Antibiotic Prophylaxis of Infective Endocarditis During Digestive Endoscopy: Over- and Underuse in Switzerland Despite Professed Adherence to Guidelines

Background and Study Aims: Guidelines for antibiotic prophylaxis of infective endocarditis associated with gastrointestinal endoscopy are not uniform. Though based on weak scientific evidence, they do represent an attempt to unify the management of antibiotic prophylaxis. We investigated whether physicians who profess to adhere to these guidelines actually do apply them correctly.
Materials and Methods: A questionnaire was sent to all 195 Swiss gastroenterologists asking whether they adhered to antibiotic prophylaxis guidelines and under what conditions did they apply antibiotic prophylaxis in gastrointestinal endoscopy. We analysed whether the Swiss gastroenterologists who claim to adhere to these guidelines actually do so in practice.

Results: The response rate to our questionnaire was 95 %. Of the Swiss gastroenterologists, 60 % correctly employ antibiotic prophylaxis guidelines in gastroscopy, as do 47 % in colonoscopy. In therapeutic endoscopy, the percentage of correct antibiotic prophylaxis use depends upon the type of intervention and varies between 21 and 58 %. Overuse of antibiotic prophylaxis is at least twice as frequent in colonoscopy and therapeutic endoscopy than in gastroscopy.
Conclusions: Guidelines for antibiotic prophylaxis are not well applied and do not lead to uniform management despite a high degree of professed adherence to them. This phenomenon can be explained by “cognitive dissonance” and “reactance.” We conclude that guidelines based on unconvincing data may even prove harmful.

References

• 1 Malinverni R, Francioli P, Gerber A. et al . Schweizerische Arbeitsgruppe für Endokarditisprophylaxe. Prophylaxe der bakteriellen Endokarditis.  Schweiz Med Wochenschr. 1984;  114 1246-1252
• 2 ASGE . Antibiotic prophylaxis for gastrointestinal endoscopy. American Society for Gastrointestinal Endoscopy.  Gastrointest Endosc. 1995;  42 (6) 630-635
• 3 Grol R, Dalhuijsen J, Thomas S. et al . Attributes of clinical guidelines that influence use of guidelines in general practice: observational study.  BMJ. 1998;  317 858-861
• 4 van der Meer J TM, van Wijk W. et al . Efficacy of antibiotic prophylaxis for prevention of native-valve endocarditis.  Lancet. 1992;  339 135-139
• 5 Leport C, Horstkotte D, Burckhartd D. Antibiotic prophylaxis for infective endocarditis from an international group of experts towards a European consensus.  Eur Heart J. 1995;  16 (Suppl B) 126-131
• 6 Durack D T, Phil D. Prevention of infective endocarditis.  N Engl J Med. 1995;  332 38-44
• 7 Dajani S A, Taubert K A, Wilson W. et al . Prevention of bacterial endocarditis: recommendations by the American Heart Association.  JAMA. 1997;  277 (22) 1794-1801
• 8 Shorvon P J, Eykyn S J, Cotton P B. Gastrointestinal instrumentation, bacteremia, and endocarditis.  Gut. 1983;  24 (11) 1078-1093
• 9 Neu H C, Fleischer D. Recommendations for antibiotic prophylaxis before endoscopy.  Am J Gastroenterol. 1989;  84 1488-1491
• 10 Zuckerman G R, O'Brien J, Halsted R. Antibiotics prophylaxis in patients with infectious risk factors undergoing gastrointestinal endoscopic procedures.  Gastrointest Endosc. 1994;  40 (5) 538-543
• 11 Schlaeffer F, Riesenberg K, Mikolich D. et al . Serious bacterial infections after endoscopic procedures.  Arch Intern Med. 1996;  156 (5) 572-574
• 12 Festinger L. A theory of cognitive dissonance. Evanston, Illinois; Row, Peterson 1957
• 13 Brehm J W. A theory of psychological reactance. New York; Academic Press 1966
• 14 Moreillon P. Endocarditis prophylaxis revisited: experimental evidence of efficacy and new Swiss recommendations.  Schweiz Med Wochenschr. 2000;  130 1013-1026