Endoscopic retrograde cholangiopancreatography (ERCP) involves cannulating the biliary system in order to diagnose bile or pancreatic duct obstruction. It then affords the possibility of relieving this obstruction using various interventions. Traditionally, prophylactic antibiotics have been administered to decrease the incidence of infective complications as a result of interfering with a normally sterile biliary tree. Preventing overuse of antibiotics and consequent bacterial resistance must be aimed. If antibiotics do not prevent complications following ERCP, then antibiotics should not be used.
When we considered for analyses all randomised patients, use of antibiotics administered before the procedure to decrease the incidence of infective complications was favoured. However, in the subgroup of patients where their bile duct obstruction is relieved during the first ERCP procedure, no benefit in using antibiotics could be demonstrated. This potentially suggests that not all patients may need antibiotics before their ERCP.
Whether antibiotics can be given before the procedure, during the procedure, or immediately after the procedure once it becomes evident that the bile or pancreas duct obstruction cannot be relieved during the first ERCP needs to be tested in future randomised clinical trials.