Evaluation of Biliary Bacterial Resistance in Patients With Frequent Biliary Instrumentation: One Size Does Not Fit All

Abstract

Introduction: Bacteremia due to ascending cholangitis can be encountered as a complication of biliary instrumentation. Patients who undergo frequent endoscopic retrograde cholangiopancreatography (ERCP) usually receive periprocedural prophylactic antibiotics.Table: Demographics and clinical characteristics.Methods: This is a retrospective review of patients with more than one ERCP, and bacteremia due to ascending cholangitis. Conventional empiric antibiotics were defined as ciprofloxacin, penicillins alone or first or second-generation cephalosporin. Antibiotics with broader spectrum were defined as wide spectrum. Results: A total of 140 patients over a period of 6 years were reviewed. Sixty-two patients were excluded due to bacteremia secondary to other source. Patient characteristics are described in table 1. Over 50% of bacteria were not sensitive to conventional empiric antibiotics for biliary sepsis (ciprofloxacin or 1st or 2nd generation cephalosporin). Forty-one patients received post procedural antibiotics for one week starting from the day of the procedure, of those 58% grew bacteria resistant to the antibiotic used for prophylaxis and 26 patients (63%) required a wider-spectrum antibiotic for treatment. Number of ERCPs was not associated with resistance to prophylactic antibiotics (p 0.7103) or needing broader-spectrum antibiotics for treatment of ascending cholangitis associated bacteremia (p 0.1868). Routine use of antibiotic prophylaxis after ERCP was associated with trend towards need for wider-spectrum antibiotics for ascending cholangitis associated bacteremia, chi-square 3.7, P= 0.0540. Conclusion: Biliary bacterial resistance to conventional empiric recommended antibiotics is an emerging problem, and consideration for wider spectrum antibiotics should be made in certain patients, particularly in patients with prior antibiotic exposure. Blood cultures are needed to guide therapy.