Duration of Antibiotic Prophylaxis After ERCP
For most patients undergoing ERCP with successful biliary drainage, antibiotic prophylaxis should be discontinued within 24 hours of the procedure, or a single dose may be sufficient.
Standard Duration for Prophylactic Antibiotics
In patients without established infection who receive prophylactic antibiotics for ERCP, discontinue antibiotics within 24 hours after the procedure. 1 This applies to the vast majority of ERCP cases where complete biliary drainage is achieved and no active infection is present.
- A single dose of antibiotics at the time of ERCP may be sufficient for antibiotic prophylaxis in standard cases 1
- Recent evidence from a randomized controlled trial comparing single-dose versus short-course prophylactic antibiotics showed no significant differences in markers of inflammation, transient bacteremia, or infectious sequelae at day 5 after ERCP 1
- The urologic surgery literature, which shares similar principles for antimicrobial prophylaxis, confirms that prophylaxis should be discontinued within 24 hours of procedure termination in the absence of existing infection 1
Duration for High-Risk Patients and Special Circumstances
For patients with incomplete or difficult biliary drainage, continue antibiotics for 3-5 days post-procedure. 1, 2
- Patients with primary sclerosing cholangitis (PSC) should receive routine prophylactic antibiotics, with duration guided by drainage success 1, 2
- Meta-analyses demonstrate that prophylactic antibiotics prevent cholangitis (RR: 0.54), septicemia (RR: 0.35), and bacteremia (RR: 0.50) in high-risk patients 1, 2
- If there are no signs of systemic inflammation or peritonitis after 3-5 days of treatment, antibiotics should be stopped 1
Duration for Established Infection (Cholangitis)
When cholangitis is present at the time of ERCP, this represents therapeutic rather than prophylactic antibiotic use, and duration extends beyond standard prophylaxis.
- For immunocompetent, non-critically ill patients with adequate source control: 4 days of antibiotic therapy 2
- For immunocompromised or critically ill patients with adequate source control: up to 7 days based on clinical conditions and inflammatory markers 2
- Recent evidence supports that antimicrobial therapy for ≤2 days after successful ERCP is adequate in patients with mild and moderate acute cholangitis 3
Key Clinical Considerations
Complete biliary drainage is the most important factor influencing antibiotic duration. 4
- If biliary drainage remains incomplete after ERCP, continue antibiotics until obstruction is relieved, with a maximum duration of 7 days 4
- Monitor for signs of infection including fever, increased white blood cell count, and C-reactive protein elevation 2
- Procalcitonin is the most sensitive laboratory test for detection of infection 2
- Consider bile fluid sampling during ERCP to guide antibiotic treatment if cholangitis occurs despite prophylaxis 1
Common Pitfalls to Avoid
- Do not routinely extend antibiotics beyond 24 hours in uncomplicated cases – this increases antimicrobial resistance, morbidity, and healthcare costs without proven benefit 1
- Do not confuse prophylactic with therapeutic antibiotic use – when infection is present before or develops after ERCP, therapeutic courses (4-7 days) are appropriate 2
- Do not assume all high-risk patients need extended courses – even in PSC patients, if drainage is complete and no infection develops, prolonged antibiotics are unnecessary 1