Published online Nov 7, 2020. doi: 10.3748/wjg.v26.i41.6402
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
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.
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.
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.
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.
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.
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.
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.