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.
| Identifer | oai:union.ndltd.org:netd.ac.za/oai:union.ndltd.org:wits/oai:wiredspace.wits.ac.za:10539/10583 |
| Date | 19 October 2011 |
| Creators | Brand, Martin |
| Source Sets | South African National ETD Portal |
| Language | English |
| Detected Language | English |
| Type | Thesis |
| Format | application/pdf |
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