Role of antibiotic prophylaxis in liver transplant patients undergoing endoscopic retrograde cholangiopancreatography: a systematic review and meta-analysis.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is frequently performed in liver transplant recipients for the management of biliary complications. While frequently medically necessary, ERCP carries a risk of post-procedural infections, particularly in immunosuppressed transplant patients. Prophylactic antibiotics are sometimes recommended, but their role remains uncertain. We aimed to address this knowledge gap. Methods: This single-arm systematic review and meta-analysis included randomised controlled trials (RCTs), prospective and retrospective cohort studies, and case-control studies evaluating the use of prophylactic antibiotics prior to or during ERCP (for any indication) in liver transplant recipients. No restrictions were placed on patient age, sex, or ethnicity. PubMed, Embase, Cochrane CENTRAL, and Scopus were searched for relevant studies published between database inception and June 2025. Primary outcomes of interest were incidence of post-ERCP cholangitis, infection, or pancreatitis, incidence of overall procedural complications, and mortality attributable to procedural complications. The quality of included studies was assessed via ROBINS-I. This work is registered with PROSPERO, CRD42024604381. Findings: This review included 26 studies involving more than 3800 liver transplant recipients undergoing over 7300 ERCP procedures. All studies were non-randomised, comprising nine prospective and 17 retrospective studies. The pooled complication rate was 25.7% per patient and 6.7% per procedure; the pooled cholangitis rate was 8.6% per patient and 3.5% per procedure; and the pooled pancreatitis rate was 6.1% per patient and 1.9% per procedure. In the overall cohort, the pooled mortality rate due to post-ERCP complications was 1.1% with two deaths reported among 594 patients. Both fatalities were attributed to sepsis secondary to cholangitis. Bile cultures were positive in 80.1% of the samples with a sensitivity of 63.7% to prophylactic antibiotics used and 24.3% of isolates resistant to more than one antibiotic. The highest resistance was observed against gentamicin (54.1%) and ceftriaxone (53.7%) while resistance was lower for piperacillin/tazobactam (26.2%) and carbapenems (26.6%). Resistance rates were higher in transplant recipients compared to the general ERCP population. Interpretation: Despite widespread prophylactic antibiotic use, post-ERCP infections and antimicrobial resistance remain prevalent in liver transplant recipients. These findings support more targeted prophylactic strategies using agents with lower resistance rates, particularly in patients undergoing repeat ERCPs. This single-arm analysis did not include a direct comparator group of patients without antibiotic prophylaxis. Future prospective studies and randomised controlled trials are essential to determine the optimal prophylactic regimen, dose, and duration in this high-risk population. Funding: None.