Antimicrobial prophylaxis during biliary endoscopic procedures

Endoscopic retrograde cholangiopancreatography (ERCP) is a well-established technique and has considerable diagnostic value and therapeutic potential in patients with hepatobiliary disease. In experienced hands, ERCP is a safe procedure. The most important complications are pancreatitis, infection--ascending cholangitis and septicaemia--instrumental injury and haemorrhage. The reported incidence of bacteraemia complicating ERCP varies considerably (0.16-16%) but this may be due to differences in specimen collection and culture techniques. Clinically significant sepsis is the commonest cause of death due to ERCP with a case fatality rate of 8-20%. As the danger of sepsis was increasingly recognized, antibiotic prophylaxis was considered as routine policy in many centres; supporting evidence was retrospective. Significant differences between antibiotic and control groups are difficult to confirm in clinically controlled trials because of an insufficient number of patients and the low incidence of cholangitis and septicaemia. The optimum regimen is unknown and there is uncertainty regarding the duration of treatment required to provide adequate protection. Local variations in bacterial sensitivity should be taken into account when choosing the antimicrobial agent. In patients without clinical signs of biliary obstruction the risk of infection is low and prophylaxis may be unnecessary.