the distal tip portion is cleansed with a cotton swab moistened with 70% alcohol. The lens also is cleansed with a cotton swab. One liter of soapy water is aspirated through the instrument to cleanse the biopsy channel. Then, the outside of the instrument is carefully cleansed with povidone-iodine. This procedure has been found to render both the gastroscope and the colonoscope sterile (cultures of moist swabs that had been passed over the surfaces were negative at 48 hours). RESULTS None of the patients had evidence of bacteremia before any of the endoscopic procedures. Of the 44 patients undergoing upper gastrointestinal endoscopy, 1 patient, with a narrowed gastric antrum, had a significant positive blood cu Iture (Streptococcus pneumoniae); th is was in the 10-minute sample. None of our early attempts at retrograde cholangiopancreatography was associated with a positive blood culture; however, we were unable to enterthe ampulla in any of these cases. After colonoscopy in 20 patients, 3 patients (15%) developed bacteremia with alpha-hemolytic streptococci (Table In 2 patients bacteremia was transient because a later blood culture was negative. In 1 patient, the 20-minute and 6-hour samples were positive; follow-up is not available for this patient. The difference in frequency of bacteremia batween the 2 groups (2% vs. 15%) is statistically significant (P < 0.05; chi-square test).
n.
Table 1.
Results of blood cultures at colonoscopy in 20 patients. diagnosis or indication Polypectomy
patients culture results (no.) 12 alpha-hemolytic streptococcus, 30 min; 1 patient 2 alpha-hemolytic streptococcus, Ulcerative 20 min; 1 patient proctosigmoiditis Negative Adenocarcinoma 1 Negative 2 Diverticu losis 3 alpha-hemolytic streptococcus, Normal 20 min & 6 h; 1 patient
From Scott and White Clinic, Temple, Texas. Reprint requests: Thomas R. Liebermann, MD, Scott and White Clinic, Temple, Texas 76501.
36
GASTROINTESTINAL ENDOSCOPY
Positive blood cultures growing Staphylococcus epidermidis and Propionibacterium species were considered to represent skin contaminants (15 among the 264 cultures on upper gastrointestinal endoscopy patients). DISCUSSION It is probably safe to state that upper gastrointestinal endoscopy is not associated with an increased frequency of bacteremia in the usual patient. It was thought that the trauma, especially of the pharynx, resulting from the passage of the fiberoptic 'scope, might induce bacteremia; however, this did not prove to be the case. Further work is needed to clarify the question of bacteremia after manipulation of the pancreatic ductor biliary tree because bacterial infection in an obstructed duct would appear to be a potential setting for the development of bacteremia. Colonoscopy, on the other hand, appears to carry a somewhat greater hazard of bacteremia, and special consideration to this matter is indicated when patients with valvular heart disease or those on an immunosuppressant regimen are examined. The transient nature of the bacteremia in these patients may be a reflection of the adequate removal of the bacteria by the reticuloendothelial system of the liver. Therefore, neither upper nor lower gastrointestinal endoscopy imposes an undue hazard for the average patient. Special precautions should be taken - and possibly these procedures should be avoidedin patients in whom the consequences of bacteremia might be serious.
REFERENCES 1. SLADE N: Bacteriaemia and septicaemia after urological operations. Proc R Soc Med 51:331,1958 2. COBE HM: Transitory bacteremia. Oral Surg, Oral Med & Oral Path 7:609, 1954 3. RICHARDS jH: Bacteremia following irritation of foci of infection. lAMA 99:1496, 1932 4. FELIX jE, ROSEN 5, App GR: Detection of bacteremia afterthe use of an oral irrigation device in subjects with periodontitis. Periodonto/42:785, 1971 5. LEFROCK jL, ELLIS CA, TURCHIK jB, WEINSTEIN L: Transient bacteremia associated with sigmoidoscopy. N Engl I Med 289:467,1973 6. BUCHMAN E, BERGLUND EM: Bacteremia following sigmoidoscopy. Am Heart I 60:863, 1960 7. UNTERMAN 0, MILBERG MB, KRANIS M: Evaluation of blood cultures after sigmoidoscopy. N Engl I Med 257:773,1957 8. LEFROCK jL, ELLIS CA, KLAINER AS, WEINSTEIN L: Transient bacteremia associated with barium enema. Arch Int Med 136:835, 1975 9. GREENE WH, MOODY M, HARTLEY R, EFFMAN E, AISNERj, YOUNG VM, WIERNIK PH: Esophagoscopy as a source of Pseudomonas aeruginosa sepsis in patients with acute leukemia: the need for sterilization of endoscopes. Gastroenterology 67:912, 1974 10. COWAN ST, STEEL Kj: Manual for the Identification of Medical Bacteria. Cambridge (England), Cambridge University Press, 1965
of special note Melanosis duodeni William M. Bisordi, MD Martin S. Kleinman, MD* University of Rochester School of Medicine and Dentistry and Gastroenterology Unit Strong Memorial Hospital Rochester, New York
The accumulation of black pigment in the colonic mucosa was first described in 1829' and has been extensively reviewed. 2 Melanin pigmentation has been classically described in the colon, but there are reports of pigment occurring in the appendix, mesenteric lymph nodes 3 , ileum', and possibly the esophagus. s We recently stud ied a patient who had the surprising finding of pigment deposition in the villi of the duodenal mucosa. A careful search of the world's literature failed to reveal a similar case. CASE REPORT A 43-year-old insulin-dependent diabetic black man with chronic renal failure was being treated by chronic dialysis at Strong Memorial Hospital. Gastroenterologic consultation was requested to evaluate intermittent episodes of abdominal pain suggestive of duodenal ulcer. At endoscopy (Olympus GIF-D2) no ulcer was seen. The duodenal bulb was friable. The folds were thickened, and a peculiar deposition of pigment in the duodenal mucosa was observed. The entire mucosa beyond the bulb in the second part of the duodenum had a "peppered" appearance. (Figure 1). Multiple biopsy specimens were taken. The esophagus and stomach were normal. The rectal mucosa showed no signs of melanosis coli by sigmoidoscopic examination. Barium contrast studies of the patient's stomach and duodenum were normal. The patient vigorously denied ingestion of cathartics such as cascara. His only medications were insulin and, occasionally, liquid aluminum hydroxide gel to lower the serum phosphate. The patient was given intensive antacid therapy with subsequent improvement of his pain. Sections of duodenal mucosa stained with hematoxylinand-eosin (Figure 1) disclosed pigment deposited in the tips of the villi. Specific staining methods confirmed this pigment as melanin. ·Reprint requests: Martin 5. Kleinman, MD, Strong Memorial Hospital, 601 Elmwood Avenue, Rochester, New York 14642.
Figure 1. Endoscopic photograph of the first portion of the duodenum (left). Note the peppered appearance of the duodenal mucosa. The bleeding was caused by biopsy. In this hematoxylin-and-eosin section (40x) of the duodenal mucosa (right), the arrow points to a collection of pigment just below the epithelial surface. VOLUME 23, NO.1, 1976
37
Blood samples for cultures were obtained before and at 10, 15, 20, and 30 minutes after instrumentation of the upper or lower gastrointestinal tract in 64 consecutive patients. Of 44 patients undergoing upper gastrointestinal endoscopy, only 1, with a narrowed gastric antrum, had a positive blood culture (at 10 minutes). Three blood cultures were positive from 20 patients undergoing colonoscopy (15%); bacteremia occurred with alpha-hemolytic streptococci. Upper gastrointestinal endoscopy does not carry an undue risk of bacteremia. Colonoscopy appears to carry a somewhat greater hazard.* It is recommended that patients receiving! immunosuppressant therapy ori who have valvular heart disease be protected by appropriate antibiotic therapy.
That transient bacteremia can be caused by instrumentation is well recognized. Such bacteremia has been described after urologic instrumentation,' dental extractions/,J and gum massage;' more recently, it has been reported after routine proctosigmoidoscopy with a frequency of 9%,57 and after barium enema with a frequency of 11.4%.8 The possibility of bacteremia in patients undergoing various fiberoptic endoscopic procedures leads to the question of antibiotic prophylaxis in some circumstances, such as in patients with valvular heart disease or in those receiving immunosuppressant therapy. Pseudomonas bacteremia in leukemic patients has been recently described 9 and was thought to be related to contaminated esophagoscopes. The present study was undertaken to determine the frequency of bacteremia during fiberoptic endoscopy. MATERIALS AND METHODS Sixty-four consecutive patients referred to the endoscopy service of the Scott and White Clinic were informed of the purpose of the study and their consent was obtained. After preparation ofthe skin with soap, alcohol, povidone-iodine (Betadine), and alcohol, blood samples for aerobic and anaerobic cultures lO were obtained at 0, 10, 15, 20, and 30 minutes; a late blood sample for culture also was obtained at 6 hours for outpatients and 24 hours for inpatients. Each set of blood samples was obtained by way of separate punctures. Before the blood (1 to 2 ml) was transferred to the culture tube (Becton-Dickinson, peptone yeast extract under 2% C02), the original needle was replaced with a new one, and the top of the tube was cleansed with povidone-iodine. One tube was vented; the other was not. The cultures were incubated at 37°C for 10 days. At 38 hours, each tube was recultured. At 10 days, Gram-stained smears were made from all apparently negative tubes. Positive cultures were identified and also Gram-stained. None of the patients was receiving antibiotics at the time of endoscopy or during the 72 hours before the procedure. Our routine procedure for cleansing the endoscope is as follows. The insertion tube is wiped with sterile gauze pads. The control section light guide tube plug and camera are wiped with gauze lightly dampened with 70% alcohol. The
rubber hood is removed, and the distal tip portion is cleansed with a cotton swab moistened with 70% alcohol. The lens also is cleansed with a cotton swab. One liter of soapy water is aspirated through the instrument to cleanse the biopsy channel. Then, the outside of the instrument is carefully cleansed with povidone-iodine. This procedure has been found to render both the gastroscope and the colonoscope sterile (cultures of moist swabs that had been passed over the surfaces were negative at 48 hours). RESULTS None of the patients had evidence of bacteremia before any of the endoscopic procedures. Of the 44 patients undergoing upper gastrointestinal endoscopy, 1 patient, with a narrowed gastric antrum, had a significant positive blood cu Iture (Streptococcus pneumoniae); th is was in the 10-minute sample. None of our early attempts at retrograde cholangiopancreatography was associated with a positive blood culture; however, we were unable to enterthe ampulla in any of these cases. After colonoscopy in 20 patients, 3 patients (15%) developed bacteremia with alpha-hemolytic streptococci (Table In 2 patients bacteremia was transient because a later blood culture was negative. In 1 patient, the 20-minute and 6-hour samples were positive; follow-up is not available for this patient. The difference in frequency of bacteremia batween the 2 groups (2% vs. 15%) is statistically significant (P < 0.05; chi-square test).
n.
Table 1.
Results of blood cultures at colonoscopy in 20 patients. diagnosis or indication Polypectomy
patients culture results (no.) 12 alpha-hemolytic streptococcus, 30 min; 1 patient 2 alpha-hemolytic streptococcus, Ulcerative 20 min; 1 patient proctosigmoiditis Negative Adenocarcinoma 1 Negative 2 Diverticu losis 3 alpha-hemolytic streptococcus, Normal 20 min & 6 h; 1 patient
From Scott and White Clinic, Temple, Texas. Reprint requests: Thomas R. Liebermann, MD, Scott and White Clinic, Temple, Texas 76501.
36
GASTROINTESTINAL ENDOSCOPY
Positive blood cultures growing Staphylococcus epidermidis and Propionibacterium species were considered to represent skin contaminants (15 among the 264 cultures on upper gastrointestinal endoscopy patients). DISCUSSION It is probably safe to state that upper gastrointestinal endoscopy is not associated with an increased frequency of bacteremia in the usual patient. It was thought that the trauma, especially of the pharynx, resulting from the passage of the fiberoptic 'scope, might induce bacteremia; however, this did not prove to be the case. Further work is needed to clarify the question of bacteremia after manipulation of the pancreatic ductor biliary tree because bacterial infection in an obstructed duct would appear to be a potential setting for the development of bacteremia. Colonoscopy, on the other hand, appears to carry a somewhat greater hazard of bacteremia, and special consideration to this matter is indicated when patients with valvular heart disease or those on an immunosuppressant regimen are examined. The transient nature of the bacteremia in these patients may be a reflection of the adequate removal of the bacteria by the reticuloendothelial system of the liver. Therefore, neither upper nor lower gastrointestinal endoscopy imposes an undue hazard for the average patient. Special precautions should be taken - and possibly these procedures should be avoidedin patients in whom the consequences of bacteremia might be serious.
REFERENCES 1. SLADE N: Bacteriaemia and septicaemia after urological operations. Proc R Soc Med 51:331,1958 2. COBE HM: Transitory bacteremia. Oral Surg, Oral Med & Oral Path 7:609, 1954 3. RICHARDS jH: Bacteremia following irritation of foci of infection. lAMA 99:1496, 1932 4. FELIX jE, ROSEN 5, App GR: Detection of bacteremia afterthe use of an oral irrigation device in subjects with periodontitis. Periodonto/42:785, 1971 5. LEFROCK jL, ELLIS CA, TURCHIK jB, WEINSTEIN L: Transient bacteremia associated with sigmoidoscopy. N Engl I Med 289:467,1973 6. BUCHMAN E, BERGLUND EM: Bacteremia following sigmoidoscopy. Am Heart I 60:863, 1960 7. UNTERMAN 0, MILBERG MB, KRANIS M: Evaluation of blood cultures after sigmoidoscopy. N Engl I Med 257:773,1957 8. LEFROCK jL, ELLIS CA, KLAINER AS, WEINSTEIN L: Transient bacteremia associated with barium enema. Arch Int Med 136:835, 1975 9. GREENE WH, MOODY M, HARTLEY R, EFFMAN E, AISNERj, YOUNG VM, WIERNIK PH: Esophagoscopy as a source of Pseudomonas aeruginosa sepsis in patients with acute leukemia: the need for sterilization of endoscopes. Gastroenterology 67:912, 1974 10. COWAN ST, STEEL Kj: Manual for the Identification of Medical Bacteria. Cambridge (England), Cambridge University Press, 1965
of special note Melanosis duodeni William M. Bisordi, MD Martin S. Kleinman, MD* University of Rochester School of Medicine and Dentistry and Gastroenterology Unit Strong Memorial Hospital Rochester, New York
The accumulation of black pigment in the colonic mucosa was first described in 1829' and has been extensively reviewed. 2 Melanin pigmentation has been classically described in the colon, but there are reports of pigment occurring in the appendix, mesenteric lymph nodes 3 , ileum', and possibly the esophagus. s We recently stud ied a patient who had the surprising finding of pigment deposition in the villi of the duodenal mucosa. A careful search of the world's literature failed to reveal a similar case. CASE REPORT A 43-year-old insulin-dependent diabetic black man with chronic renal failure was being treated by chronic dialysis at Strong Memorial Hospital. Gastroenterologic consultation was requested to evaluate intermittent episodes of abdominal pain suggestive of duodenal ulcer. At endoscopy (Olympus GIF-D2) no ulcer was seen. The duodenal bulb was friable. The folds were thickened, and a peculiar deposition of pigment in the duodenal mucosa was observed. The entire mucosa beyond the bulb in the second part of the duodenum had a "peppered" appearance. (Figure 1). Multiple biopsy specimens were taken. The esophagus and stomach were normal. The rectal mucosa showed no signs of melanosis coli by sigmoidoscopic examination. Barium contrast studies of the patient's stomach and duodenum were normal. The patient vigorously denied ingestion of cathartics such as cascara. His only medications were insulin and, occasionally, liquid aluminum hydroxide gel to lower the serum phosphate. The patient was given intensive antacid therapy with subsequent improvement of his pain. Sections of duodenal mucosa stained with hematoxylinand-eosin (Figure 1) disclosed pigment deposited in the tips of the villi. Specific staining methods confirmed this pigment as melanin. ·Reprint requests: Martin 5. Kleinman, MD, Strong Memorial Hospital, 601 Elmwood Avenue, Rochester, New York 14642.
Figure 1. Endoscopic photograph of the first portion of the duodenum (left). Note the peppered appearance of the duodenal mucosa. The bleeding was caused by biopsy. In this hematoxylin-and-eosin section (40x) of the duodenal mucosa (right), the arrow points to a collection of pigment just below the epithelial surface. VOLUME 23, NO.1, 1976
37
