Retrospective Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Nov 7, 2020; 26(41): 6402-6413
Published online Nov 7, 2020. doi: 10.3748/wjg.v26.i41.6402
Older age, longer procedures and tandem endoscopic-ultrasound as risk factors for post-endoscopic retrograde cholangiopancreatography bacteremia
Liat Deutsch, Shay Matalon, Adam Phillips, Moshe Leshno, Oren Shibolet, Erwin Santo
Liat Deutsch, Shay Matalon, Adam Phillips, Oren Shibolet, Erwin Santo, The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
Liat Deutsch, Adam Phillips, Oren Shibolet, Erwin Santo, Department of Gastroenterology and Hepatology, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
Shay Matalon, Department of Gastroenterology, Assaf Harofe Medical Center, Zeriffin 70300, Israel
Moshe Leshno, Faculty of Management, Tel Aviv University, Tel Aviv 6997801, Israel
Author contributions: Deutsch L designed the study, performed data acquisition, data analysis, statistical analysis and wrote the paper; Matalon S performed data acquisition and contributed to manuscript preparation and editing; Phillips A provided clinical advise and reviewed the paper; Leshno M performed and reviewed the statistical analysis and reviewed the manuscript; Shibolet O performed language editing and reviewed the manuscript; Santo E reviewed the manuscript and approved final version for submission.
Institutional review board statement: The study was approved by the local Institutional Review Board (IRB num: 0598-13-TLV).
Informed consent statement: Data was anonymous and informed consent was waivered.
Conflict-of-interest statement: None
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Erwin Santo, MD, Chief Doctor, Chief Physician, Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Affiliated with Sackler School of Medicine, Tel Aviv University, No. 6 Weizmann Street, Tel Aviv 6423906, Israel.
Received: June 18, 2020
Peer-review started: June 18, 2020
First decision: July 28, 2020
Revised: August 16, 2020
Accepted: September 16, 2020
Article in press: September 16, 2020
Published online: November 7, 2020
Research background

Endoscopic retrograde cholangiopancreatography (ERCP) is currently the method of choice for the treatment of biliary and pancreatic duct obstruction. Clinically significant post-ERCP bacteremia (PEB) occurs in up to 5% of cases, while antibiotic prophylaxis is recommended only when an ERCP is unlikely to achieve complete biliary drainage.

Research motivation

The current recommendations do not address specific populations or procedure-related factors that require specific management in terms of antibiotic prophylaxis. Identification of risk factors for PEB may reduce its occurrence and related complications.

Research objectives

The primary objective of this study was to evaluate possible risk factors for PEB. Secondary objectives were: Evaluation of PEB prevalence and to assess "real-life" practices of antibiotic administration and their competency to ASGE guidelines.

Research methods

This was a retrospective study of all ERCP procedures performed in a single tertiary medical center. Data collection included: Demographic and clinical characteristics such as pre and post procedure antibiotic treatment and bacterial blood cultures and procedure related characteristics. Strict eligibility criteria were applied and 626 ERCPs were included in the final analysis. Stepwise Logistic Regression analysis and Decision Tree algorithms were used for prediction modeling of PEB.

Research results

A total of 626 ERCPs performed in 434 patients were included. PEB prevalence was 3.7%. Antibiotic prophylaxis was administrated in 22.2% cases but was indicated according to the guidelines only in 7% of cases. In all the PEB cases, prophylaxis was deemed not indicated. A stepwise logistic regression (ROC, 0.766), identified 3 variables as independent risk factors for PEB: Age at ERCP ≥ 75 years, Tandem EUS/ERCP with FNA and ERCP duration longer than 60 min. In a decision tree model (ROC, 0.778) the probability for PEB without any risk factors was 1% regardless of prophylaxis administration.

Research conclusions

Our study demonstrated that ERCP duration longer than 60 min, tandem EUS-ERCP with FNA and age above 75 years are significant risk factors for PEB. Moreover, the prevalence of PEB in our study was similar to previous reports, despite the fact that antibiotic prophylaxis was administrated more readily than recommended. Both conclusions support a more tailor-made approach regarding antibiotic prophylaxis before ERCP. 

Research perspectives

Future prospective studies should focus on these risk factors as indications for prophylactic antibiotic treatment before ERCP in order to reduce the prevalence of PEB.