1.1 In recent years several prominent bodies both in the UK and the USA have issued advice regarding antibiotic prophylaxis prior to barium enema in certain groups of patients.(1-3) Some of this advice has been quite specific in respect of the suggested antibiotic prophylaxis and the patients at high risk,(1,2) whilst other advice has been more vague. Two studies performed in 1988 and 1996 demonstrated that these guidelines have only been adopted in a small proportion of Radiology Departments in the United Kingdom.(4,5)

1.2 A summary of the recommendations issued by the British Society of Antimicrobial Chemotherapy (BSAC) (1,2) and modified slightly to incorporate the British Society of Gastroenterology (BSG) endoscopy guidelines (6) is set out below.

2 SUMMARY OF RECOMMENDATIONS

2.1 Antibiotic prophlyaxis should be given prior to barium enema to patients at especially high risk of developing endocarditis. These are patients with prosthetic heart valves, a previous history of endocarditis, or a surgically constructed systemic pulmonary shunt or conduit.

2.2 These guidelines do not apply to patients with damaged native valves or heart murmurs.

3 RECOMMENDED ANTIBIOTICS

3.1 Adults

3.1.1 Not allergic to penicillins

  	Amoxycillin 1 g	 		]	intravenously 15 mins
	plus gentamicin 120 mg		]	prior to procedure
	followed by amoxycillin 500 mg
	orally 6 hours later		

3.1.2 Patients allergic to penicillins or who have had a penicillin more than once in previous month.
Vancomycin 1 g by slow intravenous infusion over 100 min plus gentamicin 120 mg intravenously immediately prior to start of procedure

OR

Teicoplanin 400 mg intravenously
plus gentamicin 120 mg immediately prior to start of procedure

3.2 Children (<10 years)

3.2.1 Not allergic to penicillins

	Amoxycillin 500 mg IV as above

	plus gentamicin 2 mg/kg body weight]

	followed by amoxycillin orally 6 hours later
	5-9 years 250 mg
	0-4 years 125 mg

3.2.2 Allergic to penicillins Vancomycin 20 mg/kg by slow IV infusion over 100 minutes followed by gentamicin 2 mg/kg IV immediately prior to start of procedure OR Teicoplanin 6 mg/kg IV followed by gentamicin 2 mg/kg IV immediately prior to start of procedure

4. EVIDENCE SUPPORTING THE RECOMMENDATIONS

4.1 Bacteraemia may occur following barium enema, although the reported incidence varies from 0-23%.(6-9)

4.2 Organisms normally resident in the bowel have been shown to be causative organisms in a proportion of cases of endocarditis.(10)

4.3 Mortality from endocarditis in high risk patients is significant: reported mortality varying from 23%-53%. (11, 12)

4.4 An extensive literature search has found no proven published cases of endocarditis following barium enema in the English language literature. Similarly, no published evidence has been found which indicates that antibiotic prophylaxis given in conjunction with a barium enema will be successful in preventing infective endocarditis.

5. CONCLUSION

5.1 Despite the position outlined in section 4.4 above, the College cannot ignore the clear advice being given by the British Society of Antimicrobial Chemotherapy and the British Society of Gastroenterology that patients with prosthetic heart valves, a previous history of endocarditis or a surgically constructed systemic pulmonary shunt or conduit who undergo a barium enema examination should have antibiotic prophylaxis as indicated above.

5.2 This advice is influenced by the significant morbidity and mortality which occurs in patients with endocarditis.

5.3 As a consequence the College advises that the recommendations in this document be adopted.

Professor Jamie Weir
Dean
Faculty of Clinical Radiology

Approved by the Board of

Faculty of Clinical Radiology:	9th July 1999

Approved by Council:		30th July 1999


BFCR(99)7
References