Prospective evaluation of bacteremia rates and infectious complications among patients undergoing single-operator choledochoscopy during ERCP

Background and study aims: Choledochoscopy is increasingly performed during endoscopic retrograde cholangiopancreatography (ERCP) for direct bile duct visualization. Choledochoscopy necessitates irrigation of the bile duct with water or saline, which may increase intrabiliary pressure and consequently the risks of bacteremia and cholangitis. The aim of this study was to prospectively evaluate the risk of bacteremia and infectious complications in patients undergoing single-operator choledochoscopy (SOC).

Patients and methods: Patients requiring ERCP with SOC at two tertiary care centers were enrolled prospectively. Blood cultures were obtained immediately before the ERCP, after completion of the ERCP portion of the procedure (to determine ERCP-related bacteremia), and 15 minutes after completion of SOC.

Results: A total of 72 patients (mean age 64 years; 51.4 % male) underwent ERCP with SOC. True positive blood cultures were noted in 20 patients (27.8 %; 95 % confidence interval [CI] 17.86 % – 39.59 %), of whom 6 patients (8.3 %; 95 %CI 3.12 % – 17.26 %) had transient bacteremia following ERCP. Of 14 patients (19.4 %; 95 %CI 11.05 % – 30.46 %) with sustained bacteremia following ERCP or SOC, 10 patients (13.9 %; 95 %CI 6.86 % – 24.06 %) had sustained bacteremia related to SOC. Despite the use of post-procedure intravenous antibiotic administration, seven patients (9.7 %; 95 %CI 3.99 – 19.01 %) required further antibiotic treatment for infectious complications, three of whom (4.2 %; 95 %CI 0.86 % – 11.69 %) were hospitalized in order to receive intravenous antibiotic therapy.

Conclusion: The bacteremia associated with ERCP with SOC and the subsequent risk of hospitalization for infectious complications suggest that preprocedure antibiotic prophylaxis should be considered for patients undergoing SOC, particularly in older patients and those with prior stent placement or undergoing intraductal stone lithotripsy.

Trial registration: clinical trials.gov (NCT01414400).

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