Preprocedural screening for multidrug-resistant organisms in endoscopic retrograde cholangiopancreatography: an international, multicentre, cross-sectional observational study.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) carries a risk of patient-to-patient transmission of multidrug-resistant organisms (MDROs) via contaminated duodenoscopes. Data on preprocedural MDRO carriage are limited and essential for guiding targeted prevention strategies, including the potential use of single-use duodenoscopes. This study assessed MDRO carriage among patients undergoing ERCP across four countries. Methods: In this international, multicentre, cross-sectional observational study, adults undergoing ERCP in tertiary care centres in the Netherlands, India, Italy, and the United States were screened for MDROs using preprocedural rectal and throat-nose swabs. Consecutive adult patients (aged ≥18 years) undergoing ERCP, regardless of indication, were eligible for inclusion. Exclusion criteria included cases in which ERCP was not performed, a duodenoscope was not used, or the rectal swab was not collected. MDROs screened included extended-spectrum beta-lactamase-producing Findings: Between Jan 22, 2022, and Oct 09, 2024, 1244 patients were enrolled, of whom 798 (64.1%) were male and 446 (35.9%) were female. Among all participants, 462 (37.1%, 95% CI 34.5-39.9) carried an MDRO. Prevalence was highest in India (290/349, 83.1%, 78.8-86.7) and lowest in the Netherlands (37/343, 10.8%, 7.9-14.5), with intermediate rates in Italy (66/209, 31.5%, 25.7-38.2) and the United States (69/343, 20.1%, 16.2-24.7). MDRO species and resistance mechanisms varied by country. ESBL-E were most prevalent in India (245/349, 70.2%, 65.2-74.8) compared with Italy (42/209, 20.1%, 15.2-26.0), the Netherlands (35/343, 10.2%, 7.4-13.9), and the United States (15/343, 4.4%, 2.7-7.1) (p < 0.001). CPE were detected in 82/349 (23.5%, 19.4-28.2) patients in India but were uncommon in Italy (8/209, 3.8%, 1.9-7.4), rare in the United States (3/343, 0.9%, 0.3-2.5), and nearly absent in the Netherlands (1/343, 0.3%, 0.0-1.6) (p < 0.001). CPPA was only detected in 1/349 (0.3%, 0-1.6) patient in India, with none in the other centres (p = 0.46). Resistant Acb-complex was only detected in 1/209 (0.5%, 0-2.7) patient in Italy (p = 0.18). VRE was most frequent in the United States (37/343, 10.8%, 7.9-14.5), followed by Italy (20/209, 9.6%, 6.3-14.3) and India (26/349, 7.4%, 5.1-10.7), and was not detected in the Netherlands (p < 0.001). MRSA was detected primarily in the United States (27/343, 7.9%, 5.5-11.2), with lower prevalence in Italy (6/209, 2.9%, 1.3-6.1), India (5/349, 1.4%, 0.6-3.3), and the Netherlands (1/343, 0.3%, 0.0-1.6) (p < 0.001). Significant risk factors for MDRO carriage included country of inclusion, with higher odds observed in India (aOR 99.14, 95% CI: 48.21-203.86, p < 0.001) and Italy (aOR 6.58, 95% CI: 3.57-12.14, p < 0.001) compared with the Netherlands (reference), while the association for the United States was not statistically significant (aOR 1.61, 95% CI: 0.82-3.14, p = 0.17). Other significant risk factors were chronic lung disease (aOR 1.75, 95% CI:1.07-2.86, p = 0.025), congestive heart failure (aOR 2.20, 95% CI: 1.33-3.64, p = 0.002), and prior use of penicillins (aOR 1.66, 95% CI: 1.05-2.63, p = 0.031). Interpretation: This study shows global heterogeneity in MDRO carriage among patients undergoing ERCP, reflecting underlying differences in antimicrobial resistance, healthcare infrastructure, and infection control practices. Strategies to prevent endoscope-associated transmission should therefore be tailored to local resistance patterns rather than adopting a universal approach. Preprocedural screening and targeted infection prevention strategies should be integrated within broader, region-specific infection control frameworks. The study's limitations should be considered when interpreting the findings, including restriction to tertiary care centres, incomplete enrolment data, and inter-site variability in patient characteristics and microbiological methods, which may affect generalisability. Nevertheless, the results provide a robust foundation for developing targeted, evidence-based interventions and for future research evaluating the clinical value, cost-effectiveness, and sustainability of preprocedural screening and infection prevention policies across diverse healthcare settings. Funding: Boston Scientific International and Copan Italia SpA.