The occurrence of bacteremia after esophageal dilation David R. Raines, MD, MAJ, MC Honolulu, Hawaii
William C. Branche, PhD Daniel L. Anderson, MD H. Worth Boyce Jr, MD, COL, MC Washington, D.C.
Asymptomatic bacteremia occurs commonly after esophageal dilation. The source of the bacteremia appears to be contaminated dilators and not commensal organisms in the oropharynx. This bacteremia could be clinically important in susceptible individuals. Bacteremia can be prevented by proper cleansing of esophageal dilators immediately before use. Esophageal dilation is a commonly employed technique that is associated with low morbidity and mortality. Mercury-filled rubber dilators with either a tapered tip (Maloney) or a bluntrounded tip (Hurst) can be used in most situations. In the presence of advanced mechanical obstruction, Eder-Puestow dilators can be passed over a guide wire. Over 5000 such dilations have been performed by the gastroenterology service at the Walter Reed Army Medical Center in the past 5 years. During this time only 3 esophageal perforations have occurred, and none was fatal. Occasionally, patients have complained of chi lis and transient temperature elevations not requiring therapy. These patients have had no evidence of esophageal perforation. The possibility that transient bacteremia produced these problems was considered. This study was designed to determine the frequency of bacteremia after esophageal dilation.
PATIENTS AND METHODS Eighteen patients were included in the initial study. Nine were dilated for peptic stricture,S for carcinoma of the esophagus, and 4 for a motor disorder. Eight patients were dilated for the first time, and 10 had had previous dilations. Five patients had 2 successive dilations, and 13 had a single dilation. Fourteen patients were included in the second portion ofthe study in which sterilized dilators were used. Ten were dilated for peptic stricture, 2 for carcinoma and 2 for a motor disorder. Three of these patients were dilated for the first time, and 11 had had previous dilations. All 14 patients had only 1 dilation previous to blood culture.
Throat cultures were obtained previous to a tetracaine gargle. Blood culture was obtained immediately before dilation through a 19-9auge butterfly needle inserted after the skin was prepared with 7.5% povidone-iodine (Betadine). Oneto 2 ml of blood were removed for the culture, and the needle was flushed with heparin. The esophagus was then dilated, and blood cultures were obtained immediately after and at 5, 10, 15, and 30 minutes after dilation. Each blood sample was cu Itured on blood agar incubated aerobically, under C02, and anaerobically. Each sample was also inoculated into trypticase soy broth. Cultures were observed for 7 days. The dilators were routinely cleansed with 7.5% povidone-iodine after each use. They were hung in the open air on a wall-mounted rack in an active endoscopy room and were not routinely cleansed immediately before the next dilation. In the second portion of the study, 8 patients were dilated with sterilized dilators. The dilators were scrubbed with 7.5% povidone-iodine for the following periods: in 2 cases for 5 minutes, in 2 cases for 4 minutes, in 2 cases for 3 minutes, and in 1 case for 2 minutes. For the eighth case, a gas sterilized dilator was used. Following the scrub, the dilators were placed on a sterile barrier drape before use. Sterigel® was used to lubricate the dilator, and the physician wore sterile gloves. In order to determine the minimum preparation needed to eliminate bacteremia, each dilator was scrubbed at different times with povidone-iodine for 15, 30,45,50 and 90 seconds. They were then cultured in the same medium as the blood had been cultured. Thirty seconds of preparation with 7.5% povidoneiodine was the minimum time required for sterilization. Two patients were dilated after a 15-second scrub, and four patients were dilated after a 3D-second scrub.
From the Gastroenterology Service, Walter Reed Army Medical Center, and the Department of Diagnostic Bacteriology, Walter Reed Army Institute of Research, Washington, D.C. Reprint requests: David R. Raines, MD, MAl, Me, Gastroenterology Service, Tripier Army Medical Center, APO San Francisco 96438. 86
GASTROINTESTINAL ENDOSCOPY
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Figure 1. Numbers of patients found with bacteremia according time of sampling after esophageal dilation.
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RESULTS Of the 18 patients included in the initial study, all had negative predilation blood cultures, and all developed bacteremia following dilation. Thirteen of 18 patients had positive blood cultures immediately after dilation; 17 of 18 had at least 1 positive culture within 5 minutes. The incidence of bacteremia was less at 10 and 15 minutes postdilation, but 4 patients were still positive at 30 minutes (Figure 1). The organisms cultured were S. epidermidis, S. aureus, and B. subtilis. Eight patients had a single organism and 10 had multiple organisms cultured from their blood. The organisms obtained in the throat cultures before dilation did not correlate with the organisms recovered from the blood. Only 3 of 10 patients with S. aureus in the blood had a positive throat culture for S. aureus. No patient with positive blood cultures for S. epidermidis or B. subtilis had these organisms recovered from the throat. These results suggested that the dilators themselves might be the source of the organisms. Concomitant culture of the dilators during the initial study had not been done. Six dilators were then cultured and yielded S. aureus (3 of 5), S. epidermidis (4 of 6), and B. subtilis (4 of 6). The organisms cultured from these dilators were the same as those obtained from the blood following dilation. The inference that the organisms were carried by the dilators is further supported by the fact that mannitol-negative, coagulase-positive S. aureus organisms were present on the dilators and were also present in 7 of the 10 blood cultures which were positive for S. aureus. This correlation between the organisms recovered from the dilators and blood culture is significant since 90% of all S. aureus are mannitol-positive' and serve as a useful marker. No patient developed bacteremia after the use of a gassterilized dilator or dilators which had been scrubbed with 7.5% povidone-iodine for 5, 4, 3, and 2 minutes. Both patients VOLUME 22, NO.2, 1975
dilated after a 15-second povidone-iodine scrub developed bacteremia. The 4 patients who were dilated after a 3D-second scrub did not develop bacteremia. DISCUSSION The occurrence of bacteremia following a variety of manipulative procedures is well documented. Metastatic abscess has been reported following a retrograde esophageal dilation.' Bacteremia commonly occurs after dental manipulation. 3,4 Other gastrointestinal techniques such as proctosigmoidoscopys and biopsy8,9 have been associated with transient bacteremia. Two cases of pseudomonas septicemia after fiberoptic endoscopy with esophageal biopsy have been reported. lo Bacteremia following urologic instrumentation is also well known, the organisms usually being introduced through contaminated water used for lavage.None of the patients in our study complained of fever or chills, and none developed clinical evidence of bacteremia. While the bacteremia induced in our patients was not clinically significant, it cannot be ignored, inasmuch as certain individuals may be more susceptible to septic complications. Esophageal dilation, in most instances, probably results in breaks in the esophageal mucosa. In this respect, it might be compared with the biopsy procedures that have been reported to be associated with bacteremia. Patients receiving immunosuppressive drugs are more susceptible to infection and have developed septicemia following esophageal biopsy and brushing through a contaminated endoscope. 'o Patients with diabetes mellitus or those receiving steroids also are regarded as at increased risk. Antibiotic prophylaxis for bacterial endocarditis should be considered in these patients as well as in patients with a history of rheumatic fever and evidence of valvular heart disease. Since no bacteremia occurred after a 3D-second cleansing of the dilator, it appears that the only precaution necessary in high-risk patients is a thorough cleansing of the dilator(s) with 7.5% povidone-iodine solution for at least 30 seconds.
ACKNOWLEDGMENT The authors wish to express their appreciation to Miss Julia Annony for her typing and secretarial assistance in the preparation of this manuscript.
REFERENCES 1. COHEN JO: The Staphylococci. New York, John Wiley and Sons, Inc., pp 7-13, 1972 2. ROTAL E, MEYERHOFF W, DUVALL A: Metastatic abscess as a compl ication of retrograde esophageal dilatation. Ann Otol 82:643, 1973 3. BERRY FA, YARBOUGH 5, YARBOUGH N, RUSSEL C, CARPENTER M, HENDLEY J: Transient bacteremia during dental manipulation in children. Pediatrics 51 :476, 1973 4. BERGER SA, WEITZMAN 5, EDBERG 5, CASEY JI: Bacteremia after the use of an oral irrigation device. Ann Intern Med 80:510, 1974 5. LEFROCK JL, ELLIS CA, TURCHIK JB, WEINSTEIN L: Transient bacteremia associated with sigmoidoscopy. N Engl J Med 289:467, 1973 6. LAL D, LEVITAN R: Bacteremia following proctoscopic biopsy of a rectal polyp. Arch Intern Med, 180:127, 1972 7. MCCLOSKEY RV, GOLD M, WESER E: Bacteremia after liver biopsy. Arch Intern Med 132:213, 1973 8. MAINQUET P, BUTZLER )P, STERNON J: Septicemia following peroral biopsy of the small intestine. Endoscopy 6:140, 197; 9. PETTY AM, WENGER J: Bacteremia following peroral biopsy of the small intestine. Gastroenterology 59: 140, 1970 10. GREENE WH, MOODY M, HARTLEY R, EFFMAN E, AISNER J, 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
87
William C. Branche, PhD Daniel L. Anderson, MD H. Worth Boyce Jr, MD, COL, MC Washington, D.C.
Asymptomatic bacteremia occurs commonly after esophageal dilation. The source of the bacteremia appears to be contaminated dilators and not commensal organisms in the oropharynx. This bacteremia could be clinically important in susceptible individuals. Bacteremia can be prevented by proper cleansing of esophageal dilators immediately before use. Esophageal dilation is a commonly employed technique that is associated with low morbidity and mortality. Mercury-filled rubber dilators with either a tapered tip (Maloney) or a bluntrounded tip (Hurst) can be used in most situations. In the presence of advanced mechanical obstruction, Eder-Puestow dilators can be passed over a guide wire. Over 5000 such dilations have been performed by the gastroenterology service at the Walter Reed Army Medical Center in the past 5 years. During this time only 3 esophageal perforations have occurred, and none was fatal. Occasionally, patients have complained of chi lis and transient temperature elevations not requiring therapy. These patients have had no evidence of esophageal perforation. The possibility that transient bacteremia produced these problems was considered. This study was designed to determine the frequency of bacteremia after esophageal dilation.
PATIENTS AND METHODS Eighteen patients were included in the initial study. Nine were dilated for peptic stricture,S for carcinoma of the esophagus, and 4 for a motor disorder. Eight patients were dilated for the first time, and 10 had had previous dilations. Five patients had 2 successive dilations, and 13 had a single dilation. Fourteen patients were included in the second portion ofthe study in which sterilized dilators were used. Ten were dilated for peptic stricture, 2 for carcinoma and 2 for a motor disorder. Three of these patients were dilated for the first time, and 11 had had previous dilations. All 14 patients had only 1 dilation previous to blood culture.
Throat cultures were obtained previous to a tetracaine gargle. Blood culture was obtained immediately before dilation through a 19-9auge butterfly needle inserted after the skin was prepared with 7.5% povidone-iodine (Betadine). Oneto 2 ml of blood were removed for the culture, and the needle was flushed with heparin. The esophagus was then dilated, and blood cultures were obtained immediately after and at 5, 10, 15, and 30 minutes after dilation. Each blood sample was cu Itured on blood agar incubated aerobically, under C02, and anaerobically. Each sample was also inoculated into trypticase soy broth. Cultures were observed for 7 days. The dilators were routinely cleansed with 7.5% povidone-iodine after each use. They were hung in the open air on a wall-mounted rack in an active endoscopy room and were not routinely cleansed immediately before the next dilation. In the second portion of the study, 8 patients were dilated with sterilized dilators. The dilators were scrubbed with 7.5% povidone-iodine for the following periods: in 2 cases for 5 minutes, in 2 cases for 4 minutes, in 2 cases for 3 minutes, and in 1 case for 2 minutes. For the eighth case, a gas sterilized dilator was used. Following the scrub, the dilators were placed on a sterile barrier drape before use. Sterigel® was used to lubricate the dilator, and the physician wore sterile gloves. In order to determine the minimum preparation needed to eliminate bacteremia, each dilator was scrubbed at different times with povidone-iodine for 15, 30,45,50 and 90 seconds. They were then cultured in the same medium as the blood had been cultured. Thirty seconds of preparation with 7.5% povidoneiodine was the minimum time required for sterilization. Two patients were dilated after a 15-second scrub, and four patients were dilated after a 3D-second scrub.
From the Gastroenterology Service, Walter Reed Army Medical Center, and the Department of Diagnostic Bacteriology, Walter Reed Army Institute of Research, Washington, D.C. Reprint requests: David R. Raines, MD, MAl, Me, Gastroenterology Service, Tripier Army Medical Center, APO San Francisco 96438. 86
GASTROINTESTINAL ENDOSCOPY
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-
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-
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Figure 1. Numbers of patients found with bacteremia according time of sampling after esophageal dilation.
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RESULTS Of the 18 patients included in the initial study, all had negative predilation blood cultures, and all developed bacteremia following dilation. Thirteen of 18 patients had positive blood cultures immediately after dilation; 17 of 18 had at least 1 positive culture within 5 minutes. The incidence of bacteremia was less at 10 and 15 minutes postdilation, but 4 patients were still positive at 30 minutes (Figure 1). The organisms cultured were S. epidermidis, S. aureus, and B. subtilis. Eight patients had a single organism and 10 had multiple organisms cultured from their blood. The organisms obtained in the throat cultures before dilation did not correlate with the organisms recovered from the blood. Only 3 of 10 patients with S. aureus in the blood had a positive throat culture for S. aureus. No patient with positive blood cultures for S. epidermidis or B. subtilis had these organisms recovered from the throat. These results suggested that the dilators themselves might be the source of the organisms. Concomitant culture of the dilators during the initial study had not been done. Six dilators were then cultured and yielded S. aureus (3 of 5), S. epidermidis (4 of 6), and B. subtilis (4 of 6). The organisms cultured from these dilators were the same as those obtained from the blood following dilation. The inference that the organisms were carried by the dilators is further supported by the fact that mannitol-negative, coagulase-positive S. aureus organisms were present on the dilators and were also present in 7 of the 10 blood cultures which were positive for S. aureus. This correlation between the organisms recovered from the dilators and blood culture is significant since 90% of all S. aureus are mannitol-positive' and serve as a useful marker. No patient developed bacteremia after the use of a gassterilized dilator or dilators which had been scrubbed with 7.5% povidone-iodine for 5, 4, 3, and 2 minutes. Both patients VOLUME 22, NO.2, 1975
dilated after a 15-second povidone-iodine scrub developed bacteremia. The 4 patients who were dilated after a 3D-second scrub did not develop bacteremia. DISCUSSION The occurrence of bacteremia following a variety of manipulative procedures is well documented. Metastatic abscess has been reported following a retrograde esophageal dilation.' Bacteremia commonly occurs after dental manipulation. 3,4 Other gastrointestinal techniques such as proctosigmoidoscopys and biopsy8,9 have been associated with transient bacteremia. Two cases of pseudomonas septicemia after fiberoptic endoscopy with esophageal biopsy have been reported. lo Bacteremia following urologic instrumentation is also well known, the organisms usually being introduced through contaminated water used for lavage.None of the patients in our study complained of fever or chills, and none developed clinical evidence of bacteremia. While the bacteremia induced in our patients was not clinically significant, it cannot be ignored, inasmuch as certain individuals may be more susceptible to septic complications. Esophageal dilation, in most instances, probably results in breaks in the esophageal mucosa. In this respect, it might be compared with the biopsy procedures that have been reported to be associated with bacteremia. Patients receiving immunosuppressive drugs are more susceptible to infection and have developed septicemia following esophageal biopsy and brushing through a contaminated endoscope. 'o Patients with diabetes mellitus or those receiving steroids also are regarded as at increased risk. Antibiotic prophylaxis for bacterial endocarditis should be considered in these patients as well as in patients with a history of rheumatic fever and evidence of valvular heart disease. Since no bacteremia occurred after a 3D-second cleansing of the dilator, it appears that the only precaution necessary in high-risk patients is a thorough cleansing of the dilator(s) with 7.5% povidone-iodine solution for at least 30 seconds.
ACKNOWLEDGMENT The authors wish to express their appreciation to Miss Julia Annony for her typing and secretarial assistance in the preparation of this manuscript.
REFERENCES 1. COHEN JO: The Staphylococci. New York, John Wiley and Sons, Inc., pp 7-13, 1972 2. ROTAL E, MEYERHOFF W, DUVALL A: Metastatic abscess as a compl ication of retrograde esophageal dilatation. Ann Otol 82:643, 1973 3. BERRY FA, YARBOUGH 5, YARBOUGH N, RUSSEL C, CARPENTER M, HENDLEY J: Transient bacteremia during dental manipulation in children. Pediatrics 51 :476, 1973 4. BERGER SA, WEITZMAN 5, EDBERG 5, CASEY JI: Bacteremia after the use of an oral irrigation device. Ann Intern Med 80:510, 1974 5. LEFROCK JL, ELLIS CA, TURCHIK JB, WEINSTEIN L: Transient bacteremia associated with sigmoidoscopy. N Engl J Med 289:467, 1973 6. LAL D, LEVITAN R: Bacteremia following proctoscopic biopsy of a rectal polyp. Arch Intern Med, 180:127, 1972 7. MCCLOSKEY RV, GOLD M, WESER E: Bacteremia after liver biopsy. Arch Intern Med 132:213, 1973 8. MAINQUET P, BUTZLER )P, STERNON J: Septicemia following peroral biopsy of the small intestine. Endoscopy 6:140, 197; 9. PETTY AM, WENGER J: Bacteremia following peroral biopsy of the small intestine. Gastroenterology 59: 140, 1970 10. GREENE WH, MOODY M, HARTLEY R, EFFMAN E, AISNER J, 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
87
