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【medical-news】ERCP后是否需要抗生素预防感染
Most patients do not require antibiotic prophylaxis before ERCP, but it seems reasonable to give antibiotic prophylaxis in patients with primary sclerosing cholangitis, pseudocyst, and hilar tumor, for whom complete drainage might not be possible.
Antibiotic prophylaxis is given to prevent infective endocarditis and other infections after ERCP. Although both types of infections are uncommon after ERCP, the potential morbidity and mortality of such complications weighed against the ease of giving prophylactic antibiotics have driven their use. Our understanding of the infectious risk of endoscopy has continued to evolve. For example, the American Society for Gastrointestinal Endoscopy (ASGE) considered ERCP in obstructed biliary systems to be a high-risk procedure requiring endocarditis prophylaxis in high-risk cardiac conditions.1 However, the most recent recommendations from the American Heart Association do not endorse antibiotic prophylaxis for any GI endoscopy, including ERCP in an obstructed biliary system.2
The risk of noncardiac post-ERCP infections (thought to be approximately 1%) is uncommon enough to make randomized controlled studies of antibiotic prophylaxis difficult and impractical. Although a meta-analysis showed that antibiotic prophylaxis did not reduce post ERCP infections, and recommended against it,3 the ASGE endorsed it in patients with biliary obstruction or pancreatic cysts undergoing ERCP.1 The actual clinical use of prophylaxis before ERCP has not been well documented.
In this issue of Gastrointestinal Endoscopy, Cotton et al4 report the results of their quality improvement project that reduced pre-ERCP antibiotic prophylaxis over an 11-year period. They administered broad-spectrum intravenous antibiotics to 95% of patients undergoing ERCP from July 1994 to December 1996 and retrospectively documented only 11 (0.48%) postprocedure infections. This prompted them to change prophylaxis to oral ciprofloxacin for the following year, which was then given only to patients with suspected biliary or pancreatic obstruction and immunosuppression over the next 4 years. Finally, between 2002 and 2005 they gave oral ciprofloxacin only to patients with predicted incomplete drainage (primary sclerosing cholangitis, pseudocyst, gallstones, or hilar tumor) or immunosuppression, and intravenous ciprofloxacin prophylaxis after unsuccessful endoscopic drainage. The authors did not state the number of patients receiving intravenous ciprofloxacin, but a high rate of technical success is implied from the 98% success rate recorded during the third phase. Likewise, we assume that an alternate broad-spectrum antibiotic was given to patients with allergy to ciprofloxacin and that patients already on antibiotics continued them.
This quality improvement project reduced the use of prophylaxis for patients undergoing ERCP from 95% to 26% without significantly increasing post-ERCP infections. Infection developed in 25 of 6150 treated patients (0.42%) and in 7 of 5334 untreated patients (0.13%); infections developed in 5 of 1065 patients (0.47%) and in 4 of 2974 patients (0.13%), respectively, during the last phase between 2002 and 2005. The slightly higher rate of infection observed after prophylaxis probably reflects patient selection, because prophylaxis would not have been given in the absence of any known risk factors for infection. Thus, the 0.13% rate could be considered as the true rate of infectious complications resulting from ERCP unrelated to any known underlying risk factors.
Post–liver transplant stricture was the only variable significantly associated with infection on multivariate analysis (OR = 5.2; 95% CI, 2.4-11.2.) Risk of infection fell significantly (OR=0.89; 95% CI, 0.80-0.98) over the study period, despite reducing antibiotic prophylaxis—perhaps reflecting improvements in endoscopic drainage.
We agree with the authors that most patients do not require antibiotic prophylaxis before ERCP. The American Heart Association may have finally settled the issue of endocarditis prophylaxis by not recommending it for any GI endoscopy. Alternatively, not many will argue with giving prophylaxis after unsuccessful endoscopic drainage. Although it seems reasonable to give antibiotic prophylaxis to patients with primary sclerosing cholangitis, pseudocyst, and hilar tumor, for whom complete drainage might not be possible, the very high success rate of drainage achieved by the authors argues against routine prophylaxis in such patients, because almost all will have successful drainage. We agree with the authors that prophylaxis is indicated in patients with a “predictably undrainable biliary system,” but just what this means remains to be clarified. Again, the very high rate of technical success suggests that most patients can be successfully drained in their unit. A reasonable compromise might be to delay antibiotic treatment until endoscopic drainage has clearly failed.
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作者:admin@医学,生命科学 2010-12-28 05:14
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