Does a biliary leak require antibiotics?

From the Guidelines

Antibiotics are not routinely required for uncomplicated biliary leaks, but should be initiated if there are signs of infection or cholangitis, as recommended by the most recent guidelines 1. The primary management of biliary leaks focuses on drainage and decompression of the biliary system, typically through endoscopic retrograde cholangiopancreatography (ERCP) with stent placement or percutaneous drainage. Some key points to consider in the management of biliary leaks include:

• The use of broad-spectrum antibiotics covering gram-negative organisms and anaerobes, such as piperacillin-tazobactam or a combination of ceftriaxone plus metronidazole, if signs of infection are present 1.
• The duration of antibiotic therapy, which should be based on clinical conditions and inflammation indices, and may range from 4 to 7 days in immunocompetent and critically ill patients, respectively 1.
• The importance of addressing the underlying leak through proper drainage techniques and allowing the biliary system to heal, as unnecessary antibiotic use can lead to resistance and side effects.
• The role of biliary drainage, which should be based on the severity of the clinical presentation, and the availability and feasibility of drainage techniques, such as ERCP, percutaneous transhepatic cholangiography (PTC), and open surgical drainage 1. In cases where antibiotics are necessary, the treatment should be adapted according to bile culture findings and clinical response, as recommended by the guidelines 1.

From the Research

Biliary Leaks and Antibiotics

• The use of antibiotics in cases of biliary leaks is not universally required, but rather depends on the specific clinical scenario and the presence of infection or risk of infection 2.
• Bactobilia, or the presence of bacteria in the bile, is a common accompaniment of biliary obstruction and can lead to infection 3.
• The choice of antibiotic regimen should take into account the expected antibiotic sensitivities of the organisms colonizing the bile, as well as the presence of biliary obstruction or bacteraemia 3.

Antibiotic Use in Biliary Infections

• Antibiotic therapy is indicated in cases of acute cholecystitis, especially if there is evidence of systemic toxicity or if surgery is to be delayed 3.
• The use of antibiotics such as ampicillin, cephalosporins, or fluoroquinolones may be appropriate in less severe cases, while more severe cases may require the use of broader-spectrum antibiotics such as aminoglycosides or carbapenems 3, 4.
• The results of in-vitro testing of different antibiotics against biliary isolates suggest that imipenem, colistin, and tobramycin may be effective options 4.

Perioperative Antibiotics

• The use of perioperative antibiotics covering bile contamination may prevent abdominal infectious complications after pancreatoduodenectomy in patients with preoperative biliary drainage 5.
• A perioperative antibiotic strategy particular to preoperative biliary drainage procedures is valid for covering biliary microorganisms during pancreatoduodenectomy 5.

Risk Factors for Biliary Infection

• The distribution and antibiotic-resistant characteristics of biliary bacteria are dynamic, and risk factors such as the administration of third- or fourth-generation cephalosporins may contribute to the development of biliary infection 6.
• Gram-negative bacilli, especially Escherichia coli, are the most common pathogenic bacteria isolated from biliary infection patients, and the rates and patterns of drug resistance are high and in constant flux 6.