Ascending cholangitis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Anila Hussain, MD [2]

Overview

When acute ascending cholangitis is suspected, the patient should be hospitalized. Fluid resuscitation and antibiotics are the key interventions and antibiotic treatment should be targeted against gram-negative organisms and, possibly, anaerobes. Empiric antibiotics of choice usually include piperacillin-tazobactam, ticarcillin-clavulanate, ceftriaxone plus metronidazole or ampicillin-sulbactam

Medical Therapy

The main goal of treatment of acute cholangitis is treating both causes of acute cholangitis that are biliary infection and biliary obstruction. Therefore, both antibiotic therapy and biliary drainage are important components of therapy in addition to supportive care. Urgency of treatment depends on the illness severity. About 80 percent of patients with mild cholangitis respond well to medical therapy and 10-15 percent who don not respond need surgical or endoscopic intervention. Markers for these people are persistent abdominal pain, hypotension, fever >102 F, and confusion.. Sick patients should be promptly resuscitated and transferred to intensive care unit for further management and immediate decompression should be done.

SUPPORTIVE CARE

• IV hydration
• Correction of electrolyte abnormalities
• Analgesics for pain control
• Invasive monitoring
• Ionotropic Support (in severe cholangitis)
• Ventilation support (if needed)

ANTIBIOTICS

• Should be given emprically to all patients with suspected diagnosis of ascending cholangitis (after taking cultures)
• Broad spectrum antibiotics are used to cover wide range of organisms include gram negative and mixed bacteria
• Choice of antibiotic also depends on whether infection was community aquired (organisms like E.coli, Klebseilla, or Enterococcus) or hospital care associated (multiple or resistant organisms like Pseudomonas, CRE, vancomycin-resistant enterococcus or methicillin-resistant Staphylococcus aureus) along with individual risk factors and comorbidities (renal failure, cirrhosis, drug allergies) in every person
• Empiric antibiotics of choice usually include piperacillin-tazobactam, ticarcillin-clavulanate, ceftriaxone plus metronidazole or ampicillin-sulbactam
• In penicillin sensitive patients, ciprofloxacin plus metronidazole, carbapenems or gentamicin plus metronidazole can be used
• Antibiotics are later adjusted according to blood culture results
• 90 percent of patients respond well to antibiotics and supportive treatment in first 24-48 hours

Following are the agents and regimens that can Be used for the initial empiric treatment of biliary infection in adults

• 1. Community-acquired acute cholecystitis of mild-to-moderate severity
  • Preferred regimen (1): Cefazolin 1–2 g IV q8h
  • Preferred regimen (2): Cefuroxime 1.5 g IV q8h
  • Preferred regimen (3): Ceftriaxone 1–2 g IV q12–24 h
• 2. Community-acquired acute cholecystitis of severe physiologic disturbance, advanced age, or immunocompromised state
  • Preferred regimen (1): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h, AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
  • Preferred regimen (2): Meropenem 1 g IV q8h, AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
  • Preferred regimen (3): Doripenem 500 mg IV q8h, AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
  • Preferred regimen (4): Piperacillin-tazobactam 3.375 g IV q6h, AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
  • Preferred regimen (5): Ciprofloxacin 400 mg IV q12h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
  • Preferred regimen (6): Levofloxacin 750 mg IV q24h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
  • Preferred regimen (7): Cefepime 2 g IV q8–12h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
• 3. Acute cholangitis following bilio-enteric anastamosis of any severity
  • Preferred regimen (1): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
  • Preferred regimen (2): Meropenem 1 g IV q8h, AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
  • Preferred regimen (3): Doripenem 500 mg IV q8h, AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
  • Preferred regimen (4): Piperacillin-tazobactam 3.375 g IV q6h, AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
  • Preferred regimen (5): Ciprofloxacin 400 mg IV q12h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
  • Preferred regimen (6): Levofloxacin 750 mg IV q24h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
  • Preferred regimen (7): Cefepime 2 g IV q8–12h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
• 4. Health care-associated biliary infection of any severity
  • Preferred regimen (1): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h AND Vancomycin 15–20 mg/kg IV q8–12 h
  • Preferred regimen (2): Meropenem 1 g IV q8h, AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h AND Vancomycin 15–20 mg/kg IV q8–12 h
  • Preferred regimen (3): Doripenem 500 mg IV q8h, AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h AND Vancomycin 15–20 mg/kg IV q8–12 h
  • Preferred regimen (4): Piperacillin-tazobactam 3.375 g IV q6h, AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h AND Vancomycin 15–20 mg/kg IV q8–12 h
  • Preferred regimen (5): Ciprofloxacin 400 mg IV q12h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h AND Vancomycin 15–20 mg/kg IV q8–12 h
  • Preferred regimen (6): Levofloxacin 750 mg IV q24h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h AND Vancomycin 15–20 mg/kg IV q8–12 h
  • Preferred regimen (7): Cefepime 2 g IV q8–12h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h AND Vancomycin 15–20 mg/kg IV q8–12 h
• Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer duration of therapy has not been associated with improved outcomes.