From the Guidelines
Antibiotic prophylaxis is not routinely recommended for choledocolithiasis with no sign of infection. In patients undergoing endoscopic stone extraction, such as ERCP, for common bile duct stones without evidence of infection, prophylactic antibiotics can be safely avoided, according to the updated guideline on the management of common bile duct stones 1. This recommendation is based on very low-quality evidence, but it suggests that patients should be managed in accordance with the guidelines on antibiotic prophylaxis during endoscopy. The guideline emphasizes that in the absence of specific risk factors for sepsis, such as sclerosing cholangitis or hilar strictures, prophylactic antibiotics are not necessary 1.
Some key points to consider when deciding on antibiotic prophylaxis include:
- The patient's underlying health status and risk factors for infection
- The type of procedure being performed and the anticipated risk of infection
- The potential benefits and risks of antibiotic prophylaxis, including the risk of developing resistant organisms and adverse effects
- The availability of alternative prophylactic measures, such as rectal NSAIDs, which have been shown to reduce the risk of post-ERCP pancreatitis 1
In general, the use of prophylactic antibiotics should be reserved for high-risk patients or those with specific risk factors for infection, and even then, the decision to use antibiotics should be made on a case-by-case basis 1. The focus should be on providing appropriate care while minimizing unnecessary antibiotic exposure and reducing the risk of adverse effects.
From the Research
Antibiotic Prophylaxis for Choledocolithiasis
- The use of antibiotic prophylaxis in patients with choledocolithiasis without signs of infection is a topic of debate 2, 3, 4.
- A study published in 2024 found that prophylactic antibiotics significantly reduced the risk of infectious complications, including cholangitis, after endoscopic retrograde cholangiopancreatography (ERCP) in patients with biliary obstruction 2.
- The American Society for Gastrointestinal Endoscopy (ASGE) guideline on the role of endoscopy in the evaluation and management of choledocholithiasis does not specifically address antibiotic prophylaxis for patients without signs of infection 5.
- A clinical spotlight review on the management of choledocholithiasis recommends antibiotic prophylaxis for patients undergoing ERCP, but does not provide specific guidance for patients without signs of infection 6.
- A Cochrane review published in 2010 found that prophylactic antibiotics reduced the risk of bacteriaemia, cholangitis, and septicaemia in patients undergoing elective ERCP, but the effect was less evident in patients with uncomplicated ERCP 4.
- A report by the British Society of Gastroenterology Endoscopy Committee recommends antibiotic prophylaxis for ERCP in patients with biliary stasis or pancreatic pseudocyst, but does not provide specific guidance for patients with choledocolithiasis without signs of infection 3.
Recommendations
- The available evidence suggests that antibiotic prophylaxis may be beneficial in reducing the risk of infectious complications after ERCP in patients with biliary obstruction, including those with choledocolithiasis without signs of infection 2, 4.
- However, the decision to use antibiotic prophylaxis should be made on a case-by-case basis, taking into account the individual patient's risk factors and the potential benefits and harms of antibiotic use 2, 3, 4.