{"id":21169,"date":"2026-04-14T07:00:00","date_gmt":"2026-04-14T07:00:00","guid":{"rendered":"https:\/\/endoscopiaterapeutica.net\/pt\/?p=21169"},"modified":"2026-04-13T02:31:18","modified_gmt":"2026-04-13T02:31:18","slug":"antibioticoprofilaxia-cpre","status":"publish","type":"post","link":"https:\/\/endoscopiaterapeutica.net\/pt\/artigoscomentados\/antibioticoprofilaxia-cpre\/","title":{"rendered":"Antibioticoprofilaxia em pacientes com obstru\u00e7\u00e3o biliar submetidos \u00e0 CPRE"},"content":{"rendered":"\n<h2 class=\"wp-block-heading\" id=\"h-introducao\"><strong>Introdu\u00e7\u00e3o<\/strong><\/h2>\n\n\n\n<p>O uso de <strong>antibi\u00f3ticos profil\u00e1ticos<\/strong> de rotina em pacientes submetidos \u00e0 <strong>Colangiopancreatografia Retr\u00f3grada Endosc\u00f3pica (CPRE)<\/strong> n\u00e3o \u00e9 recomendado pelas principais sociedade de endoscopia do mundo, incluindo a <em>American Society for Gastrointestinal Endoscopy<\/em> (ASGE) e <em>European Society of Gastrointestinal Endoscopy<\/em> (ESGE) (1,2). Embora exista consenso de que a antibioticoprofilaxia peri-procedimento reduz a incid\u00eancia de bacteremia p\u00f3s-CPRE, seu impacto na preven\u00e7\u00e3o de colangite e sepse ainda permanece controverso. An\u00e1lises de subgrupos de diferentes trabalhos identificaram popula\u00e7\u00f5es que poderiam se beneficiar do uso profil\u00e1tico de antibi\u00f3ticos antes da CPRE \u2013 pacientes com <strong>alto risco de drenagem biliar dif\u00edcil\/incompleta<\/strong>, <strong>imunocomprometidos<\/strong> e submetidos \u00e0 <strong>colangioscopia<\/strong> &#8211; limitando a indica\u00e7\u00e3o do uso de antibioticoprofilaxia apenas para esses grupos (1,2).<\/p>\n\n\n\n<p>Uma metan\u00e1lise publicada em 2022, com 10 ensaios cl\u00ednicos randomizados (ECR) comparando o uso de antibioticoprofilaxia em pacientes submetidos \u00e0 CPRE eletiva, incluiu 1757 pacientes e demonstrou redu\u00e7\u00e3o da bacteremia no grupo antibi\u00f3tico, por\u00e9m n\u00e3o houve diferen\u00e7a em rela\u00e7\u00e3o \u00e0 colangite ou sepse (3).<\/p>\n\n\n\n<p>Uma importante cr\u00edtica em rela\u00e7\u00e3o aos estudos utilizados para embasar as recomenda\u00e7\u00f5es \u00e9 a falta de sele\u00e7\u00e3o adequada de pacientes. Trabalhos mais antigos sugeriram poss\u00edvel benef\u00edcio da antibioticoprofilaxia em pacientes com obstru\u00e7\u00e3o biliar (4,5). Nesse contexto, um grupo sul-coreano conduziu um ECR comparando o uso de antibioticoprofilaxia em pacientes com obstru\u00e7\u00e3o biliar submetidos \u00e0 CPRE (6).<\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-metodos\"><strong>M\u00e9todos<\/strong><\/h2>\n\n\n\n<h3 class=\"wp-block-heading\" id=\"h-desenho-do-estudo\">Desenho do estudo<\/h3>\n\n\n\n<p>Ensaio cl\u00ednico randomizado 1:1, duplo-cego, realizado em centro terci\u00e1rio \u00fanico.<\/p>\n\n\n\n<p><\/p>\n\n\n\n<h3 class=\"wp-block-heading\" id=\"h-selecao-de-pacientes\">Sele\u00e7\u00e3o de pacientes<\/h3>\n\n\n\n<p>Crit\u00e9rios de inclus\u00e3o: adultos com obstru\u00e7\u00e3o biliar documentada por exame de imagem (tomografia ou resson\u00e2ncia magn\u00e9tica) submetidos \u00e0 CPRE.<\/p>\n\n\n\n<p>Crit\u00e9rios de exclus\u00e3o: evid\u00eancia de infec\u00e7\u00e3o (leuc\u00f3citos &gt; 11.000 e\/ou febre T&gt;= 38oC), uso de antibi\u00f3ticos nas \u00faltimas 72 horas, gravidez e alergia ao antibi\u00f3tico.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\" id=\"h-grupos-do-estudo\">Grupos do estudo<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li><span style=\"text-decoration: underline;\">Interven\u00e7\u00e3o <\/span>(antibi\u00f3tico): Cefoxitina 1g IV em 10ml de SF0,9% 30min antes da CPRE.<\/li>\n\n\n\n<li><span style=\"text-decoration: underline;\">Controle<\/span> (placebo): 10ml de SF0,9% 30 min antes da CPRE. A escolha do antibi\u00f3tico foi baseada no perfil microbiol\u00f3gico local, em conjunto com a equipe de infectologia do hospital.<\/li>\n<\/ul>\n\n\n\n<p><\/p>\n\n\n\n<h3 class=\"wp-block-heading\" id=\"h-desfechos\">Desfechos<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li><span style=\"text-decoration: underline;\">Prim\u00e1rio<\/span>: incid\u00eancia de <strong>complica\u00e7\u00e3o infecciosa p\u00f3s-CPRE<\/strong> (bacteremia, colangite e colecistite).<\/li>\n\n\n\n<li><span style=\"text-decoration: underline;\">Secund\u00e1rio<\/span>: incid\u00eancia de cada complica\u00e7\u00e3o infecciosa espec\u00edfica, demais complica\u00e7\u00f5es p\u00f3s-CPRE (pancreatite e sangramento).<\/li>\n<\/ul>\n\n\n\n<p><\/p>\n\n\n\n<h3 class=\"wp-block-heading\" id=\"h-calculo-amostral\">C\u00e1lculo amostral<\/h3>\n\n\n\n<p>400 pacientes (considerando 10% de perda).<\/p>\n\n\n\n<div style=\"height:26px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-resultados\"><strong>Resultados<\/strong><\/h2>\n\n\n\n<h3 class=\"wp-block-heading\" id=\"h-populacao\"><br>Popula\u00e7\u00e3o<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li>378 pacientes randomizados entre 2017\u20132021<\/li>\n\n\n\n<li>189 em cada grupo<\/li>\n\n\n\n<li>An\u00e1lise final: 176 (antibi\u00f3tico) vs. 173 (placebo)<\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\" id=\"h-desfecho-primario\"><br>Desfecho prim\u00e1rio<\/h3>\n\n\n\n<p id=\"h-desfecho-primario\">Houve <strong>redu\u00e7\u00e3o significativa de complica\u00e7\u00f5es infecciosas<\/strong> no grupo antibi\u00f3tico.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><span style=\"text-decoration: underline;\">Antibi\u00f3tico<\/span>: 2,8% (5\/176)<\/li>\n\n\n\n<li><span style=\"text-decoration: underline;\">Placebo<\/span>: 9,8% (17\/173)<\/li>\n\n\n\n<li><span style=\"text-decoration: underline;\">Risco Relativo (RR)<\/span>: 0,29; IC 95%, 0,11\u20130,74; <em>p=0.0073<\/em><\/li>\n<\/ul>\n\n\n\n<h3 class=\"wp-block-heading\" id=\"h-desfechos-secundarios\"><br>Desfechos secund\u00e1rios<\/h3>\n\n\n\n<p><strong>Bacteremia<\/strong>: sem diferen\u00e7a estatisticamente significativa.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><span style=\"text-decoration: underline;\">Antibi\u00f3tico<\/span>: 2,3% (4\/176)<\/li>\n\n\n\n<li><span style=\"text-decoration: underline;\">Placebo<\/span>: 6,4% (11\/173)<\/li>\n\n\n\n<li><span style=\"text-decoration: underline;\">RR<\/span>: 0,36; 95% CI, 0,12\u20131,04; <em>p=0,0599<\/em><br><\/li>\n\n\n\n<li>Dos 15 pacientes com bacteremia, <strong>10 evolu\u00edram com sepse<\/strong>.<\/li>\n<\/ul>\n\n\n\n<p><strong>Colangite:<\/strong> houve redu\u00e7\u00e3o significativa.<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li><span style=\"text-decoration: underline;\">Antibi\u00f3tico<\/span>: 1,7% (3\/176)<\/li>\n\n\n\n<li><span style=\"text-decoration: underline;\">Placebo<\/span>: 6,4% (11\/173)<\/li>\n\n\n\n<li><span style=\"text-decoration: underline;\">RR<\/span>: 0,27; 95% CI, 0.08\u20130.87; <em>p=0,0267<\/em><\/li>\n<\/ul>\n\n\n\n<p><strong>Colecistite<\/strong>: ocorreu em apenas 1 paciente do grupo placebo.<\/p>\n\n\n\n<p><strong>Demais complica\u00e7\u00f5es (sangramento, pancreatite): <\/strong>sem diferen\u00e7a entre os grupos.<\/p>\n\n\n\n<figure class=\"wp-block-image size-large\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/?attachment_id=21170\"><img fetchpriority=\"high\" decoding=\"async\" width=\"1024\" height=\"317\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2026\/04\/tabela-1-desfecho-primario-1024x317.png\" alt=\"Desfechos da antibioticoprofilaxia na CPRE\" class=\"wp-image-21170\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2026\/04\/tabela-1-desfecho-primario-1024x317.png 1024w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2026\/04\/tabela-1-desfecho-primario-300x93.png 300w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2026\/04\/tabela-1-desfecho-primario-768x238.png 768w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2026\/04\/tabela-1-desfecho-primario-585x181.png 585w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2026\/04\/tabela-1-desfecho-primario.png 1139w\" sizes=\"(max-width: 1024px) 100vw, 1024px\" \/><\/a><figcaption class=\"wp-element-caption\"><br>Tabela 1: desfechos prim\u00e1rios e secund\u00e1rios (<a href=\"https:\/\/journals.lww.com\/ajg\/fulltext\/2024\/01000\/randomized_trial_of_prophylactic_antibiotics_for.26.aspx\" type=\"link\" id=\"https:\/\/journals.lww.com\/ajg\/fulltext\/2024\/01000\/randomized_trial_of_prophylactic_antibiotics_for.26.aspx\">original do artigo<\/a>)<\/figcaption><\/figure>\n\n\n\n<h3 class=\"wp-block-heading\" id=\"h-analise-de-subgrupos\"><br>An\u00e1lise de subgrupos<\/h3>\n\n\n\n<h4 class=\"wp-block-heading\" id=\"h-etiologia-maligna-vs-benigna\"><strong>Etiologia maligna vs. benigna<\/strong><\/h4>\n\n\n\n<p>Houve maior incid\u00eancia de complica\u00e7\u00f5es no grupo placebo em ambas as etiologias.<br>Entretanto, a diferen\u00e7a foi significativa apenas para colangite na etiologia benigna, com incid\u00eancia de 3,1% no grupo antibi\u00f3tico vs. 10,2% no grupo placebo (<em>p=0,0421<\/em>)<\/p>\n\n\n\n<h4 class=\"wp-block-heading\" id=\"h-drenagem-biliar-completa\"><strong>Drenagem biliar completa<\/strong><\/h4>\n\n\n\n<p>Mesmo nos casos em que houve drenagem biliar completa, observou-se benef\u00edcio do antibi\u00f3tico profil\u00e1tico:<\/p>\n\n\n\n<p><span style=\"text-decoration: underline;\">Complica\u00e7\u00f5es infecciosas:<\/span> antibi\u00f3tico 3,1% vs. placebo 10,6% (<em>p=0,0077<\/em>)<br><span style=\"text-decoration: underline;\">Colangite:<\/span><strong> <\/strong>antibi\u00f3tico 1,9% vs. placebo 6,9% (<em>p=0,0279<\/em>)<\/p>\n\n\n\n<p><br>Fatores de risco relacionados ao procedimento, como <strong>CPRE pr\u00e9via<\/strong>, <strong>retirada de c\u00e1lculos<\/strong> e <strong>dilata\u00e7\u00e3o balonada<\/strong>, apresentaram tend\u00eancia a maior risco de complica\u00e7\u00f5es infecciosas p\u00f3s-CPRE no grupo placebo; contudo, n\u00e3o houve signific\u00e2ncia estat\u00edstica (Figura 2).<\/p>\n\n\n<div class=\"wp-block-image\">\n<figure class=\"aligncenter size-full\"><a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/?attachment_id=21171\"><img decoding=\"async\" width=\"731\" height=\"439\" src=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2026\/04\/tabela-2.png\" alt=\"\" class=\"wp-image-21171\" srcset=\"https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2026\/04\/tabela-2.png 731w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2026\/04\/tabela-2-300x180.png 300w, https:\/\/endoscopiaterapeutica.net\/pt\/wp-content\/uploads\/2026\/04\/tabela-2-585x351.png 585w\" sizes=\"(max-width: 731px) 100vw, 731px\" \/><\/a><figcaption class=\"wp-element-caption\"><br>Figura 2: risco relativo de complica\u00e7\u00e3o infecciosa p\u00f3s-CPRE no grupo placebo, de acordo com procedimentos realizados (<a href=\"https:\/\/journals.lww.com\/ajg\/fulltext\/2024\/01000\/randomized_trial_of_prophylactic_antibiotics_for.26.aspx\" type=\"link\" id=\"https:\/\/journals.lww.com\/ajg\/fulltext\/2024\/01000\/randomized_trial_of_prophylactic_antibiotics_for.26.aspx\">original do artigo<\/a>).<\/figcaption><\/figure>\n<\/div>\n\n\n<h2 class=\"wp-block-heading\" id=\"h-discussao\"><strong>Discuss\u00e3o<\/strong><\/h2>\n\n\n\n<p>Este ECR duplo-cego robusto demonstrou que o uso de <strong>antibi\u00f3tico profil\u00e1tico pr\u00e9-CPRE<\/strong>, em pacientes com obstru\u00e7\u00e3o biliar sem infec\u00e7\u00e3o manifesta, <strong>reduz a incid\u00eancia de complica\u00e7\u00f5es infecciosas p\u00f3s-procedimento<\/strong>, incluindo colangite, <strong>mesmo em pacientes nos quais houve drenagem biliar completa. <\/strong><\/p>\n\n\n\n<p>Esses achados contrastam com as recomenda\u00e7\u00f5es atuais dos guidelines das principais sociedades de endoscopia do mundo (ASGE e ESGE), e podem representar uma poss\u00edvel <strong>mudan\u00e7a de paradigma<\/strong>.<\/p>\n\n\n\n<p>Embora a colangite tenha apresentado redu\u00e7\u00e3o significativa, esse achado deve ser interpretado com cautela, pois se trata de desfecho secund\u00e1rio, o que significa que o estudo n\u00e3o foi dimensionado especificamente para avali\u00e1-lo. Ainda assim, a magnitude do efeito observada sugere um poss\u00edvel benef\u00edcio cl\u00ednico real, que idealmente deve ser confirmado em estudos com c\u00e1lculo amostral direcionado para esse desfecho.<\/p>\n\n\n\n<p>Apesar dos benef\u00edcios demonstrados, os autores colocam que \u00e9 importante estudar o impacto do aumento do uso de antibi\u00f3ticos profil\u00e1ticos no perfil de resist\u00eancia das bact\u00e9rias, sendo importante uma avalia\u00e7\u00e3o conjunta com o servi\u00e7o de infectologia de cada hospital para a escolha do antibi\u00f3tico ideal.<\/p>\n\n\n\n<p>\u00c9 importante ressaltar que o estudo <strong>n\u00e3o recomenda antibioticoprofilaxia de rotina para toda CPRE<\/strong>, mas sim apenas em pacientes com <strong>obstru\u00e7\u00e3o biliar manifesta. <\/strong><\/p>\n\n\n\n<p>Por fim, os autores sugerem que o benef\u00edcio da antibioticoprofilaxia pode ser maior em pacientes com <strong>CPRE pr\u00e9via<\/strong> e quando h\u00e1 maior manipula\u00e7\u00e3o da via biliar \u2013 como quando h\u00e1 <strong>dilata\u00e7\u00e3o balonada e retirada de c\u00e1lculos.<\/strong><\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-conclusao\"><strong>Conclus\u00e3o<\/strong><\/h2>\n\n\n\n<p>O estudo traz evid\u00eancia robusta de que a antibioticoprofilaxia em pacientes com obstru\u00e7\u00e3o biliar submetidos \u00e0 CPRE reduz complica\u00e7\u00f5es infecciosas, incluindo a colangite \u2014 mesmo em casos de drenagem completa.<\/p>\n\n\n\n<p>Diante desses achados, \u00e9 poss\u00edvel que as diretrizes passem por reavalia\u00e7\u00e3o nos pr\u00f3ximos anos \u00e0 luz de toda a literatura dispon\u00edvel. Enquanto isso, na pr\u00e1tica cl\u00ednica, vale considerar o uso de antibioticoprofilaxia em pacientes selecionados com obstru\u00e7\u00e3o biliar e indica\u00e7\u00e3o de CPRE, individualizando a decis\u00e3o caso a caso.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-referencias\"><strong>Refer\u00eancias<\/strong><\/h2>\n\n\n\n<ol class=\"wp-block-list\">\n<li>ASGE Standards of Practice Committee, Khashab MA, Chithadi KV, et al. Antibiotic prophylaxis for GI endoscopy.&nbsp;<em>Gastrointest Endosc<\/em>. 2015;81(1):81-89. doi:10.1016\/j.gie.2014.08.008<\/li>\n\n\n\n<li>ASGE Standards of Practice Committee, Khashab MA, Chithadi KV, et al. Antibiotic prophylaxis for GI endoscopy.&nbsp;<em>Gastrointest Endosc<\/em>. 2015;81(1):81-89. doi:10.1016\/j.gie.2014.08.008<\/li>\n\n\n\n<li>Merchan MFS, de Moura DTH, de Oliveira GHP, et al. Antibiotic prophylaxis to prevent complications in endoscopic retrograde cholangiopancreatography: A systematic review and meta-analysis of randomized controlled trials.&nbsp;<em>World J Gastrointest Endosc<\/em>. 2022;14(11):718-730. doi:10.4253\/wjge.v14.i11.718<\/li>\n\n\n\n<li>Niederau C, Pohlmann U, L\u00a8ubke H, et al. Prophylactic antibiotic treatment in therapeutic or complicated diagnostic ERCP: Results of a randomized controlled clinical study. Gastrointest Endosc 1994;40(5):533\u20137.<\/li>\n\n\n\n<li>van den Hazel SJ, Speelman P, Dankert J, et al. Piperacillin to prevent cholangitis after endoscopic retrograde cholangiopancreatography. A randomized, controlled trial. Ann Intern Med 1996;125(6):442\u20137.<\/li>\n\n\n\n<li>Leem G, Sung MJ, Park JH, et al. Randomized Trial of Prophylactic Antibiotics for Endoscopic Retrograde Cholangiopancreatography in Patients With Biliary Obstruction.&nbsp;<em>Am J Gastroenterol<\/em>. 2024;119(1):183-190. doi:10.14309\/ajg.0000000000002495<\/li>\n<\/ol>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"h-como-citar-este-artigo\"><strong>Como citar este artigo<\/strong><\/h2>\n\n\n\n<p class=\"has-very-light-gray-to-cyan-bluish-gray-gradient-background has-background\">Proen\u00e7a IM. Antibioticoprofilaxia em pacientes com obstru\u00e7\u00e3o biliar submetidos \u00e0 CPRE. Endoscopia Terapeutica, 2026 Vol I. Dispon\u00edvel em: <a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/?p=21169\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/endoscopiaterapeutica.net\/pt\/assuntosgerais\/antibioticoprofilaxia-em-pacientes-com-obstrucao-biliar-submetidos-a-cpre\/<\/a><\/p>\n\n\n\n<p>Para saber mais sobre as cl\u00e1ssicas indica\u00e7\u00f5es de antibioticoprofilaxia na CPRE, confira este material: <a href=\"https:\/\/endoscopiaterapeutica.net\/pt\/quiz\/quiz-profilaxia-antibiotica-em-cpre\/?utm_source=chatgpt.com\"><strong>Profilaxia antibi\u00f3tica em CPRE<\/strong>.<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Introdu\u00e7\u00e3o O uso de antibi\u00f3ticos profil\u00e1ticos de rotina em pacientes submetidos \u00e0 Colangiopancreatografia Retr\u00f3grada&hellip;<\/p>\n","protected":false},"author":2381,"featured_media":21176,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_lmt_disableupdate":"","_lmt_disable":"","footnotes":""},"categories":[142,151],"tags":[865,294],"ano":[847],"tipo":[791,155],"volume":[263],"class_list":["post-21169","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-artigoscomentados","category-assuntosgerais","tag-antibioticoprofilaxia","tag-cpre","ano-847","tipo-artigos-comentados","tipo-cpre","volume-volume-i"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.2 (Yoast SEO v27.4) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>Antibioticoprofilaxia na CPRE: mudan\u00e7as nas diretrizes?<\/title>\n<meta name=\"description\" content=\"Novo estudo mostra que a antibioticoprofilaxia na CPRE pode reduzir complica\u00e7\u00f5es infecciosas, com 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