Are prophylactic antibiotics indicated for endoscopic retrograde cholangiopancreatography?

Date
2011-10-19
Authors
Brand, Martin
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Abstract
Background The use of prophylactic antibiotics before endoscopic retrograde cholangiopancreatography (ERCP) is recommended by all major international gastroenterological societies, especially in the presence of an obstructed biliary system. Their use is intended to decrease or eliminate the incidence of complications following the procedure, namely cholangitis, cholecystitis, septicaemia, and pancreatitis. Objectives To assess the benefits and harms of antibiotics before elective ERCP in patients without evidence of acute or chronic cholecystitis, or acute or chronic cholangitis, or severe acute pancreatitis. Data collection and analysis We audited South African endoscopists who perform ERCPs in the form of a questionnaire. The review was conducted according to the recommendations of The Cochrane Collaboration as well as the Cochrane Hepato-Biliary Group. Review Manager 5 was used employing fixed-effect and random-effects model meta-analyses. Only randomised clinical trials were included in the analyses, irrespective of blinding, language, or publication status. Participants were patients that underwent elective ERCP that were not on antibiotics, without evidence of acute or chronic cholecystitis, cholangitis, or severe acute pancreatitis before the procedure. We compared patients that received prophylactic antibiotics before the procedure with patients that were given placebo or no intervention before the procedure. Results The audit revealed that no specific protocols were being implemented in South Africa, and there was a marked difference in the practice between surgical and medical gastroenterologists, with surgeons using antibiotics more often. There was also a wide spectrum of antibiotic types and combinations being used. Nine randomised clinical trials (1573 patients) were included into the review analyses. The majority of the trials had risks of bias. When all patients providing data for a certain outcome were included, the fixed-effect meta-analyses significantly favoured the use of prophylactic antibiotics in preventing cholangitis (relative risk (RR) 0.54, 95% CI 0.33 to 0.91), septicaemia (RR 0.35, 95% CI 0.11 to 1.11), bacteriaemia (RR 0.50, 95% CI 0.33 to 0.78), and pancreatitis (RR 0.54, 95% CI 0.29 to 1.00). In random-effects meta- analyses, only the effect on bacteriaemia remained significant. Overall mortality was not reduced (RR 1.33, 95% CI 0.32 to 5.44). If one selects patients in whom the ERCP resolved the biliary obstruction at the first procedure, there seem to be no significant benefit in using prophylactic antibiotics to prevent cholangitis (RR 0.98, 95% CI 0.35 to 2.69, only three trials). Conclusions Prophylactic antibiotics reduce bacteriaemia and seem to prevent cholangitis and septicaemia in patients undergoing elective ERCP. In the subgroup of patients with uncomplicated ERCP, the effect of antibiotics may be less evident. Further research is required to determine whether antibiotics can be given during or after an ERCP if it becomes apparent that biliary obstruction cannot be relieved during that procedure.
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Keywords
prophylactic antibiotics, ERCP
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