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Masuda S, Imamura Y, Jinushi R, Kimura K, Ryozawa S, Koizumi K. Navigating antibiotic therapy in acute cholangitis: Best practices and new insights. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2025; 32:44-57. [PMID: 39537571 PMCID: PMC11780307 DOI: 10.1002/jhbp.12087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2024]
Abstract
Globally, antibiotic resistance is linked to increased morbidity, mortality, and healthcare costs, which necessitates further research on optimal antibiotic usage. Acute cholangitis (AC), a common cause of community-acquired bacteremia, often requires antimicrobial therapy. Therefore, studying the appropriate use of antibiotics for AC is considered crucial for suppressing the emergence of resistant bacteria and reducing adverse antibiotic-associated events. The Tokyo Guidelines 2018 (TG18) recommend 4-7 days of antibiotics post-biliary drainage. However, this lacks strong evidence and is based primarily on various evidence and expert opinions. Recent retrospective studies advocate for a shorter 1-3-day antibiotic course for AC, thereby prompting a need to reassess the treatment duration to balance therapeutic efficacy and minimize resistance and adverse effects. Choosing the appropriate duration and antibiotics based on susceptibility to pathogens causing cholangitis is important. Awareness of local resistance patterns and understanding patients' risks of resistant pathogens are prerequisite for effective treatment. We must explore the applicability of these guidelines in specific scenarios such as severe AC, positive blood cultures, fever, or hilar biliary obstructions due to malignancy. This comprehensive review considers both the duration and type of antibiotics and aims to enhance treatment outcomes while reducing the risk of resistant bacterial infections.
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Affiliation(s)
- Sakue Masuda
- Department of Gastroenterology, Medicine CenterShonan Kamakura General HospitalKamakuraJapan
| | | | - Ryuhei Jinushi
- Department of GastroenterologySaitama Medical University International Medical CenterSaitamaJapan
| | - Karen Kimura
- Department of Gastroenterology, Medicine CenterShonan Kamakura General HospitalKamakuraJapan
| | - Shomei Ryozawa
- Department of GastroenterologySaitama Medical University International Medical CenterSaitamaJapan
| | - Kazuya Koizumi
- Department of Gastroenterology, Medicine CenterShonan Kamakura General HospitalKamakuraJapan
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Masuda S, Imamura Y, Ichita C, Jinushi R, Kubota J, Kimura K, Makazu M, Sato R, Kako M, Kobayashi M, Uojima H, Taguri M, Orihara S, Koizumi K. Comparison of antimicrobial therapy termination in febrile and afebrile patients with acute cholangitis after drainage. Sci Rep 2024; 14:17858. [PMID: 39090409 PMCID: PMC11294559 DOI: 10.1038/s41598-024-68999-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 07/30/2024] [Indexed: 08/04/2024] Open
Abstract
The standard treatment duration for acute cholangitis (AC) involves a 4-7-day antimicrobial treatment post-biliary drainage; however, recent studies have suggested that a ≤ 2-3 days is sufficient. However, clinical practice frequently depends on body temperature as a criterion for discontinuing antimicrobial treatment. Therefore, in this study, we assessed whether patients with AC can achieve successful outcomes with a ≤ 7-day antimicrobial treatment, even with a fever, assuming the infection source is effectively controlled. We conducted a single-center retrospective study involving patients with AC, defined following the Tokyo Guidelines 2018 for any cause, who underwent successful biliary drainage and completed a ≤ 7-day antimicrobial treatment. Patients were categorized into the febrile and afebrile groups based on their body temperature within 24 h before completing antimicrobial treatment. The primary outcome was the clinical cure rate, defined as no initial presenting symptoms by day 14 post-biliary drainage without recurrence or death by day 30. The secondary outcome was a 3-month recurrence rate. Logistic regression with inverse probability of treatment weighting was used. Overall, 408 patients were selected, among whom 40 (9.8%) were febrile. The two groups showed no significant differences in the clinical cure and 3-month recurrence rates. Notably, the subgroups limited to patients with a ≤ 3-day antibiotic treatment duration also showed no differences in these outcomes. Therefore, our results suggest that discontinuing antibiotics within the initially planned treatment period was sufficient for successful drainage cases of AC, regardless of the patient's fever status during the 24 h leading up to termination.
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Affiliation(s)
- Sakue Masuda
- Department of Gastroenterology, Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan.
| | - Yoshinori Imamura
- Division of Medical Oncology/Hematology, Department of Medicine, Kobe University Graduate School of Medicine, Kobe, Hyogo, 650-0017, Japan
| | - Chikamasa Ichita
- Department of Gastroenterology, Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Ryuhei Jinushi
- Department of Gastroenterology, Saitama Medical University International Medical Center, Hidaka, Saitama, 350-1298, Japan
| | - Jun Kubota
- Department of Gastroenterology, Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Karen Kimura
- Department of Gastroenterology, Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Makomo Makazu
- Department of Gastroenterology, Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Ryo Sato
- Department of Gastroenterology, Saitama Medical University International Medical Center, Hidaka, Saitama, 350-1298, Japan
| | - Makoto Kako
- Department of Gastroenterology, Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Masahiro Kobayashi
- Department of Gastroenterology, Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Haruki Uojima
- Department of Gastroenterology, Internal Medicine, Kitasato University School of Medicine, Kamakura, Kanagawa, 252-0375, Japan
| | - Masataka Taguri
- Department of Health Data Science, Tokyo Medical University Graduate School of Medicine, Shinjyuku-ku, Tokyo, 160-0023, Japan
| | - Shunichiro Orihara
- Department of Health Data Science, Tokyo Medical University Graduate School of Medicine, Shinjyuku-ku, Tokyo, 160-0023, Japan
| | - Kazuya Koizumi
- Department of Gastroenterology, Medicine Center, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
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Yamamoto S, Kataoka Y, Kurai H, Sugiura T, Yamamoto Y. Prognosis of Postoperative Cholangitis Following Pancreaticoduodenectomy: A Single-Centered Retrospective Cohort Study. Cureus 2024; 16:e60392. [PMID: 38883123 PMCID: PMC11179028 DOI: 10.7759/cureus.60392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2024] [Indexed: 06/18/2024] Open
Abstract
Introduction Postoperative cholangitis (POC) after pancreaticoduodenectomy is a serious complication. However, the prognostic factors are unclear. We aimed to investigate the relationships between biliary lesions and prognosis in patients with cholangitis after pancreaticoduodenectomy. Methods We conducted a single-centered retrospective cohort study. The unit of analysis was hospital admissions. We extracted patients who underwent pancreaticoduodenectomy from 2010 to 2018, and have a record of hospitalization of cholangitis from January 2010 to October 2019. We defined the bile duct lesions as the presence of one of the following: biliary stent, intrahepatic bile duct dilatation, intrahepatic bile duct stones, or common bile duct stones on imaging studies. The primary outcome was the treatment failure of POC. We defined the failure as a composite outcome of death within 30 days of initiation of treatment, relapse during treatment, or recurrence of cholangitis. We used logistic regression analysis to examine the association between the presence of bile duct lesions and the occurrence of outcomes. Results Of 154 admissions included in the present study, 120 cases (77.9%) were with bile duct lesions. Bile duct lesions were associated with the treatment failure (crude odds ratio [OR] 2.56, 95% confidence intervals [CI] 1.08 to 6.32; adjusted OR 2.81, 95%CI 1.08 to 7.34). Conclusions Clinicians should follow the patient of POC with bile duct lesions on imaging carefully because of the high risk of treatment failure, especially for recurrence. Further studies are warranted to confirm our results.
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Affiliation(s)
- Shuhei Yamamoto
- Division of Infectious Diseases, Shizuoka Cancer Center, Nagaizumi, JPN
- Department of Psychosomatic and General Internal Medicine, Kansai Medical University, Hirakata, JPN
| | - Yuki Kataoka
- Section of Clinical Epidemiology, Department of Community Medicine, Kyoto University Graduate School of Medicine, Kyoto, JPN
- Department of Healthcare Epidemiology, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, JPN
- Department of Systematic Reviewers, Scientific Research Works Peer Support Group, Osaka, JPN
- Department of Internal Medicine, Kyoto Min-iren Asukai Hospital, Kyoto, JPN
| | - Hanako Kurai
- Division of Infectious Diseases, Shizuoka Cancer Center, Nagaizumi, JPN
| | - Teiichi Sugiura
- Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center, Nagaizumi, JPN
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, School of Public Health in the Graduate School of Medicine, Kyoto University, Kyoto, JPN
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Masuda S, Imamura Y, Ichita C, Jinushi R, Kubota J, Kimura K, Makazu M, Sato R, Uojima H, Koizumi K. Efficacy of Short-Course Antibiotic Therapy for Acute Cholangitis With Positive Blood Cultures: A Retrospective Study. Cureus 2024; 16:e58883. [PMID: 38800172 PMCID: PMC11117024 DOI: 10.7759/cureus.58883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Short-term treatment of acute cholangitis is sufficient for cure compared with the standard treatment duration. Whether this short-course antimicrobial therapy is effective in patients with acute cholangitis with positive blood cultures has not been fully investigated. This study assessed whether patients with acute cholangitis could achieve successful outcomes with a three-day or shorter antimicrobial treatment period, even with a positive blood culture. METHODS This single-center retrospective study involved patients with acute cholangitis, defined according to the Tokyo Guidelines 2018 for any cause, who underwent successful biliary drainage and completed a seven-day or shorter antimicrobial treatment. Patients were categorized into six groups based on the duration of antibiotic use (short or standard) after endoscopic retrograde cholangiopancreatography and blood culture findings (positive, negative, or no collection). The primary outcome was the clinical cure rate, defined as no initial presenting symptoms by day 14 after biliary drainage and no recurrence or death by day 30. Secondary outcomes included a three-month recurrence rate and length of hospital stay. RESULTS In total, 389 cases were selected, and 27 patients (6.9%) undergoing short-course therapy tested positive for blood culture. The clinical cure rate (n=25, 92.6%) in this group was comparable to that in the other groups. For the three-month recurrence rate (n=1, 3.7%) and median hospital stay (six days), this group's outcomes were either better or similar to those of the other groups. CONCLUSIONS For cases of successful drainage in acute cholangitis, even with positive blood cultures, short-term antibiotic therapy may be appropriate.
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Affiliation(s)
- Sakue Masuda
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura, JPN
| | - Yoshinori Imamura
- Division of Medical Oncology/Hematology, University of Fukui Hospital, Fukui, JPN
| | - Chikamasa Ichita
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura, JPN
| | - Ryuhei Jinushi
- Department of Gastroenterology, Saitama Medical University international Medical Center, Hidaka, JPN
| | - Jun Kubota
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura, JPN
| | - Karen Kimura
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura, JPN
| | - Makomo Makazu
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura, JPN
| | - Ryo Sato
- Department of Gastroenterology, Saitama Medical University International Medical Center, Hidaka, JPN
| | - Haruki Uojima
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura, JPN
| | - Kazuya Koizumi
- Gastroenterology Medicine Center, Shonan Kamakura General Hospital, Kamakura, JPN
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Masuda S, Imamura Y, Jinushi R, Kubota J, Kimura K, Makazu M, Sato R, Kako M, Kobayashi M, Uojima H, Ichita C, Koizumi K. Antimicrobial therapy outcomes in acute cholangitis: Hilar multiple obstructions versus single hilar and common bile duct obstructions. JGH Open 2024; 8:e13047. [PMID: 38486876 PMCID: PMC10938463 DOI: 10.1002/jgh3.13047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/13/2024] [Accepted: 02/18/2024] [Indexed: 03/17/2024]
Abstract
Background and Aim The appropriate duration of antimicrobial therapy for acute cholangitis (AC) arising from multiple hilar biliary obstructions as opposed to simple obstruction in the extrahepatic bile duct has not been established. This study assessed the efficacy of the duration of antimicrobial treatments in the Tokyo Guidelines 2018 for AC based on the cause and site of obstruction. Methods This single-center retrospective study involved patients with AC who underwent successful biliary drainage and completed a 7-day or shorter antimicrobial treatment. Patients were categorized into three groups: Group 1, bile duct stone or benign obstruction; Group 2, simple biliary obstruction due to malignancy; and Group 3, multiple hilar biliary obstruction due to malignancy. The primary outcome was clinical cure rate, and the secondary outcomes were 3-month recurrence rate and length of hospital stay. Results A total of 373 patients were selected. Patients in Group 3 were younger or had Charlson Comorbidity Index ≥4, and had fewer positive blood cultures. In Group 3, the clinical cure rate (87.1%) and 3-month recurrence rate (32.3%) were less favorable than those in the other groups. In Group 1, the clinical cure rate was significantly higher (98.1%, P = 0.02) with a much lower 3-month recurrence rate of only 3.4% (P < 0.001) than that in the other groups. The median hospital stay for all groups was 7 days. Conclusion This study suggests that the outcomes in Group 3 may be worse than those in Groups 1 or 2, regardless of the duration of the antibiotic treatment.
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Affiliation(s)
- Sakue Masuda
- Department of GastroenterologyMedicine Center, Shonan Kamakura General HospitalKamakuraKanagawaJapan
| | - Yoshinori Imamura
- Division of Medical Oncology/Hematology, Department of MedicineKobe University Graduate School of MedicineKobeHyogoJapan
| | - Ryuhei Jinushi
- Department of GastroenterologySaitama Medical University International Medical CenterSaitamaJapan
| | - Jun Kubota
- Department of GastroenterologyMedicine Center, Shonan Kamakura General HospitalKamakuraKanagawaJapan
| | - Karen Kimura
- Department of GastroenterologyMedicine Center, Shonan Kamakura General HospitalKamakuraKanagawaJapan
| | - Makomo Makazu
- Department of GastroenterologyMedicine Center, Shonan Kamakura General HospitalKamakuraKanagawaJapan
| | - Ryo Sato
- Department of GastroenterologySaitama Medical University International Medical CenterSaitamaJapan
| | - Makoto Kako
- Department of GastroenterologyMedicine Center, Shonan Kamakura General HospitalKamakuraKanagawaJapan
| | - Masahiro Kobayashi
- Department of GastroenterologyMedicine Center, Shonan Kamakura General HospitalKamakuraKanagawaJapan
| | - Haruki Uojima
- Department of Gastroenterology, Internal MedicineKitasato University School of MedicineSagamiharaKanagawaJapan
| | - Chikamasa Ichita
- Department of GastroenterologyMedicine Center, Shonan Kamakura General HospitalKamakuraKanagawaJapan
| | - Kazuya Koizumi
- Department of GastroenterologyMedicine Center, Shonan Kamakura General HospitalKamakuraKanagawaJapan
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Srinu D, Shah J, Jena A, Jearth V, Singh AK, Mandavdhare HS, Sharma V, Irrinki S, Sakaray YR, Gupta R, Gautam V, Rana S, Dutta U. Conventional vs Short Duration of Antibiotics in Patients With Moderate or Severe Cholangitis: Noninferiority Randomized Trial. Am J Gastroenterol 2024; 119:176-182. [PMID: 37732816 DOI: 10.14309/ajg.0000000000002499] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 08/25/2023] [Indexed: 09/22/2023]
Abstract
INTRODUCTION Successful biliary drainage and antibiotics are the mainstays of therapy in management of patients with acute cholangitis. However, the duration of antibiotic therapy after successful biliary drainage has not been prospectively evaluated. We conducted a single-center, randomized, noninferiority trial to compare short duration of antibiotic therapy with conventional duration of antibiotic therapy in patients with moderate or severe cholangitis. METHODS Consecutive patients were screened for the inclusion criteria and randomized into either conventional duration (CD) group (8 days) or short duration (SD) group (4 days) of antibiotic therapy. The primary outcome was clinical cure (absence of recurrence of cholangitis at day 30 and >50% reduction of bilirubin at day 15). Secondary outcomes were total days of antibiotic therapy and hospitalization within 30 days, antibiotic-related adverse events, and all-cause mortality at day 30. RESULTS The study included 120 patients (the mean age was 55.85 ± 13.52 years, and 50% were male patients). Of them, 51.7% patients had malignant etiology and 76.7% patients had moderate cholangitis. Clinical cure was seen in 79.66% (95% confidence interval, 67.58%-88.12%) patients in the CD group and 77.97% (95% confidence interval, 65.74%-86.78%) patients in the SD group ( P = 0.822). On multivariate analysis, malignant etiology and hypotension at presentation were associated with lower clinical cure. Total duration of antibiotics required postintervention was lower in the SD group (8.58 ± 1.92 and 4.75 ± 2.32 days; P < 0.001). Duration of hospitalization and mortality were similar in both the groups. DISCUSSION Short duration of antibiotics is noninferior to conventional duration in patients with moderate-to-severe cholangitis in terms of clinical cure, recurrence of cholangitis, and overall mortality.
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Affiliation(s)
- Deshidi Srinu
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Jimil Shah
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Anuraag Jena
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vaneet Jearth
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Anupam K Singh
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Harshal S Mandavdhare
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vishal Sharma
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Santosh Irrinki
- Department of General Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Yashwant Raj Sakaray
- Department of General Surgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rajesh Gupta
- Department of Surgical Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vikas Gautam
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Surinder Rana
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Usha Dutta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Kasparian K, Christou CD, Petidis K, Doumas M, Giouleme O. Short vs long-course antibiotic therapy in adults with acute cholangitis: A systematic review, meta-analysis, and evidence quality assessment. World J Gastroenterol 2023; 29:3027-3039. [PMID: 37274798 PMCID: PMC10237100 DOI: 10.3748/wjg.v29.i19.3027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 04/11/2023] [Accepted: 04/23/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND Acute cholangitis (AC) constitutes an infection with increased mortality rates in the past. Due to new diagnostic tools and therapeutic methods, the mortality of AC has been significantly reduced nowadays. The initial antibiotic treatment of AC has been oriented to the most common pathogens connected to this infection. However, the optimal duration of the antibiotic treatment of AC is still debatable.
AIM To investigate if shorter-course antibiotic treatments could be similarly effective to long-course treatments in adults with AC.
METHODS This study constitutes a systematic review and meta-analysis of the existing literature concerning the duration of antibiotic therapy of AC and an assessment of the quality of the evidence. The study was conducted in accordance with the recommendations of the Preferred Reporting Items for Systematic Review and Meta-Analyses. Fifteen studies were included in the systematic review, and eight were eligible for meta-analysis. Due to heterogeneous duration cutoffs, three study-analysis groups were formed, with a cutoff of 2-3, 6-7, and 14 d.
RESULTS A total of 2763 patients were included in the systematic review, and 1313 were accounted for the meta-analysis. The mean age was 73.66 ± 14.67 years, and the male and female ratio was 1:08. No significant differences were observed in the mortality rates of antibiotic treatment of 2-3 d, compared to longer treatments (odds ratio = 0.78, 95% confidence interval: 0.23-2.67, I2 = 9%) and the recurrence rates and hospitalization length were also not different in all study groups.
CONCLUSION Short- and long-course antibiotic treatments may be similarly effective concerning the mortality and recurrence rates of AC. Safe conclusions cannot be extracted concerning the hospitalization duration.
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Affiliation(s)
- Karampet Kasparian
- Clinic of Oncology, Gastroenterology and Hematology, Alfried Krupp Hospital, Essen 45131, Germany
- Second Propedeutic Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Chrysanthos D Christou
- Department of Transplantation Surgery, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Konstantinos Petidis
- Second Propedeutic Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Michail Doumas
- Second Propedeutic Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Olga Giouleme
- Second Propedeutic Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
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Miuțescu B, Vuletici D, Burciu C, Turcu-Stiolica A, Bende F, Rațiu I, Moga T, Sabuni O, Anjary A, Dalati S, Ungureanu BS, Gadour E, Horhat FG, Popescu A. Identification of Microbial Species and Analysis of Antimicrobial Resistance Patterns in Acute Cholangitis Patients with Malignant and Benign Biliary Obstructions: A Comparative Study. Medicina (B Aires) 2023; 59:medicina59040721. [PMID: 37109679 PMCID: PMC10141179 DOI: 10.3390/medicina59040721] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/29/2023] [Accepted: 04/03/2023] [Indexed: 04/08/2023] Open
Abstract
Background and Objectives: Acute cholangitis (AC) is still lethal if not treated promptly and effectively. Biliary drainage, also known as source control, has been acknowledged as the backbone treatment for patients with AC; nonetheless, antimicrobial therapy allows these patients to undergo non-emergent drainage procedures. This retrospective study aims to observe the bacterial species involved in AC and analyze the antimicrobial resistance patterns. Materials and Methods: Data were collected for four years, comparing patients with benign and malignant bile duct obstruction as an etiology for AC. A total of 262 patients were included in the study, with 124 cases of malignant obstruction and 138 cases of benign obstruction. Results: Positive bile culture was obtained in 192 (73.3%) patients with AC, with a higher rate among the benign group compared with malignant etiologies (55.7%.vs 44.3%). There was no significant difference between the Tokyo severity scores in the two study groups, identifying 34.7% cases of malignant obstruction with Tokyo Grade 1 (TG1) and 43.5% cases of TG1 among patients with benign obstruction. Similarly, there were no significant differences between the number of bacteria types identified in bile, most of them being monobacterial infections (19% in the TG1 group, 17% in the TG2 group, and 10% in the TG3 group). The most commonly identified microorganism in blood and bile cultures among both study groups was E. coli (46.7%), followed by Klebsiella spp. (36.0%) and Pseudomonas spp. (8.0%). Regarding antimicrobial resistance, it was observed that significantly more patients with malignant bile duct obstruction had a higher percentage of bacterial resistance for cefepime (33.3% vs. 11.7%, p-value = 0.0003), ceftazidime (36.5% vs. 14.5%, p-value = 0.0006), meropenem (15.4% vs. 3.6%, p-value = 0.0047), and imipenem (20.2% vs. 2.6%, p-value < 0.0001). Conclusions: The positive rate of biliary cultures is higher among patients with benign biliary obstruction, while the malignant etiology correlates with increased resistance to cefepime, ceftazidime, meropenem, and imipenem.
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Affiliation(s)
- Bogdan Miuțescu
- Department of Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
- Advanced Regional Research Center in Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy, 30041 Timisoara, Romania
| | - Deiana Vuletici
- Department of Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
- Advanced Regional Research Center in Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy, 30041 Timisoara, Romania
| | - Călin Burciu
- Department of Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
- Advanced Regional Research Center in Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy, 30041 Timisoara, Romania
| | - Adina Turcu-Stiolica
- Department of Pharmacoeconomics, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Felix Bende
- Department of Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
- Advanced Regional Research Center in Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy, 30041 Timisoara, Romania
| | - Iulia Rațiu
- Department of Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
- Advanced Regional Research Center in Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy, 30041 Timisoara, Romania
| | - Tudor Moga
- Department of Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
- Advanced Regional Research Center in Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy, 30041 Timisoara, Romania
| | - Omar Sabuni
- Faculty of General Medicine, Altinbas University, Dilmenler Cd., 34217 Istanbul, Turkey
| | - Adnan Anjary
- Faculty of General Medicine, Yeditepe University, Kayısdagı Cd., 34755 Istanbul, Turkey
| | - Sami Dalati
- Faculty of General Medicine, Baskent University, Fatih Sultan, 06790 Ankara, Turkey
| | - Bogdan Silviu Ungureanu
- Research Center of Gastroenterology and Hepatology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Eyad Gadour
- Department of Gastroenterology, King Abdulaziz Hospital-National Guard Health Affairs, Al Ahsa 31982, Saudi Arabia
- Department of Medicine, Zamzam University College, Khartoum 11113, Sudan
| | - Florin George Horhat
- Multidisciplinary Research Center on Antimicrobial Resistance (MULTI-REZ), Microbiology Department, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Alina Popescu
- Department of Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy Timisoara, Eftimie Murgu Square 2, 300041 Timisoara, Romania
- Advanced Regional Research Center in Gastroenterology and Hepatology, “Victor Babes” University of Medicine and Pharmacy, 30041 Timisoara, Romania
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9
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Antibiotic Administration within Two Days after Successful Endoscopic Retrograde Cholangiopancreatography Is Sufficient for Mild and Moderate Acute Cholangitis. J Clin Med 2022; 11:jcm11102697. [PMID: 35628824 PMCID: PMC9143657 DOI: 10.3390/jcm11102697] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/04/2022] [Accepted: 05/09/2022] [Indexed: 02/05/2023] Open
Abstract
To prevent the increase of resistant bacteria, it is important to minimize the use of antimicrobial agents. Studies have found that administration for ≤3 days after successful endoscopic retrograde cholangiopancreatography (ERCP) is appropriate. Therefore, the present study aimed to verify if administration of antimicrobial agents can be further shortened to ≤2 days after ERCP. We divided 390 patients with mild and moderate cholangitis who underwent technically successful ERCP from January 2018 to June 2020 and had positive blood or bile cultures into two groups: antibiotic therapy within two days of ERCP (short-course therapy, SCT; n = 59, 15.1%), and for >3 days (long-course therapy, LCT; n = 331, 84.9%). The increased severity after admission and other outcomes were compared between the two groups, and the risk factors for increased severity were verified. There were no between-group differences in patient characteristics. Total length of hospital stay was shorter in SCT than in LCT, and other outcomes in SCT were not significantly different from those in LCT. Being 80 or older was a risk factor for increased severity; however, SCT was not associated with increased severity. Antimicrobial therapy for ≤2 days after successful ERCP is adequate in patients with mild and moderate acute cholangitis.
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10
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Lipocalin2 as a useful biomarker for risk stratification in patients with acute cholangitis: A single-center prospective and observational study. Clin Chim Acta 2022; 533:22-30. [DOI: 10.1016/j.cca.2022.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/18/2022] [Accepted: 05/25/2022] [Indexed: 12/07/2022]
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11
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Colling KP, Besshoff KE, Forrester JD, Kendrick D, Mercier P, Huston JM. Surgical Infection Society Guidelines for Antibiotic Use in Patients Undergoing Cholecystectomy for Gallbladder Disease. Surg Infect (Larchmt) 2022; 23:339-350. [PMID: 35363086 DOI: 10.1089/sur.2021.207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Abstract
Background: Manifestations of gallbladder disease range from intermittent abdominal pain (symptomatic cholelithiasis) to potentially life-threatening illness (gangrenous cholecystitis). Although surgical intervention to treat acute cholecystitis is well defined, the role of antibiotic administration before or after cholecystectomy to decrease morbidity or mortality is less clear. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee convened to develop guidelines for antibiotic use in patients undergoing cholecystectomy for gallbladder disease to prevent surgical site infection, other infection, hospital length of stay, or mortality. PubMed, Embase, and the Cochrane Database were searched for relevant studies. Evaluation of the published evidence was performed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. Using a process of iterative consensus, all authors voted to accept or reject each recommendation. Results: We recommend against routine use of peri-operative antibiotic agents in low-risk patients undergoing elective laparoscopic cholecystectomy. We recommend use of peri-operative antibiotic agents for patients undergoing laparoscopic cholecystectomy for acute cholecystitis. We recommend against use of post-operative antibiotic agents after elective laparoscopic cholecystectomy for symptomatic cholelithiasis. We recommend against use of post-operative antibiotic agents in patients undergoing laparoscopic cholecystectomy for mild or moderate acute cholecystitis. We recommend a maximum of four days of antibiotic agents, and perhaps a shorter duration in patients undergoing cholecystectomy for severe (Tokyo Guidelines grade III) cholecystitis. Conclusions: This guideline summarizes the current Surgical Infection Society recommendations for antibiotic use in patients undergoing cholecystectomy for gallbladder disease.
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Affiliation(s)
| | - Kovi E Besshoff
- Department of Surgery, Stanford University, Stanford, California, USA
| | | | - Daniel Kendrick
- Department of Surgery, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Phillip Mercier
- Department of Surgery, University of Minnesota Twin Cities, Minneapolis, Minnesota, USA
| | - Jared M Huston
- Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
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12
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Zhang X, Tian Y, Feng L, Yu Y, Ma L. Effectiveness of Short-Course Antibacterial Therapy on Acute Cholecystitis after Successful Percutaneous Transhepatic Gallbladder Drainage: A Retrospective Study. Surg Infect (Larchmt) 2022; 23:248-253. [PMID: 35099300 DOI: 10.1089/sur.2021.244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022] Open
Affiliation(s)
- Xiaoxia Zhang
- Department of Infectious Diseases, First Hospital of Qinhuangdao, Qinhuangdao, Hebei Province, PR China
| | - Ye Tian
- Department of Interventional Treatment, First Hospital of Qinhuangdao, Qinhuangdao, Hebei Province, PR China
| | - Li Feng
- Department of Infectious Diseases, First Hospital of Qinhuangdao, Qinhuangdao, Hebei Province, PR China
| | - Ying Yu
- Department of Infectious Diseases, First Hospital of Qinhuangdao, Qinhuangdao, Hebei Province, PR China
| | - Li Ma
- Department of Infectious Diseases, First Hospital of Qinhuangdao, Qinhuangdao, Hebei Province, PR China
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13
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Haal S, Wielenga MCB, Fockens P, Leseman CA, Ponsioen CY, van Soest EJ, van Wanrooij RLJ, Sieswerda E, Voermans RP. Antibiotic Therapy of 3 Days May Be Sufficient After Biliary Drainage for Acute Cholangitis: A Systematic Review. Dig Dis Sci 2021; 66:4128-4139. [PMID: 33462749 PMCID: PMC8589797 DOI: 10.1007/s10620-020-06820-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 12/31/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND The optimal antibiotic therapy duration for cholangitis is unclear. Guideline recommendations vary between 4 and 14 days after biliary drainage. Clinical observations and some evidence however suggest that shorter antibiotic therapy may be sufficient. OBJECTIVE To compare the effectiveness and safety of short-course therapy of ≤ 3 days with long-course therapy of ≥ 4 days after biliary drainage in cholangitis patients. METHODS We searched the databases PubMed, EMBASE, Cochrane Library, and trial registers for literature up to August 5, 2020. RCTs and observational studies including case series reporting on antibiotic therapy duration for acute cholangitis were eligible for inclusion. Two reviewers independently evaluated study eligibility, extracted data, assessed risk of bias and quality of evidence. A meta-analysis was planned if the included studies were comparable with regard to important study characteristics. Primary outcomes included recurrent cholangitis, subsequent other infection, and mortality. RESULTS We included eight studies with 938 cholangitis patients. Four observational studies enrolled patients treated for ≤ 3 days. Recurrent cholangitis occurred in 0-26.8% of patients treated with short-course therapy, which did not differ from long-course therapy (range 0-21.1%). Subsequent other infection and mortality rates were also comparable. Quality of available evidence was very low. CONCLUSION There is no high-quality evidence available to draw a strong conclusion, but heterogeneous observational studies suggest that antibiotic therapy of ≤ 3 days is sufficient in cholangitis patients with common bile duct stones.
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Affiliation(s)
- Sylke Haal
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
- Department of Internal Medicine, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Mattheus C. B. Wielenga
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Charlotte A. Leseman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Cyriel Y. Ponsioen
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Ellert J. van Soest
- Department of Gastroenterology, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Roy L. J. van Wanrooij
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Elske Sieswerda
- Department of Medical Microbiology and Infection Control, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Rogier P. Voermans
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
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14
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An Z, Braseth AL, Sahar N. Acute Cholangitis: Causes, Diagnosis, and Management. Gastroenterol Clin North Am 2021; 50:403-414. [PMID: 34024448 DOI: 10.1016/j.gtc.2021.02.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Acute cholangitis, also referred to as ascending cholangitis, is an infection of the biliary tree characterized by fever, jaundice, and abdominal pain, which in most cases is the consequence of biliary obstruction. Diagnosis is commonly made by the presence of clinical features, laboratory tests, and imaging studies. The treatment modalities include administration of intravenous fluids, antimicrobial therapy, and prompt drainage of the bile duct. Early diagnosis and treatment of acute cholangitis are crucial to prevent unwanted clinical outcome of the disease. This article provides an update on early diagnosis and management of acute cholangitis.
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Affiliation(s)
- Zhibo An
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 4608 JCP, Iowa City, IA 52242, USA
| | - Annie L Braseth
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 4608 JCP, Iowa City, IA 52242, USA
| | - Nadav Sahar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 4608 JCP, Iowa City, IA 52242, USA.
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