Introduction

There is no clear duration of antimicrobial treatment of acute cholangitis complicated by Gram-positive coccus (GPC) bacteremia. The American guideline¹ suggests 4-7 days of antimicrobial treatment after appropriate source control, irrespective of the organism or presence of bacteremia, while the Japanese guideline² suggests 14 days when GPC bacteremia is present. However, data to support these recommendations are limited and deviation from real-world practice is proposed, therefore, studies for adequate treatment duration are warranted.

Aims & Methods

We conducted a single-center, retrospective study of adult patients with acute cholangitis with GPC bacteremia treated with ERCP (Endoscopic Retrograde Cholangiopancreatography) from July 2003 to December 2023. We analyzed two groups according to the duration of effective antimicrobial treatment: short-course (SCT, <14 days) and long-course (LCT, ≧14 days). We constructed logistic regression models for mortality and a composite outcome, including mortality, recurrence, and infection of the same organism related to cholangitis. Malignant biliary strictures were excluded.

Results

A total of 45 patients with acute cholangitis complicated by GPC bacteremia underwent ERCP in our hospital, 22 in the SCT group and 23 in the LCT group. The median duration of antimicrobial treatment was 9 days (IQR 5.5-12.5) in the SCT group and 16 days (IQR 14.5-19.5) in the LCT group, with a significant difference between the two groups (p<0.05). There were no significant differences in age, gender, severity, cause of cholangitis, the complication rate of pancreatitis and cholecystitis, heart valve disease, community acquisition, number of positive blood cultures, rate of echocardiography during treatment, intravascular devices or time to biliary drainage between the two groups. Common bile duct stones were the most common cause with 82.2% of all patients, followed by diverticulum and stent obstruction with 8.9% and 6.7%, respectively. Regarding the causative organisms, mixed infections were found in 71.1%, and Enterococcus spp. was the most common strain with 66.7%, of which E. faecalis with 23.3%, E. faecium with 16.7%, and followed by Streptococcus spp. with 31.1% of all patients, with no significant differences between the two groups. Regarding antibiotics, penicillins were most commonly used with 73.3%, followed by cephalosporins with 66.7%, and glycopeptides with 26.7% in all patients. Penicillins (91.3% vs. 54.5%, p<0.05) and glycopeptides (43.4% vs. 9.1%, p<0.05) were used more frequently in the LCT group. The 30-day mortality and reinfection with the same organisms within 3 months were 0.0% in both groups, and the length of hospital stay was significantly shorter in the SCT group (median 14.0 vs 10.5 days, p < 0.05). The rate of cholangitis recurrence within 3 months was 5% (1/20) in the SCT group and 9.5% (2/22) in the LCT group, with no significant difference.

Conclusion

For acute cholangitis complicated by GPC bacteremia, antimicrobial treatment for less than 14 days might be considered after appropriate biliary drainage.

References

1. Solomkin JS et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010;50:133–164.
2. Gomi H et al. Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci. 2018;25:3-16.

Disclosure

The authors declare no conflicts of interest associated with this manuscript.

Introduction

The cornerstone of acute cholangitis treatment is antibiotic therapy combined with biliary drainage. The Tokyo Guidelines 2018 provide severity grading criteria that help predict prognosis and identify patients requiring early biliary drainage. While mild cholangitis can often be managed initially with antibiotics alone, moderate and severe cases typically require early and emergent drainage, respectively. Our aim is to explore factors influencing the timing of ERCP in acute cholangitis and its impact on clinical outcomes.

Aims & Methods

This retrospective single-center cohort study included patients diagnosed with acute cholangitis who underwent ERCP between March 2022 and March 2023 in a tertiary hospital with ERCP. Diagnosis and severity grading were based on the Tokyo Guidelines 2018. Descriptive and statistical analyses were performed to evaluate patient characteristics, severity classification, timing to ERCP and related clinical outcomes.

Results

A total of 104 patients underwent ERCP for acute cholangitis; 55 were female (52.9%) and the median age was 77 years. Based on the Tokyo 2018 criteria, 28 patients (26.9%) had grade III cholangitis, 52 (50%) grade II and 24 (23%) grade I. Only 5 patients (4.8%) underwent ERCP within 24 hours of admission—2 with grade III, 1 with grade II and 2 with grade I. Within 72 hours, 31 patients (29.8%) had undergone ERCP—9 with grade III, 16 with grade II and 6 with grade I. Notably, 70.8% of grade III cases were submitted to ERCP more than 72 hours after admission, with a median of 3 days of antibiotics before the procedure. There was no statistically significant association between ERCP timing and patient age, cholangitis severity, intensive/intermediate care admission or anticoagulant/antiplatelet use. However, admission on a Friday or Saturday was significantly associated with delayed ERCP (p=0.007), with 91% of these patients undergoing ERCP after 72 hours, compared to 56% for admissions on other days. Cholangitis severity correlated significantly with total hospital stay (grade I: 7 ± 3 days, grade II: 8 ± 3.8 days, grade III: 10.5 ± 9 days; p=0.001). ERCP timing was also associated with total antibiotic duration (<24h: 9 ± 2.6 days, 24–72h: 8 ± 3 days, >72h: 10 ± 4.8 days; p=0.043). The 30-day mortality rate was 4.8%, with no significant association with ERCP timing or severity grade.

Conclusion

In this real-world cohort, ERCP was frequently delayed beyond the recommended window, even in severe acute cholangitis. Weekend admission was a significant contributor to this delay. However, no association was found between ERCP timing and 30-day mortality, likely due to small sample size. These findings highlight the need for optimized access to biliary drainage, particularly during weekends, to better meet guideline recommendations.

Introduction

Acute cholangitis is an important cause of mortality and morbidity, especially in elderly patients and those with multiple comorbidities. However, the appropriate duration of antibiotic therapy after biliary drainage remains controversial. The aim of this study is to evaluate the efficacy of a short versus a long course of antibiotics after biliary drainage in patients with acute cholangitis.

Aims & Methods

Retrospective analytical cohort study of patients with acute cholangitis treated at a fourth level hospital in Bogotá, Colombia, from 2014 to 2022. Short antibiotic therapy was defined as ≤ 4 days after successful post-ERCP drainage. The primary outcome was a composite of in-hospital mortality, ICU admission, and hospital readmission 30 days after discharge. A univariate and multivariate logistic regression model was performed to assess the association between duration of antibiotic therapy and the primary composite outcome.

Results

317 patients were included. E. coli was the most commonly isolated microorganism regardless of severity, and 54% proved 100% antimicrobial susceptibility. 59 patients received short therapy and 258 received long therapy. There were no statistically significant differences in the primary outcome (p=1), but a longer hospital stay was observed in the long-term treatment group (p<0.001). The presence of Tokyo III severity and carbapenem resistance were risk factors for the primary outcome (OR 32.07; 95% CI 11.84-113.16, p<0.001) and (OR 4.07; 95% CI 1.02-16.96, p=0.04) respectively.

Univariate and multivariate analysis of clinical factors associated with mortality, ICU admission or hospital readmission at 30 days in patients with acute cholangitis undergoing ERCP

Conclusion

Shorter courses of antibiotics after ERCP drainage can be considered a therapeutic option for patients with acute cholangitis. However, the methodological limitations of this study should be considered.

References

[1] M. Ahmed, “Acute cholangitis - an update,” World J Gastrointest Pathophysiol, vol. 9, no. 1, pp. 1–7, Feb. 2018, doi: 10.4291/wjgp.v9.i1.1.

[2] S. Kiriyama et al., “Clinical application and verification of the TG13 diagnostic and severity grading criteria for acute cholangitis: an international multicenter observational study,” J Hepatobiliary Pancreat Sci, vol. 24, no. 6, pp. 329–337, Jun. 2017, doi: 10.1002/jhbp.458.

[3] R. Mohan et al., “Validation of Tokyo Guidelines 2007 and Tokyo Guidelines 2013/2018 Criteria for Acute Cholangitis and Predictors of In-Hospital Mortality,” Visceral Medicine, vol. 37, no. 5. S. Karger AG, pp. 434–442, Oct. 01, 2021. doi: 10.1159/000516424.

[4] R. Mohan, S. W. L. Goh, G. W. Tan, S. P. Junnarkar, C. W. Huey, and V. G. Shelat, “Validation of TG07 and TG13/TG18 criteria for acute cholangitis and predictors of in-hospital mortality in patients over 80 years old,” Clin Exp Hepatol, vol. 7, no. 4, pp. 396–405, 2021, doi: 10.5114/ceh.2021.110996.

[5] P. A. Lipsett and H. A. Pitt, “Acute Cholangitis.”

[6] Z. An, A. L. Braseth, and N. Sahar, “Acute Cholangitis: Causes, Diagnosis, and Management,” Gastroenterology Clinics of North America, vol. 50, no. 2. W.B. Saunders, pp. 403–414, Jun. 01, 2021. doi: 10.1016/j.gtc.2021.02.005.

Disclosure

Nothing to disclose

Introduction

Aims & Methods

Results

Conclusion

Introduction

The "Antimicrobial Resistance in Acute Cholangitis" (ARISE) study is a prospective investigation focused on the antimicrobial resistance patterns in patients with acute cholangitis undergoing ERCP. Conducted across multiple tertiary gastroenterology centers in Romania, this study aims to identify, analyze, and mitigate the challenges posed by multidrug-resistant (MDR) organisms in managing acute cholangitis.

Aims & Methods

Data collected included microbial cultures from bile samples, patient demographics, clinical outcomes, and antibiotic resistance profiles. From the study's onset in January 2024, 138 eligible patients were identified as having positive bile cultures. Among these patients, the predominant symptoms included abdominal pain (82.6%), jaundice (71%), and fever or shaking chills (36.2%). The diagnosis of acute cholangitis was established using TG18 criteria.

Results

Bile cultures were positive in 71.0% of cases. The most frequently isolated bacteria were Escherichia coli, found in 23.2% of positive cultures, followed closely by Enterococcus spp., present in 22.5% of cases. Klebsiella pneumoniae was also notably prevalent, identified in 7.2% of the bile samples. Ciprofloxacin showed the highest resistance rate among the tested antibiotics, with a resistance rate of 23.9%. Ampicillin and gentamicin displayed significant resistance rates at 10.9% and 18.8%, respectively. Piperacillin/tazobactam and trimethoprim/sulfamethoxazole each showed a resistance rate of 15.2%. The study's data on tigecycline and linezolid showed lower resistance rates, with tigecycline maintaining a sensitivity rate of 20.3% and linezolid at 19.6% in cultures where testing was applicable. In comparison, their resistance rates were only 0.7% for each. Multidrug resistance was identified in a significant fraction of isolates, with 15.2% of samples. A concerning finding was the presence of MDR strains of Escherichia coli, which exhibited resistance rates to ampicillin (21.0% sensitivity, 10.9% resistance) and amoxicillin/clavulanic acid (17.4% sensitivity, 14.5% resistance).

Conclusion

We observed a concerning prevalence of MDR organisms in acute cholangitis cases, particularly against antibiotics such as ampicillin, gentamicin, and ciprofloxacin, with a high incidence of MDR Escherichia coli strains.

Introduction

According to the latest clinical practice guidelines, the empirical antimicrobial therapy used for managmente of patients with acute cholangitis should be established according to its level of severity. However, this recommendation have been highly questioned in those settings where the prevalence of broad spectrum beta-lactamase (ESBL) producing E.coli or Klebsiella exceeds 10-20%, and some experts recommend starting with a broader coverage in a systematic way.

Aims & Methods

To evaluate the prevalence of multidrug-resistant cholangitis in our hospital setting, identify possible predictors and antibiotic adequacy.
We made a retrospective analysis of 331 patients diagnosed with acute cholangitis (gathering demographic, clinical, analytical and microbiological data) admitted to the Hospital del Mar during the period from 2018 to 2021.

Results

After assessing the baseline characteristics of theses sample, we obtained a mean age of 78 years, and 53% male. Blood cultures were extracted in 92% of the patients, of which 49% were positive (149 patients) and of these, 12% had multiresistant germs (19 patients, with 17 cases positive for BLEE). The most frequent empirical regimens were amoxicillin-clavulanic acid (112 cases) and cephalosporins with metronidazole (120 cases) with 94.8% and 96.1% of therapeutic adequacy, respectively. The bacteria identified were mainly: E.coli (88%), Enterobacter spp (16%) and Klebsiella spp (21%). Previous colonization by multidrug-resistant germs (3.9%) and institutionalized patients (5.14%) were the only variables related to the presence of cholangitis due to multidrug-resistant germs, but in the multivariate analysis only colonization was a predictor factor (OR 6.69, CI 1.16-38.35). No analytical or hemodynamic variables were found to be associated to bacteremia due to multidrug-resistant germs. Otherwise, bacteremia due to multidrug-resistant germs didn't correlate with a higher mortality.

Conclusion

The prevalence of multidrug-resistant cholangitis in our setting is considerable. However, high antibiotic adequacy is achieved with amoxicillin-clavulanic acid or third generation cephalosporins in most cases. In patients with history of infection or previous colonization by conflicting germs, a broad-spectrum antibiotic coverage including multidrug-resistant germs should be considered empirically.

Introduction

Early drainage of the biliary tract is significant in managing patients with acute cholangitis. In cases where endoscopic retrograde cholangiopancreatography (ERCP) is not feasible, percutaneous transhepatic gallbladder drainage (PTGBD) is considered as an alternative treatment. Several studies indicate that PTGBD is a well-established treatment as well as ERCP, however there is limited literature of evaluation and comparison of these procedures in elderly people.

Aims & Methods

This study aimed to compare the clinical outcomes of ERCP and PTGBD in elderly patients with acute cholangitis. We retrospectively compared patients aged 70 years or older who underwent ERCP or PTGBD between 2019 and 2022.

Results

Among 129 cases of acute cholangitis, 101 patients underwent ERCP, while 28 patients underwent PTGBD. Benign and malignant biliary obstruction were present in 76% (98/129) and 24% (31/129), respectively. The mean age was 84.2 years in ERCP and 84.5 years in PTGBD. Main reasons for performing PTGBD were postoperative stomach in 21% (6/28), unstable vital signs in 46% (13/28), full-stomach in 25% (7/28), and failure to perform ERCP in 14% (4/28). The overall technical success rate was 91% (92/101) in ERCP and 100% (28/28) in PTGBD. Senior residents performed the entire PTGBD procedure, while only 63% (64/101) of ERCP cases were performed by senior residents. Both ERCP and PTGBD showed improvement in jaundice (T-Bil -0.72 vs. -0.45, P>0.05), liver dysfunction (AST -178.7 vs. -206.6, P>0.05; ALT -57.4 vs. -77.4, P>0.05), and inflammatory response (white blood cell count -5.4x103 vs. -7.4x103, P>0.05) in blood tests after the procedure. However, acute pancreatitis occurred in 5% (5/101) after ERCP, leading to mortality in 2% (2/101). Other complications were observed in 19% (19/101), including bleeding after endoscopic sphincterotomy (EST) in 4% (4/101). In contrast, PTGBD caused no major complications or drainage failure, although tube dislocation occurred in 18% (5/28). The median length of stay was longer in PTGBD (25 days) compared to ERCP (15.2 days).

Conclusion

Both ERCP and PTGBD are effective treatments for acute cholangitis in elderly patients. Besides, PTGBD has an advantage of a higher technical success rate and fewer procedure-related complications compared to ERCP.

References

1. Li YL, Wong KH, Chiu KW, Cheng AK, Cheung RK, Yam MK, Chan AL, Chan VS, Law MW, Lee PS. Percutaneous cholecystostomy for high-risk patients with acute cholangitis. Medicine (Baltimore). 2018 May;97(19):e0735. doi: 10.1097/MD.0000000000010735. PMID: 29742738; PMCID: PMC5959387.
2. Kiriyama S, Kozaka K, Takada T, et al.Tokyo guidelines 2018: Diagnostic criteria and severity grading of acute cholangitis (with videos).J Hepatobiliary Pancreat Sci2018;25:17–30.