Is Antibiotic Prophylaxis Warranted in All Patients With Biliary Obstruction Undergoing Endoscopic Retrograde Cholangiopancreatography?

GOALS: To evaluate whether prophylactic antibiotics improve infectious complication rates after endoscopic retrograde cholangiopancreatography (ERCP). BACKGROUND: Current guidelines recommend prophylactic antibiotics before ERCP only in cases of anticipated incomplete biliary drainage or severe immunosuppression. A recent randomized controlled trial (RCT) suggested a benefit regardless of drainage status. This systematic review and meta-analysis assess the impact of prophylactic antibiotics on post-ERCP infectious complications. STUDY: A systematic search of major databases was conducted through June 2024 for RCTs comparing ERCP outcomes with and without antibiotic prophylaxis. Pooled data were analyzed for the composite outcome of infectious complications, including cholangitis, bacteremia, and sepsis. Mortality and pancreatitis were also analyzed. Publication bias was evaluated using funnel plots and regressions for funnel plot asymmetry. Our analysis implemented a dichotomous regression model with random effects using R software. RESULTS: Eleven RCTs with 2105 patients were included, with 1086 receiving antibiotics and 1019 serving as controls. Infectious complications were significantly lower in the antibiotic group [risk difference (RD): -0.08, 95% CI: -0.14 to -0.02, P =0.00001, I2 : 83%]. Beta-lactam and cephalosporin antibiotics had a greater effect (RD: -0.10, 95% CI: -0.17 to -0.04, P =0.00001, I2 : 85%). Bacteremia rates were also reduced (RD: -0.06, 95% CI: -0.11 to -0.01, P =0.01, I2 : 58%). No significant differences were found in cholangitis, sepsis, pancreatitis, or mortality. Sensitivity analyses confirmed robustness. CONCLUSIONS: Antibiotic prophylaxis reduces post-ERCP infectious complications and should be considered in all patients with biliary obstruction who are undergoing ERCP.