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 Enterobacterales (ESBLE-E), carbapenemase-producing Enterobacterales (CPE), carbapenemase-producing Pseudomonas aeruginosa (CPPA), resistant Acinetobacter calcoaceticus baumannii complex (Acb-complex), vancomycin-resistant Enterococcus faecium (VRE), and methicillin-resistant S. aureus (MRSA). The primary outcome was the prevalence of MDRO among patients undergoing ERCP defined by growth of these organisms on preprocedural swab cultures. Secondary outcome was identification of risk factors for MDRO carriage through multivariable logistic regression analysis. Clinical and procedural variables, as well as microbiological results, were systematically retrieved from patients’ medical records and institutional laboratory databases. This study is registered at ClinicalTrials.gov, NCT05303662. 

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.