Post-ERCP pancreatitis: Reduction by routine antibiotics

Cholangitis and pancreatitis are severe complications of endoscopic retrogr ade cholangiopancreatography, (ERCP). Antibiotics have been considered impo rtant in preventing cholangitis, especially in those with jaundice. Some ha ve suggested that bacteria may play a role in the induction of post-ERCP pa ncreatitis. It is not clear, however, whether the incidence of post-ERCP pa ncreatitis could be reduced by antibiotic prophylaxis, as is the case with septic complications. In this prospective study, a total of 321 consecutive patients were randomized to the following two groups: (1) a prophylaxis gr oup (n = 161) that was given 2 g of cephtazidime intravenously 30 minutes b efore ERCP, and (2) a control group (n = 160) that received no antibiotics. All patients admitted to the hospital for ERCP who had not taken any antib iotics during the preceding week were included. Patients who were allergic to cephalosporins, patients with immune deficiency or any other condition r equiring antibiotic prophylaxis, patients with clinical jaundice, and pregn ant patients were excluded. In the final analysis six patients were exclude d because of a diagnosis of bile duct obstruction but with unsuccessful bil iary drainage that required immediate antibiotic treatment. The diagnosis o f cholangitis was based on a rising fever, an increase in the C-reactive pr otein (CRP) level, and increases in leukocyte count and liver function valu es, which were associated with bacteremia in some. The diagnosis of acute p ancreatitis was based on clinical findings, and increases in the serum amyl ase level (> 900 IU/L), CRP level, and leukocyte count with no increase in liver chemical values. The control group had significantly more patients wi th post-ERCP pancreatitis (15 of 160 in the prophylaxis group vs. 4 of 155 in the control group; P = 0.009) and cholangitis (7 of 160 vs. 0 of 155; P = 0.009) compared to the prophylaxis group. Nine patients in the prophylaxi s group (6%) and 15 patients in the control group (9%) had remarkably incre ased serum amylase levels (> 900 IU/L) after ERCP, but clinical signs of ac ute pancreatitis with leukocytosis, CRP reaction, and pain developed in fou r of nine patients in the prophylaxis group compared to 15 of 15 patients w ith hyperamylasemia in the control group (P = 0.003). In a multivariate ana lysis, the lack of antibiotic prophylaxis (odds ratio 6.63, P = 0.03) and s phincterotomy (odds ratio 5.60, P = 0.05) were independent risk factors for the development of post-ERCP pancreatitis. We conclude that antibiotic pro phylaxis effectively decreases the risk of pancreatitis, in addition to cho langitis after ERCP, and can thus be routinely recommended prior to ERCP Th ese results suggest that bacteria could play a role in the pathogenesis of post-ERCP pancreatitis.