Prophylaxis of post-ERC infectious complications in patients with biliary obstruction by adding antimicrobial agents into ERC contrast media- a single center retrospective study

Abstract

BackgroundPatients with biliary obstruction are at high risk to develop septic complications after endoscopic retrograde cholangiography (ERC). We evaluated the benefits of local application of antimicrobial agents into ERC contrast media in preventing post-ERC infectious complications in a high-risk study population.MethodsPatients undergoing ERC at our tertiary referral center were retrospectively included. Addition of vancomycin, gentamicin and fluconazol into ERC contrast media was evaluated in a case-control design. Outcomes comprised infectious complications within 3 days after ERC.ResultsIn total, 84 ERC cases were analyzed. Primarily indications for ERC were sclerosing cholangitis (75%) and malignant stenosis (9.5%). Microbial testing of collected bile fluid in the treatment group was positive in 91.4%. Detected organisms were sensitive to the administered antimicrobials in 93%. The use of antimicrobials in contrast media was associated with a significant decrease in post-ERC infectious complications compared to non-use (14.3% vs. 33.3%; odds ratio [OR]: 0.33, 95% confidence interval [CI]: 0.114–0.978). After adjusting for the variables acute cholangitis prior to ERC and incomplete biliary drainage, the beneficial effect of intraductal antibiotic prophylaxis was even more evident (OR = 0.153; 95% CI: 0.039–0.598, p = 0.007). Patients profiting most obviously from intraductal antimicrobials were those with secondary sclerosing cholangitis.ConclusionLocal application of a combination of antibiotic and antimycotic agents to ERC contrast media efficiently reduced post-ERC infectious events in patients with biliary obstruction. This is the first study that evaluates ERC-related infectious complications in patients with secondary sclerosing cholangitis. Our first clinical results should now be prospectively evaluated in a larger patient cohort to improve the safety of ERC, especially in patients with secondary sclerosing cholangitis.

Endoscopic biliary stenting: indications, choice of stents, and results: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline – Updated October 2017

“…Recent studies are summarized below: ▪ A nationwide prospective study (31 188 patients) found, after adjustment for confounders, a 26 % risk reduction in postoperative adverse events when prophylactic antibiotics were used (OR 0.74, 95%CI 0.69 -0.79) [119]; nevertheless, the absolute risk reduction in adverse events (2.6 % in unselected patients and 3.8 % in patients with obstructive jaundice) was estimated to be insufficient by the authors to justify routine antibiotic prophylaxis in unselected patients; ▪ A prospective study (183 unselected patients) found similar incidences of cholangitis with vs. without antibiotic prophylaxis, and all patients who developed cholangitis had incomplete drainage [120]; ▪ A retrospective series (605 unselected patients) found that the increase in the incidence of post-ERCP cholangitis after routine antibiotic prophylaxis had been abandoned (1.7 % vs. 2.0 %) was not statistically significant [121]. In that study, sclerosing cholangitis and incomplete biliary drainage were significant risk factors for postoperative cholangitis; ▪ Another retrospective study (84 procedures, mostly in patients with sclerosing cholangitis) suggested that addition of antibiotics and antifungal agents to the contrast medium was associated with a lower risk of post-ERCP infectious complications (OR 0.33, 95%CI 0.11 -0.98), in particular in patients with incomplete biliary drainage [122].…”

Percutaneous stent placement for malignant hilar biliary obstruction: side-by-side versus stent-in-stent technique

“…Noticeably, cholangitis was less frequently observed in the SBS group than in the SIS group. Several studies have demonstrated that incomplete biliary drainage is a significant risk factor for postoperative cholangitis [19][20][21]. In patients with Bismuth III and IV strictures, more than two stents are often required to drain all opacified ducts [16].…”

Percutaneous stent placement for malignant hilar biliary obstruction: side-by-side versus stent-in-stent technique

“…Noticeably, cholangitis was less frequently observed in the SBS group than in the SIS group. Several studies have demonstrated that incomplete biliary drainage is a signi cant risk factor for postoperative cholangitis (19)(20)(21). In patients with Bismuth III and IV strictures, more than two stents are often required to drain all opaci ed ducts (16).…”