What are the recommended antibiotics for acute cholangitis?

From the Guidelines

For acute cholangitis, empiric antibiotic therapy should be initiated immediately, with the recommended first-line regimen being piperacillin-tazobactam 3.375g IV every 6 hours or 4.5g IV every 8 hours, as this regimen has been shown to be effective in targeting common biliary pathogens, including Escherichia coli, Klebsiella, Enterococcus, and anaerobes 1. The goal of antibiotic therapy is to target these common biliary pathogens, and the choice of antibiotic agent should be directed by local practice after taking into consideration the history, severity of liver or renal disease, and bacterial sensitivities.

• Alternative options include ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours, or ciprofloxacin 400mg IV every 12 hours plus metronidazole if there are contraindications to beta-lactams.
• For severe cases or healthcare-associated infections, consider meropenem 1g IV every 8 hours or imipenem 500mg IV every 6 hours.
• Antibiotics should be continued for a total of 4-7 days, with longer durations for complicated cases, and dosage adjustments are necessary for patients with renal impairment.
• While antibiotics are crucial, definitive treatment requires biliary decompression via ERCP, percutaneous drainage, or surgery within 24-48 hours, especially for severe cases, as the mortality in those untreated is high 1.
• Antibiotic therapy can be narrowed based on culture results and clinical improvement, with transition to oral therapy when the patient is clinically stable and can tolerate oral intake.
• It is also important to note that biliary infections are often polymicrobial, and the most common organisms are Eschericia coli, Klebsiella, Enterococcus, Clostridium, Steptococcus, Pseudomonas, and Bacteroides species, and antifungal therapy should be considered in those with cholangitis not responding to antibiotic therapy 1.

From the Research

Antibiotic Therapy for Acute Cholangitis

• The current management of acute cholangitis consists of antibiotic therapy in combination with biliary drainage 2.
• The optimal duration of antibiotic therapy after the resolution of clinical symptoms by biliary drainage is unclear, but fever-based antibiotic therapy has been shown to be safe and effective 2.
• Antibiotic therapy should be administered promptly, along with intravenous fluids and biliary decompression and drainage, to reduce mortality and morbidity 3, 4.

Choice of Antibiotics

• Cefmetazole sodium and meropenem hydrate can be used as initial antibiotic therapy for patients with moderate and severe acute cholangitis, respectively 2.
• The Tokyo Guidelines 2018 provide recommendations for the appropriate use of antimicrobials for community-acquired and healthcare-associated infections, including acute cholangitis 5.
• Cefmetazole may be an alternative to carbapenems and piperacillin/tazobactam as initial therapy for bacteremic acute cholangitis, with potential benefits including shorter length of stay and lower antibiotic costs 6.

Duration of Antibiotic Therapy

• The duration of antibiotic therapy for acute cholangitis is systematically reviewed in the Tokyo Guidelines 2018, with recommendations for prudent antimicrobial usage and early de-escalation or termination of antimicrobial therapy 5.
• Antibiotic therapy can be stopped when the body temperature of < 37 ° C is maintained for 24 h, with no recurrence of acute cholangitis within 3 days after the withdrawal of antibiotics 2.