Cholangitis medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Overview

Most cases of acute cholangitis respond to conservative therapy and elective drainage. Antimicrobial therapy is indicated for acute cholangitis.

Medical Therapy

• 80% of patients with acute cholangitis will respond to conservative therapy and elective drainage.
• In 15-20%, the cholangitis will progress requiring emergent drainage. Markers for these people are persistent abdominal pain, hypotensive, fever >102, and confusion.

Patients should be kept NPO, given intravenous fluids, broad spectrum antibiotics, Vitamin K and be drained.

Choices for drainage are ERCP with stone removal and sphincterotomy/stent placement, surgical drainage or percutaneous drainage. Intrahepatic stones cannot be removed via ERCP and should be drained percutaneously.

Randomized trials comparing ERCP and surgery showed morbidity and mortality benefit for ERCP (4.7-10% versus 10-50%). A nasobiliary catheter can be placed if ERCP is impossible (<5%), either because of coagulopathy, precluding sphincterotomy, or too large a stone (>2cm) etc. Next step should be percutaneous drainage as a bridge to elective surgery since emergent surgery has an up to 40% mortality.

Antibiotic Regimen

• 1. Community-acquired acute cholecystitis of mild-to-moderate severity

• Preferred regimen (1): Cefazolin 1–2 g IV q8h
• Preferred regimen (2): Cefuroxime 1.5 g IV q8h
• Preferred regimen (3): Ceftriaxone 1–2 g IV q12–24 h

• 2. Community-acquired acute cholecystitis of severe physiologic disturbance, advanced age, or immunocompromised state

• Preferred regimen (1): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h, AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
• Preferred regimen (2): Meropenem 1 g IV q8h, AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
• Preferred regimen (3): Doripenem 500 mg IV q8h, AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
• Preferred regimen (4): Piperacillin-tazobactam 3.375 g IV q6h, AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
• Preferred regimen (5): Ciprofloxacin 400 mg IV q12h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
• Preferred regimen (6): Levofloxacin 750 mg IV q24h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
• Preferred regimen (7): Cefepime 2 g IV q8–12h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h

• 3. Acute cholangitis following bilio-enteric anastamosis of any severity

• Preferred regimen (1): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
• Preferred regimen (2): Meropenem 1 g IV q8h, AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
• Preferred regimen (3): Doripenem 500 mg IV q8h, AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
• Preferred regimen (4): Piperacillin-tazobactam 3.375 g IV q6h, AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
• Preferred regimen (5): Ciprofloxacin 400 mg IV q12h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
• Preferred regimen (6): Levofloxacin 750 mg IV q24h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h
• Preferred regimen (7): Cefepime 2 g IV q8–12h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h

• 4. Health care-associated biliary infection of any severity

• Preferred regimen (1): Imipenem-cilastatin 500 mg IV q6h OR 1 g q8h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h AND Vancomycin 15–20 mg/kg IV q8–12 h
• Preferred regimen (2): Meropenem 1 g IV q8h, AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h AND Vancomycin 15–20 mg/kg IV q8–12 h
• Preferred regimen (3): Doripenem 500 mg IV q8h, AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h AND Vancomycin 15–20 mg/kg IV q8–12 h
• Preferred regimen (4): Piperacillin-tazobactam 3.375 g IV q6h, AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h AND Vancomycin 15–20 mg/kg IV q8–12 h
• Preferred regimen (5): Ciprofloxacin 400 mg IV q12h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h AND Vancomycin 15–20 mg/kg IV q8–12 h
• Preferred regimen (6): Levofloxacin 750 mg IV q24h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h AND Vancomycin 15–20 mg/kg IV q8–12 h
• Preferred regimen (7): Cefepime 2 g IV q8–12h AND Metronidazole 500 mg IV q8–12 h OR 1500 mg q24h AND Vancomycin 15–20 mg/kg IV q8–12 h

• Note: Antimicrobial therapy of established infection should be limited to 4–7 days, unless it is difficult to achieve adequate source control. Longer durations of therapy have not been associated with improved outcome.

References

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