Retrospective Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Nov 7, 2020; 26(41): 6402-6413
Published online Nov 7, 2020. doi: 10.3748/wjg.v26.i41.6402
Older age, longer procedures and tandem endoscopic-ultrasound as risk factors for post-endoscopic retrograde cholangiopancreatography bacteremia
Liat Deutsch, Shay Matalon, Adam Phillips, Moshe Leshno, Oren Shibolet, Erwin Santo
Liat Deutsch, Shay Matalon, Adam Phillips, Oren Shibolet, Erwin Santo, The Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
Liat Deutsch, Adam Phillips, Oren Shibolet, Erwin Santo, Department of Gastroenterology and Hepatology, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
Shay Matalon, Department of Gastroenterology, Assaf Harofe Medical Center, Zeriffin 70300, Israel
Moshe Leshno, Faculty of Management, Tel Aviv University, Tel Aviv 6997801, Israel
Author contributions: Deutsch L designed the study, performed data acquisition, data analysis, statistical analysis and wrote the paper; Matalon S performed data acquisition and contributed to manuscript preparation and editing; Phillips A provided clinical advise and reviewed the paper; Leshno M performed and reviewed the statistical analysis and reviewed the manuscript; Shibolet O performed language editing and reviewed the manuscript; Santo E reviewed the manuscript and approved final version for submission.
Institutional review board statement: The study was approved by the local Institutional Review Board (IRB num: 0598-13-TLV).
Informed consent statement: Data was anonymous and informed consent was waivered.
Conflict-of-interest statement: None
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Erwin Santo, MD, Chief Doctor, Chief Physician, Department of Gastroenterology and Liver Diseases, Tel Aviv Medical Center, Affiliated with Sackler School of Medicine, Tel Aviv University, No. 6 Weizmann Street, Tel Aviv 6423906, Israel. erwins@tlvmc.gov.il
Received: June 18, 2020
Peer-review started: June 18, 2020
First decision: July 28, 2020
Revised: August 16, 2020
Accepted: September 16, 2020
Article in press: September 16, 2020
Published online: November 7, 2020
Processing time: 141 Days and 0.5 Hours
Abstract
BACKGROUND

Clinically significant post-endoscopic retrograde cholangiopancreatography (ERCP) bacteremia (PEB) occurs in up to 5% of cases, while antibiotic prophylaxis is recommended only when an ERCP is unlikely to achieve complete biliary drainage. However, the current recommendations may not cover all potential risk factors for PEB.

AIM

To identify novel risk factors for PEB and evaluate appropriateness of antibiotic prophylaxis.

METHODS

A retrospective study of 1082 ERCP procedures performed between January 2012 - December 2013 in a single tertiary medical center. Data collection included: Demographic and clinical characteristics such as pre and post procedure antibiotic treatment and bacterial blood cultures. Exclusion criteria were: (1) Age < 18 years; (2) Positive bacterial blood culture before ERCP; (3) Scheduled antibiotic treatment prior to ERCP; (4) Hospitalization longer than 14 d before ERCP; and (5) missing critical data. Stepwise Logistic Regression analysis and Decision Tree algorithms were used for prediction modeling of PEB.

RESULTS

A total of 626 ERCPs performed in 434 patients were included. Mean age 66.49 ± 15.4 years and 46.5% were males. PEB prevalence was 3.7%. Antibiotic prophylaxis was administrated in 139/626 (22.2%) cases but was indicated according to the guidelines only in 44/626 (7%) cases. In all the PEB cases, prophylaxis was deemed not indicated. A stepwise logistic regression [receiver operating characteristic (ROC), 0.766], identified 3 variables as independent risk factors for PEB: Age at ERCP ≥ 75 years (OR, 3.780, 95%CI: 1.519-9.408, P = 0.004); Tandem EUS/ERCP with fine needle aspiration (FNA) (OR, 14.528, 95%CI: 3.571-59.095, P < 0.001); ERCP duration longer than 60 min (OR, 5.396, 95%CI: 1.86-15.656, P = 0.002). In a decision tree model (ROC, 0.778) the probability for PEB without any risk factors was 1% regardless of prophylaxis administration. 

CONCLUSION

The prevalence of PEB in our study is similar to previous reports, despite the fact that antibiotic prophylaxis was administrated more readily than recommended. ERCP duration longer than 60 min, tandem EUS-ERCP with FNA and age above 75 years are significant risk factors for PEB. These factors should be further evaluated as indications for prophylactic antibiotic treatment before ERCP.

Keywords: Endoscopic retrograde cholangiopancreatography; Bacteremia; Tandem-procedures; Fine needle aspiration; Antibiotic prophylaxis; Biliary drainage

Core Tip: Clinically significant post-endoscopic retrograde cholangiopancreatography (ERCP) bacteremia (PEB) occurs in up to 5% of cases, while antibiotic prophylaxis is recommended when an ERCP is unlikely to achieve complete biliary drainage. Our aim was to identify novel risk factors for PEB and evaluate appropriateness of antibiotic prophylaxis. This retrospective cohort study included 626 ERCPs while PEB prevalence was 3.7%. Antibiotic prophylaxis was administrated in 22.2% of cases but was indicated in 7%. Independent risk factors for PEB were: Age ≥ 75 years, Tandem-EUS/ERCP with FNA and ERCP duration ≥ 60 min (P < 0.005). These novel risk factors should be further evaluated as indications for prophylactic antibiotic treatment before ERCP.