Cholangitis medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Farwa Haideri [2]

Antimicrobial therapy is indicated for acute cholangitis. Patients with community-acquired mild-to-moderate disease are treated with cephalosporins. All other patients are treated with a combination of metronidazole and either imipenem–cilastatin, meropenem, doripenem, piperacillin–tazobactam, ciprofloxacin, levofloxacin, or cefepime.

Approximately 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, hypotension, fever >102 F, and confusion.

Patients should be kept NPO, given intravenous fluids, broad spectrum antibiotics, Vitamin K and any pus should 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.
  • 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 may have up to 40% mortality.

Randomized trials comparing ERCP and surgery showed morbidity and mortality benefit for ERCP (4.7-10% versus 10-50%).

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

• 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 ^[1]

• 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 ^[1]

• 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 ^[1]

• 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 duration of therapy has not been associated with improved outcomes.

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