What is the treatment for cholangitis?

Treatment of Cholangitis

Acute cholangitis requires immediate empiric antibiotics combined with biliary decompression for patients with high-grade strictures or severe disease to reduce mortality and prevent septic complications. 1, 2

Immediate Antibiotic Therapy

Timing and Initial Management

• Start antibiotics within 1 hour if septic shock is present, otherwise within 4 hours of suspected cholangitis. 1
• Admit patients with severe disease or significant comorbidities to the intensive care unit. 1

First-Line Antibiotic Selection

For mild-to-moderate cholangitis:

• Aminopenicillin/beta-lactamase inhibitor combinations (e.g., ampicillin-sulbactam) are first-line for mild episodes and can be administered orally. 3, 1
• These agents provide adequate coverage against the most common pathogens: gram-negative bacteria (E. coli, Klebsiella, Pseudomonas, Bacteroides) and gram-positive organisms (Enterococci, Streptococci). 3

For severe cholangitis:

• Piperacillin/tazobactam is the preferred agent for severe cases as it provides sufficient anaerobic coverage without additional agents. 3, 1, 2
• Alternative: Third-generation cephalosporins with anaerobic coverage (though piperacillin/tazobactam is superior due to built-in anaerobic activity). 3
• Carbapenems (imipenem, meropenem, ertapenem) should be reserved for unstable patients or those with risk factors for ESBL-producing organisms. 1, 2

Important Antibiotic Considerations

• Avoid fluoroquinolones as first-line therapy due to high resistance rates and unfavorable side effect profiles, despite their excellent biliary penetration. 3
• Tailor antibiotic selection to local epidemiology, bacterial sensitivities, and degree of liver/renal impairment. 3
• For patients with sepsis or inadequate response to initial therapy, add gram-positive coverage targeting Enterococci with vancomycin or linezolid. 3

Duration of Therapy

• Continue antibiotics for at least 4 days after successful biliary drainage. 2
• Extend to 2 weeks if Enterococcus or Streptococcus is isolated. 2
• Without biliary decompression, short-course antibiotics alone will not eradicate bacteria in patients with high-grade strictures. 3

Biliary Decompression

Indications and Timing

• Patients with severe acute cholangitis and high-grade strictures require urgent biliary decompression as they are at high risk of mortality. 3
• For mild cholangitis, wait for antibiotic response before proceeding to ERCP if the patient is stable. 3
• ERCP with balloon dilatation is the treatment of choice for biliary decompression in moderate-to-severe cholangitis. 1

Alternative Drainage Methods

• Percutaneous transhepatic biliary drainage (PTBD) is indicated when ERCP fails or is contraindicated. 1
• Small biliary sphincterotomy may be considered if cannulation is difficult, though routine sphincterotomy is not recommended due to short-term complication risks. 3

Critical Principle

• Bacteria in bile do not worsen outcomes if high-grade stenoses are treated endoscopically and infection is adequately treated with antibiotics. 3

Severity-Based Treatment Algorithm

Grade I (Mild/Stable):

• Oral aminopenicillin/beta-lactamase inhibitor 3
• ERCP with biliary decompression if high-grade stricture present 1
• Short-course antibiotics (4+ days post-drainage) 2

Grade II-III (Moderate-to-Severe/Unstable):

• IV piperacillin/tazobactam 3, 1
• Immediate ERCP for biliary decompression 1, 2
• Consider adding vancomycin or linezolid if septic or not responding 3
• Broader-spectrum coverage (carbapenems) if risk factors for resistant organisms 1

Special Populations and Situations

Recurrent Cholangitis

• Patients with complex intrahepatic cholangiopathy may require prophylactic long-term antibiotics (e.g., co-trimoxazole) with antibiotic rotation. 3
• This should only be considered under exceptional circumstances due to antibiotic resistance risk and requires multidisciplinary assessment with formal microbiology consultation. 3

Fungal Cholangitis (Candida)

• Candida in bile is associated with poor prognosis and markedly reduced transplant-free survival, typically occurring in late-stage disease with high-grade stenoses. 3
• The benefit of antifungal treatment is unclear; patients are often not treated unless immunosuppressed or with overt cholangitis. 3
• These patients may require liver transplantation relatively quickly. 3

Culture-Guided Therapy

• Obtain bile samples for microbial testing during drainage procedures to guide targeted antibiotic therapy. 1
• Adjust antibiotics based on culture results and local resistance patterns. 1
• Patients with biliary stents or previous biliary surgery are at higher risk for resistant organisms and may require broader empiric coverage. 1

Critical Pitfalls to Avoid

• Never delay biliary drainage in moderate-to-severe cholangitis, as this significantly worsens outcomes and increases mortality. 2
• Do not use antibiotics alone without addressing biliary obstruction in patients with high-grade strictures—this will not sterilize the biliary tract. 3
• Avoid routine long-term antibiotics for PSC treatment in the absence of recurrent bacterial cholangitis due to resistance concerns. 3
• Be aware that aminoglycoside nephrotoxicity risk may be increased during cholestasis, so limit duration to a few days if used. 3