Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2010 Oct 6;2010(10):CD007345.
doi: 10.1002/14651858.CD007345.pub2.

Antibiotic prophylaxis for patients undergoing elective endoscopic retrograde cholangiopancreatography

Martin Brand  1 , Damon Bizos, Peter O'Farrell Jr
Affiliations
Meta-Analysis

Antibiotic prophylaxis for patients undergoing elective endoscopic retrograde cholangiopancreatography

Martin Brand et al. Cochrane Database Syst Rev. .

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.

Search strategy: We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and LILACS until March 2010. Relevant medical and surgical international conference proceedings were also searched.

Selection criteria: 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.

Data collection and analysis: 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 models meta-analyses.

Main results: Nine randomised clinical trials (1573 patients) were included in the 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).

Authors' 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.

PubMed Disclaimer

Conflict of interest statement

None known.

Figures

1
1
Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
2
2
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
1.1
1.1. Analysis
Comparison 1 Prophylactic antibiotics vs placebo (all patients providing data for a certain outcome ), Outcome 1 All‐cause mortality.
1.2
1.2. Analysis
Comparison 1 Prophylactic antibiotics vs placebo (all patients providing data for a certain outcome ), Outcome 2 Acute cholangitis.
1.3
1.3. Analysis
Comparison 1 Prophylactic antibiotics vs placebo (all patients providing data for a certain outcome ), Outcome 3 Septicaemia.
1.4
1.4. Analysis
Comparison 1 Prophylactic antibiotics vs placebo (all patients providing data for a certain outcome ), Outcome 4 Bacteraemia.
1.5
1.5. Analysis
Comparison 1 Prophylactic antibiotics vs placebo (all patients providing data for a certain outcome ), Outcome 5 Pancreatitis.
2.1
2.1. Analysis
Comparison 2 Prophylactic antibiotics vs placebo (only including patients with biliary obstruction relieved at first ERCP), Outcome 1 Cholangitis.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Brandes 1981 {published data only}
    1. Brandes JW, Scheffer B, Lorenz‐Meyer H, Korst HA, Littmann KP. ERCP: Complications and prophylaxis. A controlled study. Endoscopy 1981;13:27‐30. - PubMed
Byl 1995 {published data only}
    1. Byl B, Deviere J, Struelens MJ, Roucloux I, Coninck A, Thys JP, et al. Antibiotic prophylaxis for infectious complications after therapeutic endoscopic retrograde cholangiopancreatography: A randomized, double‐blind, placebo‐controlled study. Clinical Infectious Diseases 1995;20:1236‐40. - PubMed
    1. Deviere J, Byl B, Roucloux I, Struelens MJ, Coninck A, Thys JP. Antibiotic prophylaxis for infectious complications after therapeutic endoscopic retrograde cholangiopancreaticography (ERCP). A randomized, double blind, placebo controlled study. Gastroenterology 1993;104(4):A359. - PubMed
    1. Deviere J, Byl B, Struelens MJ, Roucloux I, Coninck A, Cremer M, et al. Antibiotic complications for infectious complications after therapeutic endoscopic retrograde pancreaticocholangiography (ERCP). A randomized, double‐blind placebo controlled study. Endoscopy 1993;25(5):344.
Llach 2006 {published data only}
    1. Llach J, Bordas JM, Almela M, Pellise M, Mata A, Soria M, et al. Prospective assessment of the role of antibiotic prophylaxis in ERCP. Hepato‐Gastroenterology 2006;53(70):540‐2. [MEDLINE: ] - PubMed
Lorenz 1996 {published data only}
    1. Lorenz R, Hermann M, Neuhaus H, Lehn M, Classen M. Antibiotic prophylaxis using cefuroxim during endoscopic procedures involving the biliary system [Antibiotikaprophylaxe mit Cefuroxim und Erregerspektrum bei therapeutischen endoskopisehen eingriffen in Gallengangsystemen]. Zeitschrift fur Gastroenterologie 1997;35:881.
    1. Lorenz R, Lehn N, Born P, Herrmann M, Neuhaus H. Antibiotic prophylaxis with cefuroxim in therapeutic endoscopy of the bile ducts [Antibiotische Prophylaxe mit Cefuroxim bei endoskopischen Eingriffen an den Gallenwegen]. Deutsche Medizinische Wochenschrift 1996;121:223‐30. - PubMed
Niederau 1994 {published data only}
    1. Niederau C, Pohlmann H, Lubke H, Thomas L. Prophylactic antibiotic treatment in interventional ERCP: a randomized controlled clinical trial. Gastroenterology 1994;106(4):A352. - PubMed
    1. Niederau C, Pohlmann U, Lubke H, Thomas L. Antibiotic prophylaxis during therapeutic or complicated diagnostic ERCP: results of a prospective, randomized control study [Antibiotikaprophylaxe bei therapeutischer order komplizierter diagnostischer ERCP: Ergebnisse einer prospektiven, randomisierten und kontrollierten Studie]. Zeitschrift fur Gastroenterologie 1993;31:511.
    1. Niederau C, Pohlmann U, Lűbke H, Lutz T. Prophylactic antibiotic treatment in therapeutic or complicated diagnostic ERCP: results of a randomized controlled clinical study. Gastrointestinal Endoscopy 1994;40(5):533‐7. - PubMed
Räty 2001 {published data only}
    1. Räty S, Sand J, Pulkkinen M, Matikainen M, Nordback I. Post‐ ERCP pancreatitis: reduction by routine antibiotics. Journal of Gastrointestinal Surgery 2001;5(4):339‐45. - PubMed
Sauter 1990 {published data only}
    1. Sauter G, Grabein B, Mannes GA, Ruckdeschel G, Sauerbruch T. Antibiotic prophylaxis of infectious complications with endoscopic retrograde cholangiopancreatography. A randomized controlled study. Endoscopy 1990;22:164‐7. - PubMed
    1. Sauter G, Ruckdeschel G, Sauerbruch T. Antibiotic prophylaxis and treatment of infectious complications following ERCP [Antibiotische prophylaxe und Therapie infektioser Komplikationen bei der ERCP]. Leber Magen Darm 1992;5:173‐6. - PubMed
Spicak 2001 {published data only}
    1. Spicak J, Stirand P, Zavoral M, Keil R, Zavada F, Drabek J. Antibiotic prophylaxis of cholangitis complicating endoscopic management of biliary obstruction. Gastrointestinal Endoscopy 2000;55(5):AB157.
    1. Spicak J, Stirand P, Zavoral M, Keil R, Zavada F, Drabek J. Antibiotic prophylaxis of cholangitis complicating endoscopic treatment of biliary obstruction [Antibioticka profylaxe cholangitidy komplikujici endoskopickou lecbu biliarni obstrukce]. Ceska a Slovenska Gastroenterologie a Hepatologie 2001;55(6):211‐5.
Van Den Hazel 1996 {published data only}
    1. Hazel SJ, Speelman P, Dankert J, Huibregtse K, Tytgat GNJ, Leeuwen DJ. Piperacillin to prevent cholangitis after endoscopic retrograde cholangiopancreatography. A randomized, controlled trial. Annals of Internal Medicine 1996;125(6):442‐7. - PubMed
    1. Hazel, P Speelman, GNJ Tytgat, J Dankert, DJ Leeuwen. Antibiotic prophylaxis with piperacillin does not significantly reduce the incidence of ERCP induced cholangitis. Endoscopy 1995;27:S74.

Additional references

Alderson 1994
    1. Alderson D. Endoscopic procedures for the general surgeon. In: Keen G, Farndon JR editor(s). Operative Surgery and Management. 3rd Edition. Oxford: Butterworth and Heinemann, 1994:298‐300. [0750613777]
Bai 2009
    1. Bai Y, Gao F, Gao J, Zou DW, Li ZS. Prophylactic antibiotics cannot prevent endoscopic retrograde cholangiopancreatography‐induced cholangitis: a meta‐analysis. Pancreas 2009;38(2):126‐30. - PubMed
Blenkharn 1985
    1. Blenkharn JI, Habib IN, Mok D, John L, McPherson GAD, Gibson RN, et al. Decreased biliary excretion of piperacillin after percutaneous relief of extrahepatic obstructive jaundice. Antimicrobial Agents and Chemotherapy 1985;28(6):778‐80. - PMC - PubMed
Brok 2008
    1. Brok J, Thorlund K, Gluud C, Wetterslev J. Trial sequential analysis reveals insufficient information size and potentially false positive results in many meta‐analyses. Journal of Clinical Epidemiology 2008;61(8):763‐9. - PubMed
Brok 2009
    1. Brok J, Thorlund K, Wetterslev J, Gluud C. Apparently conclusive meta‐analyses may be inconclusive ‐ Trial sequential analysis adjustment for random error risk in conclusive neonatal meta‐analyses. International Journal of Epidemiology 2009;38:287‐98. - PubMed
BSG 2001
    1. British Society of Gastroenterology. Antibiotic Prophylaxis in Gastrointestinal Endoscopy. http://www.bsg.org.uk/clinical‐guidelines/endoscopy/antibiotic‐prophylax... (accessed 3 February 2010).
Gluud 2010
    1. Gluud C, Nikolova D, Klingenberg SL, Alexakis N, Als‐Nielsen B, Colli A, et al. Cochrane Hepato‐Biliary Group. About The Cochrane Collaboration (Cochrane Review Groups (CRGs)). 2010, Issue 8. Art. No.: LIVER.
Greenland 1985
    1. Greenland S, Robins J. Estimation of a common effect parameter from sparse follow‐up data. Biometrics 1985;41:55‐68. - PubMed
Harris 1999
    1. Harris A, Chan AC, Torres‐Viera C, Hammett R, Carr‐Locke D. Meta‐analysis of antibiotic prophylaxis in endoscopic retrograde cholangiopancreatography (ERCP). Endoscopy 1999;31(9):718‐24. [MEDLINE: ] - PubMed
Higgins 2002
    1. Higgins JPT, Thompson SG. Quantifying heterogeneity in a meta‐analysis. Statistics in Medicine 2002;21(11):1539‐58. - PubMed
Higgins 2009
    1. Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.2 [updated September 2009]. The Cochrane Collaboration, 2009. Available from www.cochrane‐handbook.org.
Hirota 2003
    1. Hirota WK, Petersen K, Baron TH, Goldstein JL, Jacobson BC, Leighton JA, et al. Guidelines for antibiotic prophylaxis for GI endoscopy. Gastrointestinal Endoscopy 2003;58:317‐22. - PubMed
ICH‐GCP 1997
    1. International Conference on Harmonisation Expert Working Group. International conference on harmonisation of technical requirements for registration of pharmaceuticals for human use. ICH harmonised tripartite guideline. Guideline for good clinical practice1997 CFR & ICH Guidelines. Vol. 1, PA 19063‐2043, USA: Barnett International/PAREXEL, 1997.
Kjaergard 2001
    1. Kjaergard LL, Villumsen J, Gluud C. Reported methodological quality and discrepancies between large and small randomised trials in meta‐analyses. Annals of Internal Medicine 2001;135:982‐9. - PubMed
Mantel 1959
    1. Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospective studies of disease. Journal of the National Cancer Institution 1959;22:719‐48. - PubMed
Mehal 1995
    1. Mehal WZ, Culshaw KD, Tillotson GS, Chapman RW. Antibiotic prophylaxis for ERCP: a randomized clinical trial comparing ciprofloxacin and cefuroxime in 200 hundred patients at high risk of cholangitis. European Journal of Gastroenterology and Hepatology 1995;7(9):841‐5. [MEDLINE: ] - PubMed
Moher 1998
    1. Moher D, Jadad AR, Moher M. Does quality of reports of randomised trials affect estimates of intervention efficacy reported in meta‐analyses?. Lancet 1998;352:609‐13. - PubMed
Nagar 1984
    1. Nagar H, Berger SA. The excretion of antibiotics by the biliary tract. Surgery Gynaecology and Obstetrics 1984;158:601‐7. - PubMed
Ong 2005
    1. Ong TC, Khor JL, Selamat DS, Yeoh KG, Ho KY. Complications of endoscopic retrograde cholangiography in the post MRCP‐era: a tertiary center experience. World Journal of Gastroenterology 2005;11(33):5209‐12. - PMC - PubMed
Quintiliani 1982
    1. Quintiliani R, French M, Nightingale C. First and second generation cephalosporins. Medical Clinics of North America 1982;66:183‐97. - PubMed
RevMan 2008 [Computer program]
    1. The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). Version 5.0. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2008.
Royle 2003
    1. Royle P, Milne R. Literature searching for randomized controlled trials used in Cochrane reviews: rapid versus exhaustive searches. International Journal of Technology Assessment in Health Care 2003;19(4):591‐603. - PubMed
Schulz 1995
    1. Schulz KF, Chalmers I, Hayers RJ, Altman DG. Emprirical evidence of bias. Dimensions of methodological quality associated with estimates of treatment effects in controlled trials. JAMA 1995;273:408‐12. - PubMed
Thorlund 2009
    1. Thorlund K, Devereaux PJ, Wetterslev J, Gyuatt G, Ioannidis JPA, Thabane L, et al. Can trial sequential monitoring boundaries reduce spurious inferences from meta‐analyses?. International Journal of Epidemiology 2009;38:276‐86. - PubMed
Wetterslev 2008
    1. Wetterslev J, Thorlund K, Brok J, Gluud C. Trial sequential analysis may establish when firm evidence is reached in cumulative meta‐analysis. Journal of Clinical Epidemiology 2008;61(1):64‐75. - PubMed
Wetterslev 2009
    1. Wetterslev J, Thorlund K, Brok J, Gluud C. Estimating required information size by quantifying diversity in random‐effects model meta‐analyses. BMC Medical Research Methodology 2009;9:86. - PMC - PubMed
Wood 2008
    1. Wood L, Egger M, Gluud LL, Schulz KF, Jüni P, Altman DG, et al. Empirical evidence of bias in treatment effect estimates in controlled trials with different interventions and outcomes: meta‐epidemiological study. BMJ (Clinical Research Ed) 2008;336(7644):601‐5. - PMC - PubMed

MeSH terms

LinkOut - more resources