Rishika Chugh, MD1, Ashley N. Tran, MD2, Amy Ogurick, MD1, Alyssa Grimshaw, MLS3, Maria Ciarleglio, PhD4, Yanhong Deng, PhD4, Badr Al-Bawardy, MD5, Kenneth H. Hung, MD, MS5, Loren Laine, MD2; 1Yale New Haven Hospital, New Haven, CT; 2Yale University, School of Medicine, New Haven, CT; 3Yale University, New Haven, CT; 4Center for Analytical Sciences, Yale School of Public Health, New Haven, CT; 5Yale School of Medicine, New Haven, CT
Introduction: The safety of gastrointestinal endoscopy in neutropenic patients is unclear. American Society for Gastrointestinal Endoscopy guidelines state that patients with absolute neutrophil count (ANC) < 500 cells/µL and advanced hematologic malignancies are at increased risk for bacteremia and sepsis after endoscopy. Infectious Diseases Society of America guidelines state that endoscopy should be avoided in neutropenic patients. We performed a systematic review and meta-analysis to assess the safety of endoscopy in patients with neutropenia. Methods: Bibliographic databases (Medline, EMBASE, Cochrane Library, Web of Science, Scopus, PubMed) were searched through November 2019 for studies in neutropenic patients (ANC < 1000 cells/µL) undergoing endoscopy with outcome data on infections, mortality, or fever. Abstracts from Digestive Disease Week, American College of Gastroenterology Annual Scientific Meeting, and United European Gastroenterology Week from January 2017 to January 2020 were also searched. Two independent reviewers identified studies meeting inclusion criteria, performed data extraction using a standardized form, and assessed risk of bias using the Newcastle-Ottawa scale. Co-primary outcomes were 30-day infection-related mortality and new infection within 30 days of endoscopy. Secondary outcomes included new bacteremia and new fever within 30 days. Random effects meta-analysis was used to calculate pooled proportions and effect estimates. Results: Database search identified 2733 unique citations. Four studies from database search and 1 from conference abstract review met eligibility criteria (N=928). All studies had high risk of bias. Overall proportion of infection-related mortality was 0.0% (95% CI: 0.0-0.4% I2: 0.0%) and infectious adverse events was 1.9% (95% CI: 0.0-6.4% I2: 77.0%) (Table 1). The proportion of neutropenic patients developing bacteremia was 1.7% (CI: 0.0-6.8% I2: 82.3%) and new fever was 0.0% (95% CI: 0.0-0.0% I2: 0.0%) (Table 2). Subgroup analysis was not performed due to zero events in a majority of studies and limited number of studies. However, data on antibiotic use prior to endoscopy was available in 3 studies; here the proportion of patients on antibiotics that developed new infections ranged from 0.0 to 1.2%. Discussion: This systematic review and meta-analysis showed a low rate of mortality and infection following endoscopy in neutropenic patients. Additional large studies designed to assess the safety of endoscopy in neutropenic patients are needed.
Figure 1. PRISMA flow diagram summarizing study selection.
Table 1. Primary outcomes: 30 day infection-related mortality and infectious adverse events in neutropenic patients undergoing endoscopy.
Table 2. Secondary outcomes: Bacteremia and new fever in neutropenic patients undergoing endoscopy.
Disclosures: Rishika Chugh indicated no relevant financial relationships. Ashley Tran indicated no relevant financial relationships. Amy Ogurick indicated no relevant financial relationships. Alyssa Grimshaw indicated no relevant financial relationships. Maria Ciarleglio indicated no relevant financial relationships. Yanhong Deng indicated no relevant financial relationships. Badr Al-Bawardy indicated no relevant financial relationships. Kenneth Hung indicated no relevant financial relationships. Loren Laine indicated no relevant financial relationships.