From the Guidelines
Empiric antibiotic therapy for cholangitis should include piperacillin-tazobactam 3.375g IV every 6 hours, or ceftriaxone 1-2g IV daily plus metronidazole 500mg IV every 8 hours, as these regimens cover gram-negative and gram-positive bacteria, including anaerobes, which are the most frequently encountered organisms in biliary infections 1.
Key Considerations
- The choice of antibiotics should be directed by local practice, considering bacterial sensitivities and the degree of liver and/or renal impairment 1.
- For severe cases or healthcare-associated infections, consider meropenem 1g IV every 8 hours, and for patients with penicillin allergy, aztreonam 2g IV every 8 hours plus metronidazole is an alternative.
- Treatment duration is typically 4-7 days after source control is achieved, and patients with mild-to-moderate community-acquired cholangitis can be switched to oral antibiotics once clinically improved.
- Antibiotic selection should cover gram-negative organisms (especially E. coli, Klebsiella) and anaerobes, as these are the predominant pathogens in biliary infections.
Additional Recommendations
- Prompt biliary decompression via ERCP or percutaneous drainage is essential alongside antibiotics, and adjust therapy based on culture results when available, considering local resistance patterns 1.
- Fluoroquinolones should be saved for specific cases due to high resistance and unfavorable side effect profiles, and the addition of antibiotic coverage against gram-positive organisms, such as glycopeptide antibiotics (e.g., vancomycin) or oxazolidine antibiotics (e.g., linezolid), may be considered in patients with sepsis or those who do not quickly respond to antibiotic treatment 1.
From the FDA Drug Label
Piperacillin and tazobactam are widely distributed into tissues and body fluids including intestinal mucosa, gallbladder, lung, female reproductive tissues (uterus, ovary, and fallopian tube), interstitial fluid, and bile. Piperacillin, tazobactam and desethyl piperacillin are also secreted into the bile
Cholangitis antibiotics: Piperacillin-tazobactam can be used to treat cholangitis due to its distribution into the bile and gallbladder.
- Key points:
- Widely distributed into tissues and body fluids, including bile and gallbladder
- Secreted into the bile
- Effective against a wide range of bacteria, including those that cause cholangitis 2
From the Research
Antibiotic Treatment for Cholangitis
- The choice of an antimicrobial regimen for cholangitis should take into account the antibiotic sensitivities of bacteria colonizing the biliary tree, the antibiotic excretion into bile, and whether biliary obstruction or bacteremia is present 3.
- Initial therapy should be active against E. coli and Klebsiella spp., while it is controversial whether the empirical antibiotic regimen should also include coverage against Enterococcus, Pseudomonas, and anaerobes 3.
- The ureidopenicillins are the preferred initial treatment, and the combination piperacillin-tazobactam may be active against resistant species 3.
Comparison of Antibiotic Regimens
- A retrospective study compared the effectiveness of cefmetazole versus carbapenems and piperacillin/tazobactam as initial therapy for bacteremic acute cholangitis, and found that cefmetazole may contribute to a shorter length of stay and lower antibiotic costs without worsening patient outcomes 4.
- Extended-infusion piperacillin-tazobactam therapy has been shown to be a suitable alternative to intermittent-infusion piperacillin-tazobactam therapy, with improved outcomes in critically ill patients with P. aeruginosa infection 5.
Guidelines for Antimicrobial Therapy
- The Tokyo Guidelines 2018 provide recommendations for the appropriate use of antimicrobials for community-acquired and healthcare-associated infections, including acute cholangitis and cholecystitis 6.
- The guidelines emphasize the importance of monitoring and updating local antibiograms, prudent antimicrobial usage, and early de-escalation or termination of antimicrobial therapy.