What are the first-line antibiotics for acute cholangitis?

From the Guidelines

The first-line antibiotics for acute cholangitis include a combination of a third-generation cephalosporin (such as ceftriaxone 1-2g IV every 24 hours) plus metronidazole (500mg IV every 8 hours), or alternatively, piperacillin-tazobactam (3.375g IV every 6 hours) or a carbapenem like meropenem (1g IV every 8 hours) as monotherapy, as recommended by the most recent guidelines 1.

Key Considerations

• Treatment should be initiated immediately after blood cultures are drawn and typically continues for 4-7 days, depending on clinical response 1.
• For patients with severe sepsis or septic shock, broader coverage may be necessary 1.
• The antibiotic choice should be adjusted based on culture results and local resistance patterns 1.
• These antibiotics are recommended because they provide coverage against the common causative organisms in cholangitis: gram-negative bacteria (especially E. coli, Klebsiella, and Enterobacter), enterococci, and anaerobes 1.

Additional Recommendations

• In addition to antibiotics, prompt biliary decompression through ERCP, percutaneous drainage, or surgery is essential for definitive management of the infection source 1.
• Patients with penicillin allergies can receive ciprofloxacin (400mg IV every 12 hours) plus metronidazole as an alternative regimen 1.

Important Notes

• The type and timing of biliary drainage should be based on the severity of the clinical presentation, and the availability and feasibility of drainage techniques 1.
• ERCP plays a central role in the management of biliary obstruction in patients with acute cholangitis 1.

From the Research

First Line Antibiotics for Acute Cholangitis

• The treatment of acute bacterial cholangitis requires broad-spectrum antibiotics to cover against gram-negative aerobic enteric organisms, gram-positive Enterococcus, and anaerobic bacteria 2.
• First-line antimicrobial therapy is usually recommended to be a third-generation cephalosporin, such as cefmetazole, which is stable to hydrolysis by extended-spectrum β-lactamase (ESBL)-producing Enterobacterales 3, 4.
• Systematic coverage of Enterococcus spp. and anaerobic infections remains debated, and is usually recommended in case of severity criteria for Enterococcus severity levels, or anaerobic bilio-digestive anastomosis for anaerobes 4.
• The main pathogens involved in acute cholangitis are Escherichia coli and Klebsiella spp., justifying the use of antibiotics effective against these bacteria 4.

Alternative Antibiotic Options

• Carbapenems and piperacillin/tazobactam are commonly used as initial therapy for acute cholangitis, but their overuse contributes to the spread of antimicrobial resistance 3.
• Cefmetazole may be an alternative to carbapenems and piperacillin/tazobactam, with a shorter length of stay and lower antibiotic costs without worsening patient outcomes 3.

Importance of Early Treatment

• Early diagnosis and treatment of acute cholangitis are crucial to prevent unwanted clinical outcomes of the disease 5, 6.
• Mortality in cases of acute cholangitis remains approximately 5%, despite improved management 4.
• Severe acute cholangitis was reported to have a mortality rate between 11 and 27% in the 1990s, highlighting the importance of prompt treatment 6.