Risk factors for post-ERCP infection, indications for single-use duodenoscopes and cost-benefit analysis of their use

Aims The aim of our study was, firstly, to determine the indications for single-use duodenoscope (SUD) based on a large cohort of patients who had undergone ERCP with a reusable duodenoscope, and secondly, to calculate the cost-benefit balance for SUD use in different ERCP practice scenarios.

Methods We conducted a retrospective longitudinal study including all ERCPs performed in an academic and in a non-academic center between July 1, 2021 and June 30, 2022, based on a prospective registry. Potential risk factors for post-ERCP infections, infectious data, and technical data were recorded at inclusion. Post-ERCP infection was defined as any infection occurring within 30 days of ERCP, in the absence of a more likely infectious etiology and of pre-ERCP infection. Type of infection, AGREE classification, pre- and post-ERCP length of stay, germ type and its antibiogram, and duodenoscope serial number were also recorded. A link between germ type, duodenoscope serial number, and ERCP date was sought. Extra-cost of post-ERCP infections was calculated on the basis of hospital bills. Following different incidences of duodenoscope-associated infections (DAI), the first scenario envisaged SUD use for all patients at risk of infection, while the second scenario envisaged SUD use only for MDRO-carrying or -infected patients.

Results In these 654 ERCPs, including 539 academic and 115 non-academic procedures, 14 patients were MDRO-carriers or -infected. 54 post-ERCP infections were identified, while a germ was found in 23 of these. Most of the germs (n=27) were gram-negative bacteria (n=22), with different antibiograms. Two cases of Vancomycin-Resistant Enterococci septicemia were observed, while no Pseudomonas infections were detected. Multivariate analysis showed that the presence of a Klatskin tumour, hematological disease, chemotherapy, and benign biliary stricture were significantly associated with post-ERCP infection. Considering HIV, Covid and MDRO-carriers or -infected patients, the total theoretical indications for SUD use was 37.8% of all ERCPs. However, no correlation could be seen between germ type and antibiogram in pre- or post-ERCP infection and the duodenoscope serial number, nor according to ERCP date. The cost-benefit analysis showed that the acceptable additional cost of using SUD compared with using reusable duodenoscope ranged from €50 to €2,923, varying considerably according to the prevalence of patients at high risk of infection and MDRO-carriers or -infected patients, and DAI incidence.

Conclusions We found no correlation in favour of a DAI in our cohort. Based on risk criterias for post-ERCP infection, indication rate for SUD is 37.8%. Cost-benefit analysis showed that the 'acceptable' additional cost of SUD-use varied considerably. Assuming a MDRO carriage of 2.14% and a 1% DAI incidence, the acceptable extra cost of SUD use would be around €2046.

Publication History

Article published online:
27 March 2025