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Bacteremia following sigmoidoscopy
Bacteremis
Following
Elwood Buchman,
M.D.,*
Sigmoidoscopy and Earl M. Berglund,
B.S.,**
IoozeraCity, Iowa
Bacteremia is known to follow dental extractions, many surgical procedures, and irritation of foci of infection .rmz3An excellent review of the bacteremia which follows instrumentation has been written by Nissen.lQ In a preliminary study by Unterman and associates,“r in only one instance in a series of 50 patients was a case of bacteremia found that may have been induced by sigmoidoscopy. Our interest was to explore further the possibility of sigmoidoscopy leading to transient bacteremia. If such a case of bacteremia truly occurred, there would be an excellent basis for antibiotic prophylaxis in an effort to prevent bacterial endocarditis in patients with valvular heart disease. METHOD
A sigmoidoscopic examination was performed on 100 patients who were on the Medical Service for the usual indication of the procedure. Patients who were, or had been, on antibacterial drugs within 2 weeks of sigmoidoscopy were excluded from the study. The sigmoidoscope was inserted its full length (25 centimeters or 10 inches) or nearly so in all patients. The antecubital areas of the patients’ arms were vigorously prepared with a cotton sponge saturated with 70 per cent alcohol. Approximately 5 ml. of blood were aspirated from the antecubital veins and aseptically deposited in 60 ml. of heart-infusion broth which contained traces of cystine and p-aminobenzoic acid and 0.1 per cent agar. The cultures were incubated at 37.5”C. in a 10 per cent atmosphere of carbon dioxide. They were examined daily for a period of 10 days, at the end of which time they were reported to be negative if no growth had appeared. Cultures nith growth were transferred to appropriate media for definitive identification of organisms. The specimens of blood were collected from each arm immediately hefore, immediately after. and 15 minutes after sigmoidoscopy. RESIwY,TS
In 87 of the 100 patients, blood cultures from both arms were negative before, immediately after, and 15 minutes after sigmoidoscopy. Blood cultures in 13 additional patients showed no growth in blood taken from one arm, but From the Medical Service and the Laboratory Service, Veterans Administration Hospital, Department of Internal Medicine, State rniversity of Iowa College of Medicine, Iowa City. Received for publication June 2. 1960. *Assistant Chief, Medical Service, Veterans .4dminlstratiou Hospital, and Clinical Associate fessor, Department of Internal Medicine, St.&e I’niversity of lowa College of Medicine, Iowa Iowa. **Bacteriologist, Laboratory Service. Veterans Administration Hospital, Iowa City, Iowa. the
868
and Iowa. ProCity.
864
BUCHMAN
AND
Am. Heart J. December, 1960
BERGLUND
organisms were cultured in a single specimen taken from the other arm. Thus, of the 600 blood cultures which were obtained, growth occurred in only 13 instances. These findings are tabulated in Table I. No patient whose stool was cultured showed evidence of enteric pathogens. TABLE
NUMBER OF PATIENTS
I.
RESULTS
SOURCEOF SPECIMENS
87-i I
13 4
OF BLOOD
CULTURES
IN
BEFORE SIGMOIDOSCOPY
Both arms One arm One arm
No growth No growth No growth
!
100
SIGMOIDOSCOPIC
EXAMINATIONS
IMMEDIATELY AFTER SIGMOIDOSCOPY
No growth No growth Hemolytic Staphylococcus (coagulase negative) Species of bacillus No growth
:
One arm One arm
1
One arm
No growth Nonhemolytic Staphylococcus (coagulase negative) i No growth
1
One arm
~ No growth
’ No growth
1
1 One arm
1 No growth
No growth
1
’ One arm
No growth
No growth
No growth
1.5 MINUTES AFTER SIGMOIDOSCOPY
No growth No growth No growth No growth No growth i Hemolytic Staphylococcus (coagulase negative) ’ Species of Corynebacterium / Species of anaerobic Corynebacterium i Hemolytic Staphylo; coccus epidermidis (coagulase negative)
, DISCUSSION
The majority of the patients in this study were found to have normal mucosa, whereas 11 patients had chronic ulcerative colitis in various stages of activity. Four patients had polyps, which were excised in 2 of the patients; and 1 patient had a polypoid adenocarcinoma of the rectum which was biopsied. Five individuals were found to have hemorrhoids, and 2 had fistulas. One patient had an anal fissure. Evidence of minor trauma was found in 4 patients; this was probably due to the manipulation of the sigmoidoscope or enema tip. In only 5 patients did blood cultures grow bacteria immediately after sigmoidoscopy. Two of these isolates were coagulase-negative staphylococci, and one isolate was a species of bacillus. Thus, it is believed that bacteremia was not induced by sigmoidoscopy. It is of interest that in patients in whom positive blood cultures were obtained, the mucosa at the time of sigmoidoscopy appeared to be entirely normal, without visibly active lesions. The apparent infrequency of bacteremia after sigmoidoscopy has been postulated to be due to high resistance of rectal mucosa to bacterial invasion and/or prompt removal of bacteria from the portal circulation by the reticuloendothelial system of the liver.i9!22*23The inability to recover organisms from samples of blood in this study may be due to several conditions. One likely possibility is that
no bacteremia
existed
at all. However,
the clearing
of the blood
stream
b,
“,%z “6”
BACTEREMIA
FOLLOWING
X65
SIGMOIDOSCOPY
defense mechanisms of the body should also be considered. Although the cultural environment outlined for this study would seem to be suitable for the organism requirements of the expected flora, it is possible that the proper conditions may not have been provided. It would seem that antibiotic prophylactic treatment is not necessary in the presence of cardiac abnormalities (valvular or endocardial) prior to the procedure of sigmoidoscopy. SUMMARY
AND
CONCLUSIONS
Sigmoidoscopy was evaluated as a possible cause of transient bacteremia in 100 patients who had not been on antibacterial drugs in the immediate preinstrumentation period. Specimens of blood were taken for bacterial culture before, immediately after, and 15 minutes after sigmoidoscopy. Samples of blood were taken from each arm in order to facilitate a check against contamination. In 87 patients, blood cultures were negative after sigmoidoscopy. Bacteria were recovered from only 1 of the 200 presigmoidoscopy specimens of blood, and from only 12 of the 400 cultures obtained after sigmoidoscopy. In no instance was the organism recovered from blood drawn simultaneously from each arm. Most, if not all, of the positive cultures are believed to have been chance contaminants. Bacteria infrequently followed sigmoidoscopy. The authors sigmoidoscopies
wish to express and venipunctures.
gratitude
to Doris
M.
Jones,
R.N.,
who kindly
assisted
with
the
REFERENCES
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
11. 12. 13.
14. 15.
Barrington, F. J. F., and Wright, H. D.: Bacteremia Following Operations on the Urethra, J. Path. & Bact. 33:871, 1930. Richards, J. H.: Irritation of Foci of Infection, J.A.M.A. 99:1496, 1932. Okell, C. C., and Elliott, S. D.: Bacteremia and Oral Sepsis, With Special Reference to the Etiology of Subacute Endocarditis, The Lancet 2x869, 1935. Burket. L. W.. and Burn, C. G.: Bacteremia Following Dental Extraction. Demonstration o\ Source of Bz tcteria by Means of a Nonpathogen (Serratia Marcesens), J. Dent. .. Res. 16:X 11, 1937. Elliott, S. D.: Elacteremia and Oral Sepsis, Proc. Roy. Sot. Med. 32:747, 1939. Murrav. M.. an Id Moosnick, F.: Incidence of Bacteremia in Patients With Dental Disease, Clin. Med. 2h:Ktl. 1941 j .’ Lab. & -----I -_ --. Paquin, 0.: Ba4 cteremia Fo’ llowing the Removal of Diseased Teeth, J, Am. Dent. Assoc. 28:879. lY41. Pressman, R: S., and Bender, I. B.: Effect of Sulfonamide Compounds on Transient Bacteremia Following Extraction of Teeth, Arch. Int. Med. 74:346, 1944. H. L., Vivino, J. J., Merri!, A., and Dowling, H. F.: Effect of Prophylactically AdHirsh, ministered Penicillin on Incidence of Bacteremia Following Extraction of Teeth, Arch. Int. Med. 81:868, 1948. Creevy, C. D., and Feeney, M. J.: Infection Following Transurethral Resection of the Prostate Gland, Bull. Univ. of Minnesota Hosp. and Minnesota Med. Found. 20:314, 1949. Rhoads, P. S., Schram, W. R., and Adair, D.: Bacteremia Following Tooth Extraction; Prevention With Penicillin and NU 445, J. Am. Dent. Assoc. 41:55, 1950. Merritt, W. A.: Bacterial Endocarditis as a Complication of Transurethral Prostatic Resection, J. Urol. 65:100, 19.51. Geraci, J. E., and Martin, W. J.: Antibiotic Therapy of Bacterial Endocarditis, Circulation 10:173, 1954. Cobe, H. M.: Transitory Bacteremia, Oral Surg. h Oral Path. 7:609, 1954. Pressman, R. S., and Bender, I. B.: Antibiotic Treatment of the Gingival Sulcus in the Prevention of Bacteremia. In Antibiotics Annual, 1954-1955, edited by H. Welch and F. Marti-Ibaiiez. New York, 19.55, Medical Encyclopedia, Inc., pp. 92-104.
866 16.
17. 18. 19. 20. 21. 22. 23.
BUCHMANAND
Rhoads,
BERGLUND
Am. Heart J. December, 1960
P. S., and Adair, D. M.: Further Observations of the Effect of Preoperative Treatment With Various Antibiotics on Postoperative Bacteremia and the Bacterial Content of Excised Tonsils. In Antibiotics Annual, 1955-1956, edited by H. Welch and F. Marti-Ibafiez. New York, 1956, Medical Encyclopedia, Inc., pp. 73-83. Martin, W. J., and Nichols, D. R.: Bacteremic Shock, Proc. Staff Meet. Mayo Clin. 31:333, 1956. Slade, N.: Bacteremia and Septicemia After Urological Operations, Proc. Roy. Sot. Med. 51:331, 1958. Nissen, N. I.: Bacteremia. Some Experiences Regarding Blood Cultures in a Medical Unit, Acta med. scandinav. 161:265, 1958. Reich, A., and King, J. W.: Blood Cultures for Diagnosis of Bacteremia, Cleveland Clin. Quart. 24:250, 1958. Unterman, D., Milberg, M. B., and Kranis, M.: Evaluation of Blood Cultures After Sigmoidoscopy, New England J. Med. 257:773, 1957. Beeson, P. B., Brannon, E. S., and Warren, J. V.: Observations on the Sites of Removal of Bacteria From the Blood in Patients With Bacterial Endocarditis, J. Exper. Med. 81:9, 1945. Schatten, W. E., DesPrez, J. D., and Holden, W. D.: A Bacteriologic Study of Portal-Vein Blood in Man, A.M.A. Arch. Surg. 71:404, 1955.
Following
Elwood Buchman,
M.D.,*
Sigmoidoscopy and Earl M. Berglund,
B.S.,**
IoozeraCity, Iowa
Bacteremia is known to follow dental extractions, many surgical procedures, and irritation of foci of infection .rmz3An excellent review of the bacteremia which follows instrumentation has been written by Nissen.lQ In a preliminary study by Unterman and associates,“r in only one instance in a series of 50 patients was a case of bacteremia found that may have been induced by sigmoidoscopy. Our interest was to explore further the possibility of sigmoidoscopy leading to transient bacteremia. If such a case of bacteremia truly occurred, there would be an excellent basis for antibiotic prophylaxis in an effort to prevent bacterial endocarditis in patients with valvular heart disease. METHOD
A sigmoidoscopic examination was performed on 100 patients who were on the Medical Service for the usual indication of the procedure. Patients who were, or had been, on antibacterial drugs within 2 weeks of sigmoidoscopy were excluded from the study. The sigmoidoscope was inserted its full length (25 centimeters or 10 inches) or nearly so in all patients. The antecubital areas of the patients’ arms were vigorously prepared with a cotton sponge saturated with 70 per cent alcohol. Approximately 5 ml. of blood were aspirated from the antecubital veins and aseptically deposited in 60 ml. of heart-infusion broth which contained traces of cystine and p-aminobenzoic acid and 0.1 per cent agar. The cultures were incubated at 37.5”C. in a 10 per cent atmosphere of carbon dioxide. They were examined daily for a period of 10 days, at the end of which time they were reported to be negative if no growth had appeared. Cultures nith growth were transferred to appropriate media for definitive identification of organisms. The specimens of blood were collected from each arm immediately hefore, immediately after. and 15 minutes after sigmoidoscopy. RESIwY,TS
In 87 of the 100 patients, blood cultures from both arms were negative before, immediately after, and 15 minutes after sigmoidoscopy. Blood cultures in 13 additional patients showed no growth in blood taken from one arm, but From the Medical Service and the Laboratory Service, Veterans Administration Hospital, Department of Internal Medicine, State rniversity of Iowa College of Medicine, Iowa City. Received for publication June 2. 1960. *Assistant Chief, Medical Service, Veterans .4dminlstratiou Hospital, and Clinical Associate fessor, Department of Internal Medicine, St.&e I’niversity of lowa College of Medicine, Iowa Iowa. **Bacteriologist, Laboratory Service. Veterans Administration Hospital, Iowa City, Iowa. the
868
and Iowa. ProCity.
864
BUCHMAN
AND
Am. Heart J. December, 1960
BERGLUND
organisms were cultured in a single specimen taken from the other arm. Thus, of the 600 blood cultures which were obtained, growth occurred in only 13 instances. These findings are tabulated in Table I. No patient whose stool was cultured showed evidence of enteric pathogens. TABLE
NUMBER OF PATIENTS
I.
RESULTS
SOURCEOF SPECIMENS
87-i I
13 4
OF BLOOD
CULTURES
IN
BEFORE SIGMOIDOSCOPY
Both arms One arm One arm
No growth No growth No growth
!
100
SIGMOIDOSCOPIC
EXAMINATIONS
IMMEDIATELY AFTER SIGMOIDOSCOPY
No growth No growth Hemolytic Staphylococcus (coagulase negative) Species of bacillus No growth
:
One arm One arm
1
One arm
No growth Nonhemolytic Staphylococcus (coagulase negative) i No growth
1
One arm
~ No growth
’ No growth
1
1 One arm
1 No growth
No growth
1
’ One arm
No growth
No growth
No growth
1.5 MINUTES AFTER SIGMOIDOSCOPY
No growth No growth No growth No growth No growth i Hemolytic Staphylococcus (coagulase negative) ’ Species of Corynebacterium / Species of anaerobic Corynebacterium i Hemolytic Staphylo; coccus epidermidis (coagulase negative)
, DISCUSSION
The majority of the patients in this study were found to have normal mucosa, whereas 11 patients had chronic ulcerative colitis in various stages of activity. Four patients had polyps, which were excised in 2 of the patients; and 1 patient had a polypoid adenocarcinoma of the rectum which was biopsied. Five individuals were found to have hemorrhoids, and 2 had fistulas. One patient had an anal fissure. Evidence of minor trauma was found in 4 patients; this was probably due to the manipulation of the sigmoidoscope or enema tip. In only 5 patients did blood cultures grow bacteria immediately after sigmoidoscopy. Two of these isolates were coagulase-negative staphylococci, and one isolate was a species of bacillus. Thus, it is believed that bacteremia was not induced by sigmoidoscopy. It is of interest that in patients in whom positive blood cultures were obtained, the mucosa at the time of sigmoidoscopy appeared to be entirely normal, without visibly active lesions. The apparent infrequency of bacteremia after sigmoidoscopy has been postulated to be due to high resistance of rectal mucosa to bacterial invasion and/or prompt removal of bacteria from the portal circulation by the reticuloendothelial system of the liver.i9!22*23The inability to recover organisms from samples of blood in this study may be due to several conditions. One likely possibility is that
no bacteremia
existed
at all. However,
the clearing
of the blood
stream
b,
“,%z “6”
BACTEREMIA
FOLLOWING
X65
SIGMOIDOSCOPY
defense mechanisms of the body should also be considered. Although the cultural environment outlined for this study would seem to be suitable for the organism requirements of the expected flora, it is possible that the proper conditions may not have been provided. It would seem that antibiotic prophylactic treatment is not necessary in the presence of cardiac abnormalities (valvular or endocardial) prior to the procedure of sigmoidoscopy. SUMMARY
AND
CONCLUSIONS
Sigmoidoscopy was evaluated as a possible cause of transient bacteremia in 100 patients who had not been on antibacterial drugs in the immediate preinstrumentation period. Specimens of blood were taken for bacterial culture before, immediately after, and 15 minutes after sigmoidoscopy. Samples of blood were taken from each arm in order to facilitate a check against contamination. In 87 patients, blood cultures were negative after sigmoidoscopy. Bacteria were recovered from only 1 of the 200 presigmoidoscopy specimens of blood, and from only 12 of the 400 cultures obtained after sigmoidoscopy. In no instance was the organism recovered from blood drawn simultaneously from each arm. Most, if not all, of the positive cultures are believed to have been chance contaminants. Bacteria infrequently followed sigmoidoscopy. The authors sigmoidoscopies
wish to express and venipunctures.
gratitude
to Doris
M.
Jones,
R.N.,
who kindly
assisted
with
the
REFERENCES
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
11. 12. 13.
14. 15.
Barrington, F. J. F., and Wright, H. D.: Bacteremia Following Operations on the Urethra, J. Path. & Bact. 33:871, 1930. Richards, J. H.: Irritation of Foci of Infection, J.A.M.A. 99:1496, 1932. Okell, C. C., and Elliott, S. D.: Bacteremia and Oral Sepsis, With Special Reference to the Etiology of Subacute Endocarditis, The Lancet 2x869, 1935. Burket. L. W.. and Burn, C. G.: Bacteremia Following Dental Extraction. Demonstration o\ Source of Bz tcteria by Means of a Nonpathogen (Serratia Marcesens), J. Dent. .. Res. 16:X 11, 1937. Elliott, S. D.: Elacteremia and Oral Sepsis, Proc. Roy. Sot. Med. 32:747, 1939. Murrav. M.. an Id Moosnick, F.: Incidence of Bacteremia in Patients With Dental Disease, Clin. Med. 2h:Ktl. 1941 j .’ Lab. & -----I -_ --. Paquin, 0.: Ba4 cteremia Fo’ llowing the Removal of Diseased Teeth, J, Am. Dent. Assoc. 28:879. lY41. Pressman, R: S., and Bender, I. B.: Effect of Sulfonamide Compounds on Transient Bacteremia Following Extraction of Teeth, Arch. Int. Med. 74:346, 1944. H. L., Vivino, J. J., Merri!, A., and Dowling, H. F.: Effect of Prophylactically AdHirsh, ministered Penicillin on Incidence of Bacteremia Following Extraction of Teeth, Arch. Int. Med. 81:868, 1948. Creevy, C. D., and Feeney, M. J.: Infection Following Transurethral Resection of the Prostate Gland, Bull. Univ. of Minnesota Hosp. and Minnesota Med. Found. 20:314, 1949. Rhoads, P. S., Schram, W. R., and Adair, D.: Bacteremia Following Tooth Extraction; Prevention With Penicillin and NU 445, J. Am. Dent. Assoc. 41:55, 1950. Merritt, W. A.: Bacterial Endocarditis as a Complication of Transurethral Prostatic Resection, J. Urol. 65:100, 19.51. Geraci, J. E., and Martin, W. J.: Antibiotic Therapy of Bacterial Endocarditis, Circulation 10:173, 1954. Cobe, H. M.: Transitory Bacteremia, Oral Surg. h Oral Path. 7:609, 1954. Pressman, R. S., and Bender, I. B.: Antibiotic Treatment of the Gingival Sulcus in the Prevention of Bacteremia. In Antibiotics Annual, 1954-1955, edited by H. Welch and F. Marti-Ibaiiez. New York, 19.55, Medical Encyclopedia, Inc., pp. 92-104.
866 16.
17. 18. 19. 20. 21. 22. 23.
BUCHMANAND
Rhoads,
BERGLUND
Am. Heart J. December, 1960
P. S., and Adair, D. M.: Further Observations of the Effect of Preoperative Treatment With Various Antibiotics on Postoperative Bacteremia and the Bacterial Content of Excised Tonsils. In Antibiotics Annual, 1955-1956, edited by H. Welch and F. Marti-Ibafiez. New York, 1956, Medical Encyclopedia, Inc., pp. 73-83. Martin, W. J., and Nichols, D. R.: Bacteremic Shock, Proc. Staff Meet. Mayo Clin. 31:333, 1956. Slade, N.: Bacteremia and Septicemia After Urological Operations, Proc. Roy. Sot. Med. 51:331, 1958. Nissen, N. I.: Bacteremia. Some Experiences Regarding Blood Cultures in a Medical Unit, Acta med. scandinav. 161:265, 1958. Reich, A., and King, J. W.: Blood Cultures for Diagnosis of Bacteremia, Cleveland Clin. Quart. 24:250, 1958. Unterman, D., Milberg, M. B., and Kranis, M.: Evaluation of Blood Cultures After Sigmoidoscopy, New England J. Med. 257:773, 1957. Beeson, P. B., Brannon, E. S., and Warren, J. V.: Observations on the Sites of Removal of Bacteria From the Blood in Patients With Bacterial Endocarditis, J. Exper. Med. 81:9, 1945. Schatten, W. E., DesPrez, J. D., and Holden, W. D.: A Bacteriologic Study of Portal-Vein Blood in Man, A.M.A. Arch. Surg. 71:404, 1955.