Prophylactic antibiotics help prevent post-ERCP infections

Infection rates were lower in patients with biliary obstruction undergoing endoscopic retrograde cholangiopancreatography (ERCP) who received prophylactic antibiotics before the procedure, a recent study found.

Researchers at a medical center in Korea performed a randomized, double-blind, placebo-controlled trial to determine whether prophylactic antibiotics would reduce infectious complications after ERCP in patients with biliary obstruction. Patients were randomly assigned in a 1:1 ratio to receive a single dose of IV cefoxitin, 1 g, or normal saline as a placebo 30 minutes before ERCP. After ERCP, biliary drainage was considered complete if the radiologically confirmed biliary obstructive lesion had resolved. The study's primary outcome was post-ERCP infectious complications. Results were published Sept. 15 by the American Journal of Gastroenterology.

Three hundred seventy-eight patients were included in the study between April 2017 and February 2021. One hundred eighty-nine patients were assigned to each study group, with 176 in the antibiotics group and 173 in the placebo group included in the outcomes analysis. Mean age was 65.1 and 66.5 years, respectively, and 51.7% and 59% were men. Complete biliary drainage was achieved in 91.5% of the antibiotics group and 90.9% of the placebo group. After ERCP, 2.8% of those in the antibiotics group and 9.8% in the placebo group developed infectious complications diagnosed by blood culture obtained within 24 hours of the procedure (risk ratio, 0.29 [95% CI, 0.11 to 0.74]; P=0.0073). Incidence rates were 2.3% versus 6.4% for bacteremia (risk ratio, 0.36 [95% CI, 0.12 to 1.04]; P=0.0599) and 1.7% versus 6.4% for cholangitis (risk ratio, 0.27 [95% CI, 0.08 to 0.87]; P=0.0267). Sixty-six percent of the patients diagnosed with bacteremia developed septicemia and required treatment.

The authors noted that their trial involved only one center and was not large enough to determine a benefit of prophylactic antibiotics in subgroups of patients, among other limitations. They concluded that use of antibiotics before ERCP in patients with biliary obstruction significantly reduced incidence of infectious complications versus placebo regardless of whether the obstruction was completely drained. “This result conflicts with the existing guidelines suggesting antibiotic prophylaxis before ERCP only in cases of anticipated incomplete biliary drainage or in severely immunocompromised patients,” they wrote. “We suggest reconsidering the use of prophylactic antibiotics when performing ERCP in patients with biliary obstruction.”