What is the treatment for cholangitis?

Treatment of Cholangitis

Acute cholangitis requires immediate broad-spectrum antibiotics within 1 hour for septic shock patients (within 4 hours for others) combined with biliary decompression via ERCP for moderate-to-severe cases to reduce mortality. 1

Immediate Management

Antibiotic Therapy

• Initiate empiric broad-spectrum antibiotics immediately upon suspicion, ideally within 1 hour for patients with septic shock and within 4 hours for other patients 2, 1
• First-line antibiotic regimens include:
  • Piperacillin/tazobactam 2, 1
  • 4th-generation cephalosporins 2
  • Carbapenems (imipenem/cilastatin, meropenem, ertapenem) 2
  • Aztreoam with amikacin in shock states 3
• Add fluconazole in fragile patients, delayed diagnosis, or when cholangitis fails to respond to antibiotics alone (Candida in bile carries poor prognosis) 3, 1
• Target common pathogens: E. coli, Klebsiella, Enterococcus, Clostridium, Streptococcus, Pseudomonas, and Bacteroides 1

Severity-Based Treatment Algorithm

Grade III (Severe) - Organ Dysfunction Present:

• Urgent biliary decompression required immediately along with antibiotics and ICU admission 1, 4
• Mortality is extremely high without urgent drainage 1

Grade II (Moderate) - No organ dysfunction but no response to initial treatment:

• Early biliary drainage within 24 hours to prevent progression to severe disease 2, 1
• These patients are at high risk of deterioration without intervention 1

Grade I (Mild) - Responds to initial medical treatment:

• May be managed with antibiotics alone initially 1
• Definitive biliary intervention still required later to prevent recurrence 5

Biliary Decompression

Primary Approach

• ERCP with biliary drainage is the first-line procedure for biliary decompression in moderate-to-severe cholangitis 2, 1, 5
• Endoscopic options include nasobiliary drain placement and sphincterotomy with stone extraction 2
• Obtain bile samples for microbial testing at the beginning of drainage procedures 2, 1
• Perform brush cytology and/or endoscopic biopsy to exclude malignancy, particularly in patients with dominant strictures 3, 2

Alternative Drainage When ERCP Fails

• Percutaneous transhepatic biliary drainage (PTBD) should be reserved for ERCP failures or when ERCP is not feasible due to higher complication risks 2, 1
• Open surgical drainage only when endoscopic or percutaneous approaches are contraindicated or unsuccessful 2, 1

Antibiotic Duration

• Standard duration: 3-5 days with successful biliary drainage 2
• Extend treatment until anatomical resolution in cases of residual stones or ongoing obstruction 1
• Continue for 2 weeks if Enterococcus or Streptococcus isolated to prevent infectious endocarditis 3
• For biloma and generalized peritonitis, treat for 5-7 days 3

Special Populations

Primary Sclerosing Cholangitis (PSC) with Cholangitis

• Antimicrobial therapy with correction of bile duct obstruction in dominant strictures is essential 3
• Initial management includes endoscopic dilatation with or without stenting 3, 2
• Prophylactic long-term antibiotics recommended for patients with recurrent bacterial cholangitis 3, 1
• Refractory bacterial cholangitis warrants evaluation for liver transplantation 3

Recurrent Cholangitis

• Consider prophylactic long-term antibiotics in patients with compromised biliary systems (endoprosthesis, hepaticojejunostomy) prone to recurrent episodes 3, 1, 6
• Evaluate for liver transplantation if cholangitis remains refractory despite optimal management 3

Critical Pitfalls to Avoid

• Delaying antibiotic administration beyond 1 hour in septic shock significantly increases mortality 2, 1
• Failure to achieve adequate biliary drainage is associated with poor outcomes regardless of antibiotic therapy 2, 1
• Overlooking fungal infection in patients not responding to standard antibiotic therapy 1
• Underestimating severity and failing to admit Grade III patients to ICU 1
• Prolonged antibiotic treatment without addressing underlying biliary obstruction does not prevent recurrence 1