What is the recommended treatment for cholangitis?

Treatment of Cholangitis

Acute bacterial cholangitis should be treated with antibiotics and subsequent biliary decompression if an underlying relevant stricture is present. 1

Initial Management

Antibiotic Therapy

• First-line antibiotics:

  • For mild cases: Oral aminopenicillin/beta-lactamase inhibitor (e.g., amoxicillin/clavulanate) 1
  • For moderate to severe cases: Intravenous antibiotics 1
    • Piperacillin/tazobactam (provides sufficient anaerobic coverage) 1, 2
    • Third-generation cephalosporins with anaerobic coverage 1
  • Coverage should target common biliary pathogens:
    • Gram-negative bacteria: Escherichia coli, Klebsiella, Pseudomonas
    • Gram-positive bacteria: Enterococci, Streptococci
    • Anaerobes: Bacteroides species 1, 3

• Duration of therapy:

  • 3-5 days for uncomplicated cases with successful drainage
  • 7-10 days for complicated cases or persistent infection 4

Biliary Decompression

• Endoscopic intervention is recommended for patients with relevant strictures, defined as high-grade strictures on imaging in the common bile duct or hepatic ducts with signs of obstructive cholestasis and/or bacterial cholangitis 1
• ERCP with sphincterotomy and stone extraction/stenting is the first-line approach for biliary decompression, with success rates >90% for stone extraction 5
• Percutaneous transhepatic biliary drainage (PTBD) is an alternative when endoscopic drainage fails 5, 6
• Surgical decompression is rarely needed in emergency settings but may be necessary for definitive treatment of underlying causes 6

Special Considerations

Severity Assessment

• Approximately 20% of patients with acute cholangitis fail to respond to conservative treatment with antibiotic therapy and require urgent biliary decompression 3
• Patients with benign biliary obstructions have significantly better outcomes than those with malignant obstructions (83% vs. 59% cure rate) 2

Fungal Infections

• Consider antifungal therapy in patients not responding to antibiotic therapy
• Candida species have been isolated in 12% of PSC patients undergoing ERCP 1
• Persistence of biliary candidiasis is associated with reduced transplantation-free survival 1

Recurrent Cholangitis

• For patients with recurrent bacterial cholangitis due to complex intrahepatic cholangiopathy:
  • Consider prophylactic long-term antibiotics (e.g., co-trimoxazole) and rotation of antibiotics in exceptional circumstances 1
  • This should only be done with multidisciplinary expert assessment and formal microbiology advice due to risk of antibiotic resistance 1

Common Pitfalls to Avoid

• Delaying antibiotic treatment
• Delaying biliary decompression in non-responsive cases
• Overreliance on antibiotics alone without addressing biliary obstruction
• Prolonged broad-spectrum antibiotic use without tailoring to culture results
• Failure to consider fungal infections in non-responsive cases

The prognosis depends on the nature of biliary obstruction, with better outcomes in benign conditions. Mortality is higher with delayed diagnosis and treatment, particularly in elderly patients with comorbidities 6.