Tokyo Guidelines 2018 (TG18) recommend providing empiric therapy to patients with moderate to severe (Grades III – IV) cholangitis before bile duct decompression through Endoscopic Retrograde cholagiopancreatography (ERCP). Current literature indicates an increase in antibiotic resistance, highlighting the importance of enhanced antibiotic management. If empiric antibiotic therapy is not sufficient, complications of cholangitis can result in bacteremia and subsequent organ failure. TG18 suggests taking bile culture to convert to targeted antibiotic therapy, while European Society for Gastrointestinal Endoscopy (ESGE) and American Society for Gastrointestinal Endoscopy (ASGE) guidelines do not yet specify taking bile culture during ERCP. This systematic review and meta-analysis aims to synthesize evidence that may guide conversion to earlier targeted antibiotic therapy in patients with cholangitis undergoing ERCP.​

This review follows the recommendations of the PRISMA 2020 guideline and has a registered protocol on PROSPERO (CRD420251164558). We systematically searched five major databases: MEDLINE (via PubMed), Embase, CENTRAL, SCOPUS, and Web of Science. Eligible studies include patients with cholangitis who undergo ERCP and receive empiric antibiotic therapy. We include comparative and single-arm studies reporting extractable or calculable prevalence data. Two reviewers independently performed title-abstract and full-text screening, data extraction, and risk of bias assessment using the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies. Planned analysis includes pooled proportions with 95% confidence intervals (CI), and heterogeneity will be assessed by Higgins and Thompson’s I2 statistics and variance measure (tau-square, t2).​

Preliminary results from 11 studies showed a 27% prevalence of E. coli (Figure 1), 17% for Klebsiella (Figure 2), 6% for Pseudomonas (Figure 3), and 4% for Staphylococcus (Figure 4) in patients with cholangitis undergoing ERCP.

Our preliminary data suggests Escherichia coli (E.coli) is the most common organism diagnosed from bile cultures in patients with cholangitis undergoing ERCP. Our meta-analysis will include an estimated 70 studies in the final analysis, and we will include results for more subgroups of bacteria, fungi, as well as an analysis of multidrug-resistant organisms (MDROs).