Prophylactic Antibiotics Reduce Infectious Complications After ERCP in Patients with Suspected Biliary Obstruction: A Meta-Analysis of Randomized Controlled Trials.

BACKGROUND AND AIMS: Prophylactic antibiotic use before endoscopic retrograde cholangiopancreatography (ERCP) remains controversial. Current guidelines recommend against routine prophylaxis. This meta-analysis evaluates the role of prophylactic antibiotics in reducing infectious complications in patients with suspected biliary obstruction undergoing ERCP.

METHODS

We included randomized controlled trials (RCTs) published in full and comparing antibiotics with placebo in patients undergoing ERCP for suspected biliary obstruction. Outcomes assessed were rates of cholangitis, bacteremia, and infectious complications. Data sources included CENTRAL, MEDLINE, and EMBASE from inception through January 2025. Studies published as abstract only were excluded. For subgroup analyses, studies were stratified by antibiotic class (cephalosporins vs penicillins), presence of radiologic evidence or clinical suspicion of obstruction, and sample size (n <150 vs n ≥ 150).

RESULTS

5 RCTs involving 1,154 patients met inclusion criteria, with 570 individuals receiving antibiotics and 584 serving as controls. Prophylactic antibiotics significantly reduced the risk of cholangitis (RR 0.44, 95% CI 0.22-0.89, p = 0.24; I2 27%), bacteremia (RR 0.28, 95% CI 0.13-0.58, p = 0.57, I2 0%), and infectious complications (RR 0.35, 95% CI 0.17-0.73, p = 0.16, I2 40%). The significant decrease in the rates of cholangitis, bacteremia, and infectious complications remained significant in patients with radiologic evidence of obstruction.

CONCLUSION

Prophylactic antibiotics significantly reduced post-ERCP infections in patients with biliary obstruction. These findings challenge existing guidelines that recommend antibiotics in high-risk scenarios only. Our study highlights the importance of pre-procedural antibiotics, especially in patients with radiologically confirmed biliary obstruction. While further RCTs are needed to refine recommendations, clinicians should consider prophylactic antibiotics to improve patient outcomes.