LETTER
Antibiotic Prophylaxis before Endoscopic Retrograde Cholangiopancreatography
Baudouin Byl, MD, and
Jacques Deviere, MD, PhD
15 June 1997 | Volume 126 Issue 12 | Page 1001
TO THE EDITOR:
We read with interest the paper by van den Hazel and associates [1] on antimicrobial prophylaxis of infection after endoscopic retrograde cholangiopancreatography (ERCP).
The authors concluded that single-dose prophylaxis with piperacillin is not associated with a clinically significant decrease in the incidence of acute cholangitis after ERCP performed for suspected common bile duct stones or stricture. In their large study, they considered all patients suspected of having obstruction; 52% of them had jaundice, and 21% had no biliary tract obstruction. As the authors mentioned, 44 patients inadvertently received antibiotics "... because of concern about insufficient drainage of a contaminated biliary tract or because of complications during ERCP." These 44 patients probably represent the population at highest risk for cholangitis, and this inadvertent antibiotic treatment could have masked a major beneficial effect of antibioprophylaxis. Moreover, a second ERCP or additional prophylaxis interfered with follow-up in 82 high-risk patients, and this should be taken into account.
We recently showed that by using antimicrobial prophylaxis in patients with cholestasis or obstructive jaundice, the incidence of clinical infection and proven bacteremia after ERCP dramatically decreases [2]. The difference in the incidence of cholangitis in our placebo group (7 of 34 patients) and in that of van den Hazel and associates (17 of 281 patients) is probably due to different selection criteria (only patients who had cholestasis before having ERCP were entered into our study) and to the fact that van den Hazel and associates may have missed a substantial number of episodes of cholangitis because of "inadvertent" additional antibiotic treatment.
Therefore, although we agree that antibioprophylaxis should not be recommended for every patient undergoing ERCP, we think that this treatment is highly effective in selected patients who present with signs of cholestasis. It should also be continued in cases of incomplete drainage after the first ERCP because antibiotic prophylaxis and achievement of complete bile duct drainage independently decrease the incidence of cholangitis or bacteremia after ERCP in these patients.
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Author and Article Information
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Erasme University Hospital, 1070 Brussels, Belgium
1. van den Hazel SJ, Speelman P, Dankert J, Huibregtse K, Tytgat GN, van Leeuwen DJ. Piperacillin to prevent cholangitis after endoscopic retrograde cholangiopancreatography. A randomized, controlled trial. Ann Intern Med. 1996; 125:442-7.
2. Byl B, Deviere J, Struelens MJ, Roucloux I, De Coninck A, Thys JP, et al. Antibiotic prophylaxis of infectious complications after therapeutic endoscopic retrograde cholangiopancreatography. A randomized, double-blind, placebo-controlled study. Clin Infect Dis. 1995; 20:1236-40.
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