J. of Cardiovasc. Trans. Res. DOI 10.1007/s12265-014-9553-9
Is There a Need for Bacterial Endocarditis Prophylaxis in Patients Undergoing Gastrointestinal Endoscopy? Salvatore Patanè
Received: 12 February 2014 / Accepted: 14 February 2014 # Springer Science+Business Media New York 2014
Abstract Heart valve repair or replacement is a serious problem. Patients can benefit from an open dialogue between both cardiologists and gastroenterologists for the optimal effective patients care. The focused update on infective endocarditis of the American College of Cardiology/American Heart Association 2008 (ACC/AHA guidelines) and guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009) of the European Society of Cardiology (ESC guidelines) describe prophylaxis against infective endocarditis (IE) as not recommended for gastroscopy and colonoscopy in the absence of active infection but increasing evidence suggests that the role of IE antibiotic prophylaxis remains a dark side of the cardio-oncology prevention. New evidences concerning infective endocarditis due to Streptococcus bovis, Streptococcus agalactiae, Enterococcus faecalis, Enterococcus faecium, Enterococcus durans, and new findings indicate that there is a need for bacterial endocarditis prophylaxis in patients undergoing gastrointestinal endoscopy especially in elderly patients and in cancer and i m m u n oc o m p r om i s e d pa t i e nt s , t o av o i d s e r i ou s consequences. Keywords Antibiotic prophylaxis . Cardio-oncology . Infective endocarditis . Gastrointestinal endoscopy Heart valve repair or replacement is a serious problem [1–7]. Patients can benefit from an open dialogue between both cardiologists and gastroenterologists for the optimal effective patients care [8–13]. The focused update on infective endocarditis of the American College of Cardiology/American Editor-in-Chief Jennifer L. Hall oversaw the review of this article S. Patanè (*) Cardiologia Ospedale San Vincenzo - Taormina (Me) Azienda Sanitaria Provinciale di Messina, Contrada Sirina, 98039 Taormina, Messina, Italy e-mail: [email protected]
Heart Association 2008 (ACC/AHA guidelines) [14–16] and guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009) of the European Society of Cardiology (ESC guidelines)  describe prophylaxis against infective endocarditis (IE) as not recommended for gastroscopy and colonoscopy in the absence of active infection (class III recommendation) with level of evidence: B on ACC/AHA guidelines and level of evidence: C on ESC guidelines. ACC/AHA guidelines and ESC guidelines indicate an antibiotic regimen in the case of an infection or to prevent wound infection or sepsis in highest-risk patients [14–17] but increasing evidence suggests that the role of IE antibiotic prophylaxis remains a dark side of the cardiooncology prevention . Streptococcus bovis (S. bovis) is a large anaerobic Gram-positive bacterial complex including S. bovis biotype I (mannitol fermentation-positive) known as Streptococcus gallolyticus subsp. gallolyticus, S. bovis biotype II/1 (mannitol-negative and β-glucuronidase-negative) known as Streptococcus infantarius subsp. infantarius designated as Streptococcus lutetiensis, and S. bovis biotype II/2 (mannitol-negative and β-glucuronidase-positive) known as S. gallolyticus subsp. pasteurianus, commonly designated as Streptococcus pasteurianus [19, 20]. ESC guidelines 2009 describe S. bovis as a gastrointestinal source of infection and an increasingly frequent cause of IE, especially in the elderly . S. bovis IE is frequent in immunosuppressed individuals [19, 20] and it is strongly associated with gastrointestinal malignancy [20, 21] and colonic and non-colonic neoplasm (biliary and pancreatic or esophagus-gastric) . Moreover, S. bovis asymptomatic bacteremia is emerging as an occasional finding . Streptococcus sanguis can be similarly associated with gastrointestinal carcinoma and it can promote IE . Even Streptococcus agalactiae (group B Streptococci (GBS)) can colonize the gastrointestinal tract  or the blood of healthy asymptomatic individuals [25, 26] and it has been increasingly associated with invasive disease, including IE , mainly in the elderly, in immunocompromised and in
J. of Cardiovasc. Trans. Res.
diabetic and cancer patients [24, 25]. Enterococcal endocarditis by gastrointestinal tract commensals Enterococcus faecalis and Enterococcus faecium and Enterococcus durans has also been reported in immunocompromised patients . Guidelines from the American Society for Gastrointestinal Endoscopy and the American Heart Association describe routine gastrointestinal endoscopy as a low-risk procedure that doesn’t require the use of antibiotics for endocarditis prophylaxis in all cardiac conditions [28–30] and even recently, there are no specific changes for the use of prophylactic antibiotics in the elderly .The Endoscopy Committee of the British Society of Gastroenterology recommends antibiotic prophylaxis for patients with severe neutropenia (