Antibiotic prophylaxis for patients undergoing elective endoscopic retrograde cholangiopancreatography

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) involves cannulation of the ampulla of Vater and has diagnostic as well as therapeutic capabilities, but the number of non-therapeutic ERCPs is decreasing with time. 1 Endoscopic sphincterotomy, stone extraction and stenting are not without complications. The most widely recognised of these include bleeding, which occurs in 0.7 -2% of patients, perforation (0.3 -0.6%), pancreatitis (7%), cholangitis (1%) and cholecystitis (0.2 -0.5%). Procedure-related mortality is approximately 0.2%. 2 Review of international guidelines regarding the use of prophylactic antibiotics with ERCP shows that routine use of antimicrobials is recommended for biliary obstruction and pancreatic pseudocysts. However, several studies, including a meta-analysis, fail to show any benefit. [3][4][5][6] We set out to assess the current antibiotic prescribing practice among South African endoscopists who perform ERCPs, and then review international guidelines and relevant studies. MethodsOur audit of South African endoscopists who perform ERCPs took the form of a questionnaire. This was distributed at the Hepato-Pancreatico-Biliary Association of South Africa Congress held during October 2007 in Johannesburg, and was also sent to all members of the South African Gastro-Enterology Society via email. The questionnaire was anonymous. Endoscopists were questioned regarding their years of experience, the monthly volume of ERCPs they perform, and their indications for antibiotic prophylaxis (for diagnostic biliary ERCP, diagnostic pancreatic ERCP, therapeutic biliary ERCP and therapeutic pancreatic ERCP). Respondents were also asked to indicate their antibiotic of preference and the number of doses administered. The results were then tabulated for comparison, and the chisquared test was used to calculate p-values. A p-value of 0.05 was considered significant.A Pubmed search was performed from 1978 to March 2008 using the search terms Cholangiopancreatography-Endoscopic-Retrograde Antibiotic-Prophylaxis, random* or control* or blind* or meta-analys*, all subheadings. An Internet search was also performed to identify recommendations from various international gastrointestinal societies. ResultsThirty-nine endoscopists (22 surgeons, 16 medical gastroenterologists and 1 radiologist) responded to our questionnaire. Most had more than 6 years of experience (30/39) and performed more than 10 ERCPs per month (22/39). Approximately half of the endoscopists (19/39) were aware of ERCP antibiotic protocols, either the American Society of Gastro-Enterology (ASGE) or UK National Health Service (NHS) recommendations. The results are depicted in Table I. 'Always' implied that the endoscopist used antibiotic prophylaxis with each patient, 'selected' implied specific indications, and 'never' implied no use of antibiotic prophylaxis.

Preoperative biliary drainage for distal biliary obstruction and post‐operative infectious complications

“…There is some evidence that a restricted use of antibiotics (dependent on the post‐procedure risk of cholangitis) is safe and effective . A recent Cochrane meta‐analysis concluded that while antibiotics reduced bacteraemia in patients undergoing elective ERCP; their benefit in those undergoing uncomplicated procedures was less evident . Further work is required to assess if prophylactic antibiotics (at the time of ERCP) may reduce the incidence of infectious complications after definitive surgery following PBD.…”

Pathogenesis and clinical perspectives of extraintestinal manifestations in inflammatory bowel diseases

“…It can reduce the risk of cholangitis, bacteremia, and septicemia after ERCP. 85 Patients with PSC and end-stage liver disease should be evaluated to determine whether liver transplantations should be performed according to the standard guidelines. PSC has a significantly greater risk for the development of colorectal dysplasia and carcinoma in patients with UC.…”

Antibiotic prophylaxis for endoscopic retrograde chlangiopancreatography increases the detection rate of drug‐resistant bacteria in bile

“…Guidelines published by the American Society of Gastrointestinal Endoscopy (ASGE) in 2008 did not recommend the approach as a routine procedure, stating that it has no significant prophylactic effects . However, a subsequently published systematic review found that antibiotic prophylaxis prevents bacteremia and cholangitis . There is currently no consensus on the issue, and there has been very little discussion about potential adverse effects due to antibiotic prophylaxis for ERCP.…”