Post-ERCP Antibiotic Regimen for High-Risk Patients
For patients at high risk of infection after ERCP, prophylactic antibiotics should be administered routinely, with specific regimens tailored to the patient's risk factors for multidrug-resistant organisms. 1
Risk Assessment for Post-ERCP Infections
High-risk patients who should receive prophylactic antibiotics include:
- Patients with biliary obstruction 2
- Patients with incomplete or difficult biliary drainage 1
- Patients with primary sclerosing cholangitis (PSC) 1
- Patients with pancreatic pseudocyst 3
- Patients at high risk for endocarditis 3, 4
Recommended Antibiotic Regimens
Standard Risk Patients (no MDR colonization, immunocompetent)
- Single dose of 1g intravenous cefoxitin 30 minutes before ERCP 2
- Alternative: Oral ciprofloxacin 750 mg twice daily, started at least 90 minutes prior to procedure 5
Patients with Suspected MDR Organisms or Immunocompromised
One of the following antibiotics:
- Meropenem 1g every 6 hours by extended infusion or continuous infusion 1
- Doripenem 500 mg every 8 hours by extended infusion or continuous infusion 1
- Imipenem/cilastatin 500 mg every 6 hours by extended infusion 1
Patients with Beta-lactam Allergy
- Eravacycline 1 mg/kg every 12 hours 1
Patients with Septic Shock
One of the following antibiotics:
- Meropenem 1g every 6 hours by extended infusion or continuous infusion 1
- Doripenem 500 mg every 8 hours by extended infusion or continuous infusion 1
- Imipenem/cilastatin 500 mg every 6 hours by extended infusion 1
- Eravacycline 1 mg/kg every 12 hours 1
Duration of Antibiotic Therapy
- For prophylaxis in high-risk patients without infection: Single dose administered 30 minutes before the procedure 2
- For patients with established infection (cholangitis): 4 days in immunocompetent and non-critically ill patients if source control is adequate 1
- For immunocompromised or critically ill patients with established infection: Up to 7 days based on clinical conditions and inflammatory markers if source control is adequate 1
Efficacy of Prophylactic Antibiotics
- Prophylactic antibiotics significantly reduce the risk of infectious complications after ERCP in high-risk patients (2.8% vs 9.8% without prophylaxis) 2
- Specifically, antibiotics reduce the incidence of cholangitis (1.7% vs 6.4% without prophylaxis) 2
- Meta-analyses show prophylactic antibiotics prevent cholangitis (RR: 0.54), septicemia (RR: 0.35), and bacteremia (RR: 0.50) 1
Important Considerations
- Traditional prophylaxis with second-generation cephalosporins or ceftriaxone may be inadequate due to increasing antimicrobial resistance 6
- Consider local resistance patterns when selecting antibiotics 6
- Bile fluid sampling during ERCP can guide antibiotic treatment if cholangitis occurs despite prophylaxis 1
- Routine prophylactic antibiotics are not recommended for all patients undergoing ERCP, only those at high risk 3