Gastroenterological Endoscopy. Группа авторов

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      Patients with acute cholangitis are typically treated with antibiotics and biliary drainage via ERCP.²⁶ Additional antibiotic administration for procedural prophylaxis is not recommended. Cholangitis and sepsis are known complications of ERCP, occurring in up to 3% of patients.^{27,28,29,30,31,32,33,34} Antibiotic prophylaxis has been shown to reduce the incidence of bacteremia associated with ERCP,^35,36 but this does not clearly translate into a reduction in the incidence of cholangitis. A recent Cochrane systematic review that comprised 9 randomized clinical trials and 1,573 patients established that prophylactic antibiotics reduced bacteremia and seemed to prevent cholangitis and septicemia in patients undergoing elective ERCP.³⁷ However, in the subgroup of patients with uncomplicated ERCP, the effect of antibiotics was less prominent.³⁷ In one study, incomplete biliary drainage was predictive of 91% of all cases of sepsis.³⁸ Antibiotic therapy may therefore have particular value where drainage achieved at ERCP is incomplete or achieved with difficulty, such as with hilar cholangiocarcinoma and primary sclerosing cholangitis.^38,39,40 In one of the few trials that indicated a benefit of antibiotics in patients undergoing ERCP for biliary obstruction, prophylactic antibiotics were continued postprocedurally for several days.⁴¹ The ASGE recommends against antibiotic prophylaxis prior to ERCP where obstructive biliary tract disease is not suspected or when complete biliary drainage is expected.²⁵ On the other hand, the ASGE recommends that antibiotic prophylaxis be administered prior to ERCP in patients following liver transplantation and/or known or suspected biliary obstruction, where there is a possibility that complete biliary drainage may not be achieved.²⁵ Antibiotics should also be continued postprocedure when biliary drainage is incomplete.

      There are no studies that have assessed the value of antibiotic prophylaxis in patients undergoing ERCP who have pancreatic cystic lesions that communicate with the main pancreatic duct. However, the incidence of infectious complications in this setting seems to be uncommon given that ERCP is commonly performed in patients with such cystic lesions (e.g., intraductal papillary mucinous neoplasms, pseudocysts) without reports of cyst infections.

      Acute cholecystitis may result from placement of biliary self-expandable metallic stents (SEMSs) and is believed to be due to cystic duct obstruction. This occurs in 2 to 12% of cases.⁴² In two meta-analyses, the incidence of cholecystitis was similar between covered and uncovered SEMSs.^43,44 The majority of reported cases of cholecystitis after biliary SMES placement occurred in patients with malignant biliary obstruction,⁴² and tumor involvement of the cystic duct orifice is an independent risk factor for acute cholecystitis after SEMS insertion.⁴⁵ The role of prophylactic antibiotics has not been studied, but may help prevent this complication, especially since surgery is frequently needed to manage this untoward event.