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If penicillin or cephalosporin hypersensitivity: Clindamycin 600 mg (pediatric dose 20 mg/kg) IV within 30 minutes before procedure. MRSA risk present Pre-procedural MRSA screening and attempt decolonization. (If successful decolonization not completed: Vancomycin 1 gram [pediatric dose 15 mg/kg] IV infused over 60 to 90 minutes to conclude within 30 minutes prior to procedure.) ERCP - Biliary obstruction AND cholangitis - Biliary obstruction unlikely to be successfully drained at ERCP (including malignant hilar obstruction and primary sclerosing cholangitis) - Inadequate biliary drainage following ERCP Ciprofloxacin 500 mg (pediatric dose 15 mg/kg◊) orally given 30 to 60 minutes prior to procedure or 400 mg (pediatric dose 15 mg/kg◊) IV within 30 minutes prior to procedure

OR Amoxicillin-clavulate 1750 mg (pediatric dose 45 mg/kg) orally 30 to 60 minutes prior to procedure or ampicillin-sulbactam 3 grams (pediatric dose 50 mg/kg ampicillin component) IV within 30 minutes prior to procedure

If penicillin hypersensitivity: Substitute vancomycin 1 gram (pediatric dose 15 mg/kg) IV infused over 60 to 90 minutes to conclude within 30 minutes prior to procedure plus gentamicin 1.5 mg/kg IV (maximum 120 mg) 30 minutes before procedure.

ALL above regimens are discontinued post-procedure when drainage is established absent evidence of cholangitis. For post-procedure dosing, see each drug information topic. ERCP or EUS-FNA of cystic lesion(s) - Sterile pancreatic cysts - Cysts outside pancreas (excluding solid lesions) Ciprofloxacin 500 mg orally (pediatric dose 15 mg/kg◊) 30 to 60 minutes prior to procedure or 400 mg (pediatric dose 15 mg/kg◊) IV given within 30 minutes prior to procedure. Continue 3 to 5 days post-procedure. All endoscopic procedures with high risk of bacteremia - Immunocompromised patients - Cirrhosis with ascites• - Synthetic vascular graft during first six months after graft placementΔ (antibiotic prophylaxis is NOT recommended for nonvalvular cardiovascular devices) Amoxicillin 2 grams (pediatric dose 50 mg/kg) orally 30 to 60 minutes before procedure

If penicillin hypersensitivity: Clindamycin 600 mg (pediatric dose 20 mg/kg) orally 30 to 60 minutes before procedure or IV within 30 minutes prior to procedure. PEG: percutaneous endoscopic gastrostomy; MRSA: methicillin resistant Staphylococcus aureus; ERCP: endoscopic retrograde cholangiopancreatography; EUS-FNA: endoscopic ultrasound-guided fine-needle aspiration; GI: gastrointestinal. * Pediatric dose should generally not exceed adult dose. • In patients with cirrhosis and upper gastrointestinal bleeding, antibiotics are indicated even if endoscopy is not planned. Δ American Heart Association recommendation only. Antimicrobial prophylaxis for synthetic vascular grafts is not recommended by the American Society for Gastrointestinal Endoscopy (ASGE) even if recent (<6 months) graft placement. ◊ Use fluoroquinolones cautiously in children.