Infection after ERCP, and antibiotic prophylaxis: a sequential quality-improvement approach over 11 years

Background: Infection is a known complication of ERCP procedures, and the role of antibiotic prophylaxis is uncertain. Objective: To document the incidence of infection after ERCP while changing the policy for antibiotic prophylaxis. Design: Retrospective analysis of data collected prospectively on infection complications, with progressive reduction in the use of prophylactic antibiotics. Setting: Single-center university referral hospital. Patients: A total of 11,484 ERCP procedures were documented prospectively over a period of 11 years. Interventions: After baseline assessment, the use of prophylactic antibiotics was sequentially reduced and simplified in 3 phases. Main Outcome Measurements: Incidence of infection, categorized by severity. Results: The infection rate was low overall and decreased significantly with time, from 0.48% to 0.25%, despite a marked reduction in the proportion of patients given antibiotics (from 95% to 25%). Multivariate analysis also showed that the only category of patients at increased risk for infection (despite antibiotics) was the subgroup undergoing interventions for biliary problems after liver transplantation. Limitations: A lack of routine follow-up may mean that some delayed infectious complications were not recorded. The low risk of infection in this series may reflect the high technical success rate for relief of biliary Obstruction; thus, our current minimalist antibiotic policy may not be generalizable to community practice. Conclusions: Infectious complications of ERCP can be kept to a minimum with a limited use of prophylactic antibiotics.