Epidemiology and prognostic determinants of patients with bacteremic cholecystitis or cholangitis

Increased Morbidity and One-Year Post-Discharge Mortality in Patients with Bacteremia Undergoing Emergent Cholecystectomy: An Exploratory Retrospective Observational Study

Background: Gallbladder disease, one of the most common diseases in the United States, ranges from symptomatic gallstones to severe systemic infections from cholangitis. Little research is available on how often patients undergoing emergent cholecystectomy also have bacteremia. We hypothesized that blood cultures would be performed rarely in patients undergoing emergent cholecystectomy, and that positive cultures would be associated with worse outcomes. Methods: Exploratory retrospective observational cohort study of patients admitted to a single institution from January 17, 2011, to December 31, 2018, and undergoing emergent cholecystectomy by acute care surgeons within ∼72 hours, or three days, of admission. Analyses included descriptive and by-variable statistics, binary logistic regression, and negative binomial regression. Results: Of 892 patients undergoing emergent cholecystectomy, 145 (16.2%) had blood cultures obtained three days before or on the day of surgery, of whom 33 (22.8%) had at least one positive blood culture. Male and older patients had significantly higher rates of blood cultures being obtained. One-year post-discharge mortality and complication rates were significantly higher in those with blood cultures. Versus patients with negative blood cultures, those with positive cultures were significantly older and had higher rates of sepsis and septicemia, longer hospital stays, lower rates of being discharged home, and higher one-year post-discharge mortality rates (18.2% vs. 6.3%). Cholangitis, accounting for 29% of positive blood cultures, was diagnosed in 4.5% of emergent cholecystectomies performed. Gram-negative Escherichia coli were the most common bacteria isolates. Conclusions: Positive blood cultures were associated with significantly worse patient outcomes. Surgeons performing emergent cholecystectomies could consider implementing blood culture protocols to better identify patients at risk for greater hospital morbidity and post-discharge mortality.

Epidemiology of biliary tract-associated bloodstream infections and adequacy of empiric therapy: an Australian population-based study

PURPOSE

Although the biliary tract is a common source of invasive infections, the epidemiology of cholangitis- and cholecystitis-associated bloodstream infection (BSI) is not well defined. The objective of this study was to determine the incidence, clinical determinants, microbiology of biliary tract-associated BSI, and predicted adequacy of common empiric therapy regimens.

METHODS

All biliary tract-associated BSI in Queensland during 2000-2019 were identified using state-wide data sources. Predicted adequacy of empiric antimicrobial therapy was determined according to microbiological susceptibility data.

RESULTS

There were 3,698 episodes of biliary tract-associated BSI occurred in 3,433 patients of which 2,147 (58.1%) episodes were due to cholangitis and 1,551 (41.9%) cholecystitis, for age- and sex-standardized incidence rates of 2.7, and 2.0 per 100,000 population, respectively. An increasing incidence of biliary tract-associated BSI was observed over the study that was attributable to an increase in cholangitis cases. There was a significant increased risk for biliary tract-associated BSI observed with advancing age and male sex. Patients with cholangitis were older, more likely to have healthcare associated infection, and have more comorbidities most notably liver disease and malignancies as compared to patients with cholecystitis. The distribution of infecting pathogens was significantly different with polymicrobial aetiologies more commonly observed with cholangitis (18.4% vs. 10.5%; p < 0.001). The combination of ampicillin/gentamicin/metronidazole was predicted to have the overall highest adequacy (96.1%), whereas amoxicillin/clavulanate had the lowest (77.0%). Amoxicillin/clavulanate (75.2% vs. 79.4%, p:0.03) and ceftriaxone/metronidazole (83.4% vs. 89.6%; p < 0.001) showed significantly inferior predicted adequacy for cholangitis as compared to cholecystitis.

CONCLUSIONS

Bloodstream infections related to cholecystitis and cholangitis exhibit different epidemiology, microbiology, and requirements for empiric therapy.

Outcomes in COVID-19 Patients with Acute Cholangitis: A Single-Center Retrospective Analysis

Background and Objectives: This study aimed to assess the impact of coronavirus disease 2019 (COVID-19) on patients with acute cholangitis (AC) by comparing outcomes, complications, and hospital stays in a tertiary Gastroenterology department. Materials and Methods: This retrospective observational cohort study was conducted in a tertiary gastroenterology department, collecting data from all AC and AC + COVID-19 patients between April 2020 and February 2022. Data included clinical and demographic information, COVID-19-specific details, acute cholangitis presentation, medical records, laboratory results, and interventions. AC was diagnosed using Tokyo Guidelines 2018 (TG18) criteria, with all patients undergoing bile culture sampling. Results: The study included 241 patients, 30 in the COVID group and 211 in the non-COVID group. The COVID group's mean age was significantly higher (74.3 vs. 67.3 years, p < 0.009). Abdominal pain was more common in the COVID group (90% vs. 70.6%, p < 0.025). Length of hospital stay was longer for COVID patients (13.5 vs. 7.9 days, p < 0.001). COVID patients had higher incidences of malignant causes of AC, with pancreatic cancer being the most common (30%). Pseudomonas spp. was significantly more prevalent in COVID patients (16.7% vs. 5.7%, p = 0.028). Conclusions: Our study results show that COVID-19 affected the duration of hospitalization for patients with AC. Furthermore, this study presents observations regarding the impact of COVID-19 on AC, revealing differences in microbial profiles.

Comparison of antimicrobial therapy termination in febrile and afebrile patients with acute cholangitis after drainage

The standard treatment duration for acute cholangitis (AC) involves a 4-7-day antimicrobial treatment post-biliary drainage; however, recent studies have suggested that a ≤ 2-3 days is sufficient. However, clinical practice frequently depends on body temperature as a criterion for discontinuing antimicrobial treatment. Therefore, in this study, we assessed whether patients with AC can achieve successful outcomes with a ≤ 7-day antimicrobial treatment, even with a fever, assuming the infection source is effectively controlled. We conducted a single-center retrospective study involving patients with AC, defined following the Tokyo Guidelines 2018 for any cause, who underwent successful biliary drainage and completed a ≤ 7-day antimicrobial treatment. Patients were categorized into the febrile and afebrile groups based on their body temperature within 24 h before completing antimicrobial treatment. The primary outcome was the clinical cure rate, defined as no initial presenting symptoms by day 14 post-biliary drainage without recurrence or death by day 30. The secondary outcome was a 3-month recurrence rate. Logistic regression with inverse probability of treatment weighting was used. Overall, 408 patients were selected, among whom 40 (9.8%) were febrile. The two groups showed no significant differences in the clinical cure and 3-month recurrence rates. Notably, the subgroups limited to patients with a ≤ 3-day antibiotic treatment duration also showed no differences in these outcomes. Therefore, our results suggest that discontinuing antibiotics within the initially planned treatment period was sufficient for successful drainage cases of AC, regardless of the patient's fever status during the 24 h leading up to termination.

Efficacy of Short-Course Antibiotic Therapy for Acute Cholangitis With Positive Blood Cultures: A Retrospective Study

BACKGROUND

Short-term treatment of acute cholangitis is sufficient for cure compared with the standard treatment duration. Whether this short-course antimicrobial therapy is effective in patients with acute cholangitis with positive blood cultures has not been fully investigated. This study assessed whether patients with acute cholangitis could achieve successful outcomes with a three-day or shorter antimicrobial treatment period, even with a positive blood culture.

METHODS

This single-center retrospective study involved patients with acute cholangitis, defined according to the Tokyo Guidelines 2018 for any cause, who underwent successful biliary drainage and completed a seven-day or shorter antimicrobial treatment. Patients were categorized into six groups based on the duration of antibiotic use (short or standard) after endoscopic retrograde cholangiopancreatography and blood culture findings (positive, negative, or no collection). The primary outcome was the clinical cure rate, defined as no initial presenting symptoms by day 14 after biliary drainage and no recurrence or death by day 30. Secondary outcomes included a three-month recurrence rate and length of hospital stay.

RESULTS

In total, 389 cases were selected, and 27 patients (6.9%) undergoing short-course therapy tested positive for blood culture. The clinical cure rate (n=25, 92.6%) in this group was comparable to that in the other groups. For the three-month recurrence rate (n=1, 3.7%) and median hospital stay (six days), this group's outcomes were either better or similar to those of the other groups.

CONCLUSIONS

For cases of successful drainage in acute cholangitis, even with positive blood cultures, short-term antibiotic therapy may be appropriate.

Antimicrobial therapy outcomes in acute cholangitis: Hilar multiple obstructions versus single hilar and common bile duct obstructions

Background and Aim

The appropriate duration of antimicrobial therapy for acute cholangitis (AC) arising from multiple hilar biliary obstructions as opposed to simple obstruction in the extrahepatic bile duct has not been established. This study assessed the efficacy of the duration of antimicrobial treatments in the Tokyo Guidelines 2018 for AC based on the cause and site of obstruction.

Methods

This single-center retrospective study involved patients with AC who underwent successful biliary drainage and completed a 7-day or shorter antimicrobial treatment. Patients were categorized into three groups: Group 1, bile duct stone or benign obstruction; Group 2, simple biliary obstruction due to malignancy; and Group 3, multiple hilar biliary obstruction due to malignancy. The primary outcome was clinical cure rate, and the secondary outcomes were 3-month recurrence rate and length of hospital stay.

Results

A total of 373 patients were selected. Patients in Group 3 were younger or had Charlson Comorbidity Index ≥4, and had fewer positive blood cultures. In Group 3, the clinical cure rate (87.1%) and 3-month recurrence rate (32.3%) were less favorable than those in the other groups. In Group 1, the clinical cure rate was significantly higher (98.1%, P = 0.02) with a much lower 3-month recurrence rate of only 3.4% (P < 0.001) than that in the other groups. The median hospital stay for all groups was 7 days.

Conclusion

This study suggests that the outcomes in Group 3 may be worse than those in Groups 1 or 2, regardless of the duration of the antibiotic treatment.

Septic shock and biliary sepsis: 90-day mortality and associated risk factors

BACKGROUND

Biliary sepsis is common in patients with digestive cancer. Recommendations call for antibiotic de-escalation (ADE) as a strategy for antibiotic treatment of sepsis or septic shock. The aim of this study was to identify factors influencing 90-day mortality and to evaluate the impact of ADE.

METHODS

This retrospective study was conducted between November 2008 and December 2019 in a referral cancer center. Adults with biliary sepsis or septic shock admitted to the ICU were included. Variables associated with 90-day mortality were identified using univariate and multivariate Cox proportional hazards models.

RESULTS

122 patients were included. The 90-day mortality was 30.3% (n = 37). After multivariate analysis, the factors independently associated 90-day mortality were metastatic stage (p = 0.004), biliary tract tumour compression (p = 0.001), multi drug resistant (MDR) bacteria carriage on intensive care unit (ICU)admission (p = 0.048), serum lactate on ICU admission (p < 0.001), the use of extra-renal replacement (p = 0.008), factor V < 50% (p = 0.009) and performance status (ECOG-PS) > 2 (p < 0.001). ADE of the pivotal antibiotic (p = 0.041) and recent cancer surgery (p < 0.001) appeared to be associated with survival.

CONCLUSION

The 90-day mortality of biliary sepsis seems to be favourable. The 90-day mortality is associated with organ dysfunctions, but also with ECOG-PS, cancer stage, MDR bacteria colonisation. ADE seems to be safe.

Comparative Analysis of Antibiotic Resistance in Acute Cholangitis Patients with Stent Placement and Sphincterotomy Interventions

In response to rising concerns over multidrug resistance patterns in acute cholangitis patients, this retrospective study was conducted at the Emergency County Hospital Timisoara, Romania, encompassing patients treated between August 2020 and August 2023. The study aimed to investigate the influence of prior interventions, specifically sphincterotomy (with or without stent placement), on the current clinical and microbiological profiles of acute cholangitis patients. By differentiating between patients with a history of sphincterotomy and the endoscopic retrograde cholangiopancreatography (ERCP)-naïve, we assessed the resistance of bacterial strains to antibiotics by the Tokyo Guidelines 2018, using bile cultures from 488 patients. The study identified various multidrug-resistant organisms, with a total multidrug resistance incidence of 19.9%. Significant variations were observed in the distribution of specific microorganisms and resistance patterns across different intervention groups. Patients with previous interventions, particularly those with both sphincterotomy and stent, exhibited elevated white blood cells (WBC) and C-reactive protein (CRP) levels in comparison to their ERCP-naïve counterparts. This group also presented a striking prevalence of two bacteria in their bile cultures at 50.0%, compared to 16.1% in ERCP-naïve individuals. Regarding multidrug resistance, the prior sphincterotomy with stent placement had a prevalence of 50.0%. The presence of ESBL bacteria was also significantly higher in the same group at 28.7%, contrasting with the 8.9% in ERCP-naïve patients. Additionally, the same group had a higher burden of Klebsiella spp. infections, at 37.2%, and Enterococcus spp. at 43.6%. On the antibiotic resistance front, disparities persisted. Piperacillin/Tazobactam resistance was notably more rampant in patients with a previous sphincterotomy and stent, registering at 25.5% against 11.1% in the ERCP-naïve group. This study underscores a substantial discrepancy in multidrug resistance patterns and antibiotic resistance among acute cholangitis patients with previous manipulation of the bile ducts, without expressing significant differences by the type of stent used.

Proportion of Neutrophils in White Blood Cells as a Useful Marker for Predicting Bacteremic Acute Cholangitis

Objective A positive hemoculture in acute cholangitis is serious, but a blood culture result cannot be obtained at the initial diagnosis and so cannot be used for the severity assessment and decision-making concerning urgent/early biliary drainage. Accordingly, a predictor for bacteremia at the initial diagnosis of acute cholangitis would be particularly useful. We investigated the association between neutrophil proportions in white blood cell counts (%Neutro) and bacteremic acute cholangitis. Methods Of 166 patients with acute cholangitis who were diagnosed with the Tokyo Guidelines 2018/2013 from April 2015 to March 2017, a total of 94 underwent blood culture assessments and were divided into those with a positive hemoculture (n=48) and a negative hemoculture (n=46) and then compared. A receiver operating characteristic curve analysis was used to evaluate the predictive ability of %Neutro and other inflammatory markers. Results The %Neutro values were significantly higher in the positive hemoculture group than in the negative hemoculture group (91.7±4.0% vs. 82.5±9.0%, p<0.0001). A cut-off %Neutro value of 89.7% was strongly associated with bacteremia (area under the curve 0.86, sensitivity 77.1%, specificity 80.4%). A %Neutro of ≥89.7% was a predictor of a positive hemoculture in univariate (p<0.0001) and multivariate analyses (p<0.001). Patients with a %Neutro ≥89.7% needed early biliary drainage more frequently than others (30/46, 65.2% vs. 18/48, 37.5%, p=0.0063). Conclusion %Neutro is an independent predictor of bacteremia in patients with acute cholangitis and may contribute to decision-making concerning early biliary drainage.

Racial and Ethnic Disparities Among Patients Hospitalized for Acute Cholangitis in the United States

GOALS

We sought to determine whether race/ethnicity is associated with hospitalization outcomes among patients admitted with acute cholangitis.

BACKGROUND

Few studies have evaluated the association between race and outcomes in patients with acute cholangitis.

STUDY

We analyzed United States hospitalizations from 2009 to 2018 using the Nationwide Inpatient Sample (NIS). We included patients 18 years old or above admitted with an ICD9/10 diagnosis of cholangitis. Race/ethnicity was categorized as White, Black, Hispanic, or Other. We used multivariable regression to determine the association between race/ethnicity and in-hospital outcomes of interest, including endoscopic retrograde cholangiopancreatography (ERCP), early ERCP (<48 h from admission), length of stay (LOS), and in-hospital mortality.

RESULTS

Of 116,889 hospitalizations for acute cholangitis, 70% identified as White, 10% identified as Black, 11% identified as Hispanic, and 9% identified as Other. The proportion of non-White patients increased over time. On multivariate analysis controlling for clinical and sociodemographic variables, compared with White patients, Black patients had higher in-hospital mortality (adjusted odds ratio: 1.4, 95% confidence interval: 1.2-1.6, P <0.001). Black patients were also less likely to undergo ERCP, more likely to undergo delayed ERCP, and had longer LOS ( P <0.001 for all).

CONCLUSIONS

In this contemporary cohort of hospitalized patients with cholangitis, Black race was independently associated with fewer and delayed ERCP procedures, longer LOS, and higher mortality rates. Future studies with more granular social determinants of health data should further explore the underlying reasons for these disparities to develop interventions aimed at reducing racial disparities in outcomes among patients with acute cholangitis.

Identification of Microbial Species and Analysis of Antimicrobial Resistance Patterns in Acute Cholangitis Patients with Malignant and Benign Biliary Obstructions: A Comparative Study

Background and Objectives: Acute cholangitis (AC) is still lethal if not treated promptly and effectively. Biliary drainage, also known as source control, has been acknowledged as the backbone treatment for patients with AC; nonetheless, antimicrobial therapy allows these patients to undergo non-emergent drainage procedures. This retrospective study aims to observe the bacterial species involved in AC and analyze the antimicrobial resistance patterns. Materials and Methods: Data were collected for four years, comparing patients with benign and malignant bile duct obstruction as an etiology for AC. A total of 262 patients were included in the study, with 124 cases of malignant obstruction and 138 cases of benign obstruction. Results: Positive bile culture was obtained in 192 (73.3%) patients with AC, with a higher rate among the benign group compared with malignant etiologies (55.7%.vs 44.3%). There was no significant difference between the Tokyo severity scores in the two study groups, identifying 34.7% cases of malignant obstruction with Tokyo Grade 1 (TG1) and 43.5% cases of TG1 among patients with benign obstruction. Similarly, there were no significant differences between the number of bacteria types identified in bile, most of them being monobacterial infections (19% in the TG1 group, 17% in the TG2 group, and 10% in the TG3 group). The most commonly identified microorganism in blood and bile cultures among both study groups was E. coli (46.7%), followed by Klebsiella spp. (36.0%) and Pseudomonas spp. (8.0%). Regarding antimicrobial resistance, it was observed that significantly more patients with malignant bile duct obstruction had a higher percentage of bacterial resistance for cefepime (33.3% vs. 11.7%, p-value = 0.0003), ceftazidime (36.5% vs. 14.5%, p-value = 0.0006), meropenem (15.4% vs. 3.6%, p-value = 0.0047), and imipenem (20.2% vs. 2.6%, p-value < 0.0001). Conclusions: The positive rate of biliary cultures is higher among patients with benign biliary obstruction, while the malignant etiology correlates with increased resistance to cefepime, ceftazidime, meropenem, and imipenem.

Characteristics and clinical outcomes of acute cholangitis in older patients

PURPOSE

Few studies are available on older patients with acute cholangitis. In this study, we aimed to examine the clinical characteristics of older patients with acute cholangitis.

METHODS

Patients aged 65 years and over who were diagnosed with acute cholangitis between February 2019 and August 2022 were analyzed retrospectively. Patients eligible for the study were divided into two groups as those aged ≥ 80 years (octogenarian) and those aged 65-79 years (non-octogenarian). These two groups were then compared for many clinical characteristics. In addition, factors associated with in-hospital mortality were identified. Finally, a subgroup analysis was performed in patients with non-malignant etiology.

RESULTS

Of a total of 309 enrolled patients, 120 (38.8%) were in the octogenarian group and 189 (61.2%) were in the non-octogenarian group. The mean age was 77.2 ± 8.0 years and 51.8% were women. Severe disease and intensive care unit admission rates were higher in the octogenarian group (p = 0.035 and p = 0.002, respectively), but there was no significant difference in the rate of in-hospital mortality (p = 0.146). Malignant etiology (OR 2.990, 95% CI 1.131-7.904) and hypoalbuminemia (OR 0.824, 95% CI 0.751-0.903) were independent risk factors for in-hospital mortality. In the subgroup analysis of non-malignant etiology, the octogenarian group had a significantly higher in-hospital mortality rate than the non-octogenarian group (8.8% vs. 3.2%, p = 0.048).

CONCLUSIONS

Among older patients with acute cholangitis, clinicians should closely monitor those aged 80 years and over, as well as those with malignant etiology and hypoalbuminemia, due to their high risk of serious clinical events.

Addition of anaerobic coverage for treatment of biliary tract infections: a propensity score-matched cohort study

Objectives

To evaluate whether additional antibiotics that target anaerobes, including Bacteroides spp., are associated with improved clinical outcomes in patients with biliary tract infections (BTIs).

Methods

This was a retrospective propensity score-matched cohort of adults aged ≥18 years with BTIs, admitted to hospital between 1 April 2015 and 30 March 2021. Eligible patients treated with antibiotics that provided coverage of anaerobes were compared with those treated with comparable regimens without anaerobic coverage. The primary outcome was a composite of mortality within 30 days or relapse within 90 days of source control or completion of antibiotics. Secondary outcomes included length of stay (LOS), duration of antibiotic therapy and adverse drug reactions. ORs were calculated using a weighted generalized linear regression model with propensity-score matching.

Results

Among 398 patients included, 209 were treated without anaerobic coverage and 189 with anaerobic coverage. After propensity-score matching, there was no significant difference in primary outcome between propensity-matched patients who received additional anaerobic coverage and those who did not [adjusted OR (aOR) 1.23; 95% CI 0.69-2.22)]. Those with anti-anaerobic coverage had longer LOS (aOR 4.85; 95% CI 1.68-13.98) and longer duration of antibiotic treatment (aOR 4.14; 95% CI 2.61-6.57) than those who did not receive additional anaerobic therapy, but not more adverse drug reactions (aOR 1.01; 95% CI 0.97-1.05).

Conclusions

Omitting anti-anaerobic antibiotics may be a safe antimicrobial stewardship intervention. However, a randomized controlled trial may be warranted to definitively conclude whether additional anaerobic coverage in BTI treatment is necessary.

Implications of Type 2 Diabetes Mellitus in Patients with Acute Cholangitis: A Systematic Review of Current Literature

Introduction: Type 2 diabetes mellitus (T2DM) has been associated with higher rates and poorer prognosis of infections, mainly due to poor glycemic control, reduced response of T-cells and neutrophils, and impaired migration, phagocytosis, and chemotaxis of leukocytes. However, the impact of T2DM on acute cholangitis (AC) has not been assessed so far. Thus, we aimed to explore this association by means of a systematic review of the literature. Methods: This systematic review was carried out based on the recommendations stated in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched the PubMed/MEDLINE, Web of Science and SCOPUS databases to identify relevant publications depicting an association between T2DM and AC from the inception of these search services up to present. Results: We detected a total of 435 eligible records. After we applied the inclusion and exclusion criteria, a total of 14 articles were included in the present systematic review. Included manuscripts focused on the potential role of T2DM as a risk factor for the development of AC and on its contribution to a worse prognosis in AC, e.g., development of sepsis or other complications, the risk of AC recurrence and the impact on mortality. Conclusions: As compared to non-diabetic individuals, patients with T2DM have a higher risk of AC as a complication of choledocholithiasis or gallstone pancreatitis. Several oral hypoglycemic drugs used in the management of T2DM may also be involved in the onset of AC. Diabetic patients who suffer from AC have a higher likelihood of longer hospital stays and sepsis, as well as a higher risk of mortality and more severe forms of AC as compared to non-diabetic individuals.

Clinical characteristics, aetiology and mortality/recurrence risk factors of acute cholangitis in patients with and without biliary stent

OBJECTIVES

Acute cholangitis is one of the most frequent complications in patients carrying biliary stents. The aim of our study is to analyze the demographic and clinical characteristics, as well as the microbiological profile and evolution of patients with acute bacteremic cholangitis, comparing them based upon they were or not biliary stent carriers.

METHODS

We performed a retrospective analysis of all consecutive patients over 18 years-old with a stent placement in our center between 2008 and 2017 were included. We compared them with our prospective cohort of patients with a diagnosis of acute bacteremic cholangitis. Primary outcome was 30-day mortality. Secondary outcome was clinical cure at day 7, 14-day mortality and 90-day recurrence.

RESULTS

Two hundred and seventy-three patients were analyzed, including 156 in the stent-related (SR) and 117 in the stent not-related (SNR) group, respectively. Stent-related colangitis patients were younger, with more comorbidities and with a greater severity of infection. Escherichia coli and Klebsiella pneumonia were the most frequent isolation. Enterococcus spp. was the third most frequent isolation in SR group but were uncommon in SNR patients; where E. coli was the most prevalent microorganism. Septic shock (HR 3.44, 95% [CI 1.18-8.77]), inadequate empirical treatment (HR 2.65, 95% CI [1.38-.7.98]) and advanced neoplasia (HR 2.41, 95% CI [1.55-6.44]) were independent 30-day mortality risk factors. The 90-day recurrence rate significantly higher in those patients with stent-related cholangitis (29% vs. 13%, p=0.016) and stent replacement was associated with lower recurrence rate (HR 0.38, 95% CI [0.11-0.77]).

CONCLUSIONS

Clinical and microbiological profile, as well as outcome of patients with SR and SNR cholangitis were different. In SR group, recurrence rate was high and stent replacement was associated with a lower risk.

Blood cultures should be collected for acute cholangitis regardless of severity

BACKGROUND

Despite the high frequency of bacteremia in acute cholangitis, the indications for blood cultures and the relationship between the incidence of bacteremia and severity of acute cholangitis have not been well established. This study examined the association between the 2018 Tokyo Guidelines (TG18) severity grading for acute cholangitis and incidence of bacteremia to identify the need for blood cultures among patients with acute cholangitis in each severity grade.

METHODS

Patients with acute cholangitis who visited our emergency department between 2019 and 2020 were retrospectively investigated. Patients administered antibiotics within 48 h of hospital arrival, whose prothrombin time-international normalized ratios were not measured, or who were suspected of false bacteremia were excluded.

RESULTS

Out of the included 358 patients with acute cholangitis, blood cultures were collected from 310 (87%) patients, of which 148 (48%) were complicated with bacteremia. As the TG18 severity grading increased, the frequency of bacteremia increased (Grade I, 35% [59/171]; Grade II, 59% [48/82]; Grade III, 74% [42/57]; P <0.001). Agreement with the TG18 diagnostic criteria (unfulfilled, suspected, or definite) was not different between patients with and without bacteremia; however, 36% (14/39) of the patients with "unfulfilled" criteria were complicated with bacteremia.

CONCLUSIONS

As the severity of acute cholangitis increased, the frequency of bacteremia increased; however, the incidence of bacteremia was high even in mild cases and cases that did not meet the TG18 diagnostic criteria. Blood cultures should be collected regardless of the severity of acute cholangitis for patients who visit the emergency department.

Risk of aortic dissection or aneurysm in patients with gallstone disease: a retrospective cohort study in Taiwan

OBJECTIVE

This nationwide population-based cohort study was to compare the risk of aortic dissection (AD) or aortic aneurysm (AN) between the subjects with and without gallstone disease (GD). We also compare the risk of AD/AN between the patients with GD with and without cholecystectomy.

SETTING

This nationwide population-based cohort study.

PARTICIPANTS

We extracted the hospitalisation database from the National Health Insurance Research Database of Taiwan and identified a total of 343 300 patients aged ≥20 years with GD newly diagnosed between 2000 and 2010 as the study cohort, including 191 111 with cholecystectomy and 152 189 without cholecystectomy, respectively. We randomly selected those without GD as the control cohort, by 1:1 propensity score matching with the study cohort based on age, sex, comorbidities and year of the index date for GD diagnosis.

RESULTS

The incidence of AD/AN was 6.65/10 000 person-years for the GD cohort and 6.24/10 000 person-years for the non-GD cohort (adjusted HR (aHR)=1.11, 95% CI=1.09 to 1.13), respectively (p<0.001). Furthermore, the incidence of AD/AN in the patients with GD was 9.93/10 000 person-years for the non-cholecystectomy patients (aHR=1.24, 95% CI=1.22 to 1.26) and 4.63/10 000 person-years for the cholecystectomy patients (aHR=0.97, 95% CI=0.95 to 0.99), respectively (p<0.05).

CONCLUSIONS

The GD cohort was associated with and greater risk of AD/AN than the non-GD cohort, but the risk of AD/AN in the patients with GD would decrease after cholecystectomy.

Impact of the Sensitivity to Empiric Antibiotics on Clinical Outcomes after Biliary Drainage for Acute Cholangitis

Background/Aims

Empiric antibiotics are given in combination with biliary drainage for acute cholangitis but sometimes turn out to be insensitive to microorganisms in blood and bile. Clinical outcomes were compared according to sensitivity to microorganisms detected in blood and bile culture to evaluate the impact of sensitivity to empiric antibiotics in cholangitis.

Methods

Consecutive patients who underwent biliary drainage for acute cholangitis were retrospectively studied. Clinical outcomes such as 30-day mortality, length of hospital stay and high care unit stay, organ dysfunction and duration of fever were compared in three groups: group A (sensitive to both blood and bile culture), group B (sensitive to blood culture alone) and group C (insensitive to both blood and bile culture).

Results

Eighty episodes of cholangitis were classified according to sensitivity results: 42, 32 and six in groups A, B and C. Escherichia coli and Klebsiella were two major pathogens. There were no significant differences in 30-day mortality rate (7%, 0%, and 0%, p=0.244), length of hospital stay (28.5, 21.0, and 20.5 days, p=0.369), organ dysfunction rate (14%, 25%, and 17%, p=0.500), duration of fever (4.3, 3.2, and 3.5 days, p=0.921) and length of high care unit stay (1.4, 1.2, and 1.7 days, p=0.070) in groups A, B and C. Empiric antibiotics were changed in 11 episodes but clinical outcomes appeared to be non-inferior even in 31 episodes of cholangitis who were on inadequate antibiotics throughout the course.

Conclusions

Sensitivity of empiric antibiotics was not associated with clinical outcomes in acute cholangitis.

Analysis of patterns of bacteremia and 30-day mortality in patients with acute cholangitis over a 25-year period

INTRODUCTION

Acute cholangitis (AC) is a condition of bacterial infection in the biliary tract with a high mortality rate of around 10%. Direct association between presence of bacteremia and 30-day mortality among AC patients is sparsely investigated and remains unclear.

AIMS AND METHODS

Our aim was to investigate association between bacteremia and 30-day mortality among patients with AC included over a period of 25 years. All AC patients that underwent endoscopic retrograde cholangiopancreatography (ERCP) at Odense University Hospital, between 1 January 1990 and 31 October 2015, were identified using a prospective ERCP database. Blood culture results from the patients along with antimicrobial resistance patterns were collected from a bacteremia research database.

RESULTS

During the study period, 775 consecutive AC patients underwent ERCP and blood cultures were collected from 528 patients. Among these patients 48% (n = 260) had bacteremia. Overall, 30-day mortality in patients with blood cultures performed was 13% (n = 69). In patients with bacteremia, 30-day mortality was 19% (n = 49), compared to 7% (n = 20) in patients without bacteremia (p < .01). Presence of bacteremia was associated with increased 30-day mortality (OR [95% CI]: 3.43 [1.92-6.13]; p < .01) following adjustment for confounding factors. Among the species, bacteremia with Enterobacter cloacae was significantly associated with increased 30-day mortality (OR [95% CI]: 2.97 [1.16-7.62]; p = .02).

CONCLUSION

Our results indicate that presence of bacteremia was associated with a nearly fourfold increase in 30-day mortality among AC patients.

Carrying asymptomatic gallstones is not associated with changes in intestinal microbiota composition and diversity but cholecystectomy with significant dysbiosis

Gallstone disease affects up to twenty percent of the population in western countries and is a significant contributor to morbidity and health care expenditure. Intestinal microbiota have variously been implicated as either contributing to gallstone formation or to be affected by cholecystectomy. We conducted a large-scale investigation on 404 gallstone carriers, 580 individuals post-cholecystectomy and 984 healthy controls with similar distributions of age, sex, body mass index, smoking habits, and food-frequency-score. All 1968 subjects were recruited from the population-based Study-of-Health-in-Pomerania (SHIP), which includes transabdominal gallbladder ultrasound. Fecal microbiota profiles were determined by 16S rRNA gene sequencing. No significant differences in microbiota composition were detected between gallstone carriers and controls. Individuals post-cholecystectomy exhibited reduced microbiota diversity, a decrease in the potentially beneficial genus Faecalibacterium and an increase in the opportunistic pathogen Escherichia/Shigella. The absence of an association between the gut microbiota and the presence of gallbladder stones suggests that there is no intestinal microbial risk profile increasing the likelihood of gallstone formation. Cholecystectomy, on the other hand, is associated with distinct microbiota changes that have previously been implicated in unfavorable health effects and may not only contribute to gastrointestinal infection but also to the increased colon cancer risk of cholecystectomized patients.

Prognostic factors associated with six month mortality of critically ill elderly patients admitted to the intensive care unit with severe acute cholangitis

BACKGROUND

Little is known about the outcomes of elderly patients admitted to the intensive care unit (ICU) with severe acute cholangitis (SAC). The objectives were to describe the 6-month mortality in patients with SAC ≥75 years and to identify factors associated with this mortality.

METHODS

Bi-center retrospective study of critically ill elderly patients with SAC conducted between 2013 and 2017. Demographic and clinical variables of ICU and hospital stays with a 6-month follow-up were analyzed.

RESULTS

85 patients, with a median [Q1-Q3] age of 83 [80-89] years were enrolled of whom 51 (60%) were men. SAC was due to choledocholithiasis in 72 (85%) patients. Median [Q1-Q3] ICU length of stay was 3 [2-6] days. Median [Q1-Q3] admission SAPS II was 50 [42-70]. The ICU and 6-month mortality rates were 18% and 48% respectively. Multivariate analysis showed that malnutrition (OR = 34.5, 95% CI [1.4-817.9]) and a decrease in SOFA score at 48 h (OR by unit 0.7, 95% CI [0.5-0.9]) were associated with higher 6-month mortality.

CONCLUSION

In their decision-making process, ICU physicians and hepato-pancreato-biliary surgeons could use these data to estimate the probability of survival of an elderly patient presenting with SAC and to offer time-limited trials of intensive care.

TRIAL REGISTRATION

NCT03831529.

Long-term instability of the intestinal microbiome is associated with metabolic liver disease, low microbiota diversity, diabetes mellitus and impaired exocrine pancreatic function

OBJECTIVE

The intestinal microbiome affects the prevalence and pathophysiology of a variety of diseases ranging from inflammation to cancer. A reduced taxonomic or functional diversity of the microbiome was often observed in association with poorer health outcomes or disease in general. Conversely, factors or manifest diseases that determine the long-term stability or instability of the microbiome are largely unknown. We aimed to identify disease-relevant phenotypes associated with faecal microbiota (in-)stability.

DESIGN

A total of 2564 paired faecal samples from 1282 participants of the population-based Study of Health in Pomerania (SHIP) were collected at a 5-year (median) interval and microbiota profiles determined by 16S rRNA gene sequencing. The changes in faecal microbiota over time were associated with highly standardised and comprehensive phenotypic data to determine factors related to microbiota (in-)stability.

RESULTS

The overall microbiome landscape remained remarkably stable over time. The greatest microbiome instability was associated with factors contributing to metabolic syndrome such as fatty liver disease and diabetes mellitus. These, in turn, were associated with an increase in facultative pathogens such as Enterobacteriaceae or Escherichia/Shigella. Greatest stability of the microbiome was determined by higher initial alpha diversity, female sex, high household income and preserved exocrine pancreatic function. Participants who newly developed fatty liver disease or diabetes during the 5-year follow-up already displayed significant microbiota changes at study entry when the diseases were absent.

CONCLUSION

This study identifies distinct components of metabolic liver disease to be associated with instability of the intestinal microbiome, increased abundance of facultative pathogens and thus greater susceptibility toward dysbiosis-associated diseases.

Acute cholangitis in intensive care units: clinical, biological, microbiological spectrum and risk factors for mortality: a multicenter study

Background

Little is known on the outcome and risk factors for mortality of patients admitted in Intensive Care units (ICUs) for Acute cholangitis (AC).

Methods

Retrospective multicenter study included adults admitted in eleven intensive care units for a proven AC from 2005 to 2018. Risk factors for in-hospital mortality were identified using multivariate analysis.

Results

Overall, 382 patients were included, in-hospital mortality was 29%. SOFA score at admission was 8 [5–11]. Biliary obstruction was mainly related to gallstone (53%) and cancer (22%). Median total bilirubin and PCT were respectively 83 µmol/L [50–147] and 19.1 µg/L [5.3–54.8]. Sixty-three percent of patients (n  = 252) had positive blood culture, mainly Gram-negative bacilli (86%) and 14% produced extended spectrum beta lactamase bacteria. At ICU admission, persisting obstruction was frequent (79%) and biliary decompression was performed using therapeutic endoscopic retrograde cholangiopancreatography (76%) and percutaneous transhepatic biliary drainage (21%). Adjusted mortality significantly decreased overtime, adjusted OR for mortality per year was 0.72 [0.54–0.96] (p = 0.02). In a multivariate analysis, factors at admission associated with in-hospital mortality were: SOFA score (OR 1.14 [95% CI 1.05–1.24] by point, p = 0.001), lactate (OR 1.21 [95% CI 1.08–1.36], by 1 mmol/L, p < 0.001), total serum bilirubin (OR 1.26 [95% CI 1.12–1.41], by 50 μmol/L, p < 0.001), obstruction non-related to gallstones (p < 0.05) and AC complications (OR 2.74 [95% CI 1.45–5.17], p = 0.002). Time between ICU admission and biliary decompression > 48 h was associated with in-hospital mortality (adjusted OR 2.73 [95% CI 1.30–6.22], p = 0.02).

Conclusions

In this large retrospective multicenter study, we found that AC-associated mortality significantly decreased overtime. Severity of organ failure, cause of obstruction and local complications of AC are risk factors for mortality, as well as delayed biliary drainage > 48 h.

Microbiology and risk factors for gram-positive Cocci bacteremia in biliary infections

BACKGROUND

The rapid antibiotics treatment targeted to a specific pathogen can improve clinical outcomes of septicemia. We aimed to evaluate the clinical characteristics and outcomes of biliary septicemia caused by cholangitis or cholecystitis according to causative organisms.

METHODS

We performed a retrospective cohort study in 151 patients diagnosed with cholangitis or cholecystitis with bacterial septicemia from January 2013 to December 2015. All patients showed clinical evidence of biliary tract infection and had blood isolates that demonstrated septicemia.

RESULTS

Gram-negative, gram-positive, and both types of bacteria caused 84.1% (127/151), 13.2% (20/151), and 2.6% (4/151) episodes of septicemia, respectively. The most common infecting organisms were Escherichia coli among gram-negative bacteria and Enterococcus species (Enterococcus casseliflavus and Enterococcus faecalis) among gram-positive bacteria. There were no differences in mortality, re-admission rate, and need for emergency decompression procedures between the gram-positive and gram-negative septicemia groups. In univariate analysis, previous gastrectomy history was associated with gram-positive bacteremia. Multivariate analysis also showed that previous gastrectomy history was strongly associated with gram-positive septicemia (Odds ratio = 5.47, 95% CI: 1.19-25.23; P = 0.029).

CONCLUSIONS

Previous gastrectomy history was related to biliary septicemia induced by gram-positive organisms. This information would aid the choice of empirical antibiotics.

Clinical characteristics, aetiology and mortality/recurrence risk factors of acute cholangitis in patients with and without biliary stent

OBJECTIVES

Acute cholangitis is one of the most frequent complications in patients carrying biliary stents. The aim of our study is to analyze the demographic and clinical characteristics, as well as the microbiological profile and evolution of patients with acute bacteremic cholangitis, comparing them based upon they were or not biliary stent carriers.

METHODS

We performed a retrospective analysis of all consecutive patients over 18 years-old with a stent placement in our center between 2008 and 2017 were included. We compared them with our prospective cohort of patients with a diagnosis of acute bacteremic cholangitis. Primary outcome was 30-day mortality. Secondary outcome was clinical cure at day 7, 14-day mortality and 90-day recurrence.

RESULTS

Two hundred and seventy-three patients were analyzed, including 156 in the stent-related (SR) and 117 in the stent not-related (SNR) group, respectively. Stent-related colangitis patients were younger, with more comorbidities and with a greater severity of infection. Escherichia coli and Klebsiella pneumonia were the most frequent isolation. Enterococcus spp. was the third most frequent isolation in SR group but were uncommon in SNR patients; where E. coli was the most prevalent microorganism. Septic shock (HR 3.44, 95% [CI 1.18-8.77]), inadequate empirical treatment (HR 2.65, 95% CI [1.38-.7.98]) and advanced neoplasia (HR 2.41, 95% CI [1.55-6.44]) were independent 30-day mortality risk factors. The 90-day recurrence rate significantly higher in those patients with stent-related cholangitis (29% vs. 13%, p=0.016) and stent replacement was associated with lower recurrence rate (HR 0.38, 95% CI [0.11-0.77]).

CONCLUSIONS

Clinical and microbiological profile, as well as outcome of patients with SR and SNR cholangitis were different. In SR group, recurrence rate was high and stent replacement was associated with a lower risk.

Thermodynamic interference with bile acid demicelleization reduces systemic entry and injury during cholestasis

Bile acids (BA), with their large hydrophobic steroid nucleus and polar groups are amphipathic molecules. In bile, these exist as micelles above their critical micellar concentration (CMC). In blood at low concentrations, these exist as monomers, initiating cellular signals. This micellar to monomer transition may involve complex thermodynamic interactions between bile salts alone or with phospholipids, i.e. mixed micelles and the aqueous environment. We therefore went on to test if therapeutically relevant changes in temperature could influence micellar behavior of bile salts, and in turn whether this affected the biological responses in cells, and in vivo. Sodium taurocholate (STC) belongs to a major class of bile salts. STC has a CMC in the 5–8 mM range and its infusion into the pancreatic duct is commonly used to study pancreatitis. We thus studied micellar breakdown of STC using isothermal titration calorimetry (ITC), dynamic light scattering and cryogenic transmission electron microscopy. Under conditions relevant to the in vivo environment (pH 7.4, Na 0.15 M), ITC showed STC to have a U shaped reduction in micellar breakdown between 37 °C and 15 °C with a nadir at 25 °C approaching ≈90% inhibition. This temperature dependence paralleled pancreatic acinar injury induced by monomeric STC. Mixed micelles of STC and 1-palmitoyl, 2-oleyl phosphatidylcholine, a phospholipid present in high proportions in bile, behaved similarly, with ≈75% reduction in micellar breakdown at 25 °C compared to 37 °C. In vivo pancreatic cooling to 25 °C reduced the increase in circulating BAs after infusion of 120 mM (5%) STC into the pancreatic duct, and duct ligation. Lower BA levels were associated with improved cardiac function, reduced myocardial damage, shock, lung injury and improved survival independent of pancreatic injury. Thus micellar breakdown of bile salts is essential for their entry into the systemic circulation, and thermodynamic interference with this may reduce their systemic entry and consequent injury during cholestasis, such as from biliary pancreatitis.

Dynamic Monitoring of sTREM-1 and Other Biomarkers in Acute Cholangitis

Background

Sepsis is a common complication of acute cholangitis (AC), which is associated with a high mortality rate. Our study is aimed at exploring the significance of white blood cell (WBC), C-reactive protein (CRP), procalcitonin (PCT), soluble triggering receptor expressed on myeloid cells 1 (sTREM-1), and temperature (T) alone or combined together in early identification and curative effect monitoring of AC with or without sepsis.

Methods

65 consecutive cases with AC and 76 control cases were enrolled. They were divided into three groups: Group A (AC with sepsis), Group B (AC without sepsis), and Group C (inpatients without AC or other infections). The levels of WBC, CRP, PCT, sTREM-1, and temperature were measured dynamically. The study was carried out and reported according to STARD 2015 reporting guidelines.

Results

CRP had the highest AUC to identify AC from individuals without AC or other infections (AUC 1.000, sensitivity 100.0%, specificity 100.0%, positive predictive value 100.0%, and negative predictive value 100.0%). Among various single indexes, PCT performed best (AUC 0.785, sensitivity 75.8%, specificity 72.2%, positive predictive value 68.7%, and negative predictive value 78.8%) to distinguish sepsis with AC, while different combinations of indexes did not perform better. From day 1 to day 5 of hospitalization, the levels of sTREM-1 in Group A were the highest, followed by Groups B and C (P < 0.05); on day 8, sTREM-1 levels in Groups A and B declined back to normal. However, other index levels among three groups still had a significant difference on day 10. Both in Groups A and B, sTREM-1 levels declined fast between day 1 and day 2 (P < 0.05).

Conclusions

CRP is the best biomarker to suggest infection here. PCT alone is sufficient enough to diagnose sepsis with AC. sTREM-1 is the best biomarker to monitor patients' response to antimicrobial therapy and biliary drainage.

Shortening antibiotic duration in the treatment of acute cholangitis: rationale and study protocol for an open-label randomized controlled trial

BACKGROUND

Antimicrobial therapy with appropriate biliary drainage is considered the standard of care for acute cholangitis, but the optimal duration of antimicrobial therapy remains unknown. Seven to 10 days of antimicrobial therapy are common for the treatment of acute cholangitis, but a recent retrospective cohort study suggested a shorter duration might be effective. A shorter duration of antimicrobial therapy can be beneficial in decreasing the length of hospital stay, improving patients' quality of life, decreasing adverse effects, and even contributing to a decrease in the occurrence of antimicrobial resistance.

METHODS/DESIGN

We will conduct a multi-centre, open-label, randomized, non-inferiority trial to compare short-course therapy (SCT) with conventional long-course therapy (LCT) in treating patients with acute cholangitis. SCT consists of 5-day intravenous antimicrobial therapy if the patients had clinical improvement, while at least 7 days of intravenous antibiotics will be provided to the LCT group. The primary outcome is clinical cure at 30 days after onset. Patients will be randomly assigned in an open-label fashion. A total sample size of 150 was estimated to provide a power of 80% with a one-sided α level of 2.5% and a non-inferiority margin of 10%.

DISCUSSION

This trial is expected to reveal whether SCT is non-inferior to conventional LCT or not, and may provide evidence that one can shorten the treatment duration for acute cholangitis for the benefit of patients.

TRIAL REGISTRATION

University Hospital Medical Information Network, UMIN000028382. Registered on 30 August 2017.

Trends and risk factors for 30-day readmissions in patients with acute cholangitis: analysis from the national readmission database

INTRODUCTION

Acute cholangitis (AC) can be associated with significant mortality and high risk of readmissions, if not managed promptly. We used national readmission database (NRD) to identify trends and risk factors associated with 30-day readmissions in patients with AC.

METHODS

We conducted a retrospective cohort study of adult patients admitted with AC from 2010-2014 and Q1-Q3 of 2015 by extracting data from NRD. Initial admission with a primary diagnosis of acute cholangitis (ICD-9 code: 576.1) was considered as the index admission and any admission after index admission was considered a readmission regardless of the primary diagnosis. Multivariable regression analyses were performed to assess the association.

RESULTS

From 52,906 AC index admissions, overall 30-day readmission rate was 21.48% without significant differences in the readmission rates across the study period. There was significant increase in the overall hospital charges for readmissions, while a significant reduction in the death rate was observed during the first readmission. Recurrent cholangitis (14%), septicemia (6.4%), and mechanical complication of bile duct prosthesis (3%) were the most common reasons for readmissions. The risk of readmission was significantly higher in patients with pancreatic neoplasm (OR 1.6, 95% CI 1.4-1.8), those who underwent percutaneous biliary procedures (OR 1.4, 95% CI 1.2-1.6), and who had an acute respiratory failure (OR 1.2, 95% CI 1.0-1.15). Other factors contributing to increased risk of readmissions included patients with Charleston comorbidity index > 3, diabetes, and length of stay > 3 days. Readmission risk was significantly lower in patients who underwent ERCP (OR 0.80, 95% CI 0.73-0.88) or cholecystectomy (OR 0.54, 95% CI 0.43-0.69).

CONCLUSIONS

AC is associated with a high 30-day readmission rate of over 21%. Patients with malignant biliary obstruction, increased comorbidities, and those who undergo percutaneous drainage rather than ERCP seem to be at the highest risk.

Clinical predictors and outcome impact of community-onset polymicrobial bloodstream infection

OBJECTIVES

Very few studies have characterised community-onset polymicrobial bloodstream infections (BSIs). This study determined the incidence, risk factors, and outcomes of polymicrobial BSI as compared with monomicrobial BSI in a cohort of patients with community-onset BSIs.

METHODS

This prospective cohort study enrolled consecutive patients with laboratory confirmed BSIs who were admitted to two tertiary emergency departments in Taiwan between 1 January 2015 and 31 December 2016. It assessed the independent impact of polymicrobial BSIs on survival by a propensity score weighting method. Subsequently, independent clinical predictors were identified with multivariate logistic regression model analysis with internal validation by 10-fold cross validation.

RESULTS

Among 1166 patients with community-onset BSI, 133 (10.9%) episodes of polymicrobial BSIs occurred. Anaerobe, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii, Enterococcus spp., and Candida spp. were the most common isolated microorganisms in polymicrobial BSI. Polymicrobial BSIs were associated with an increased 90-day mortality rate (OR 2.20, 95% CI 1.98-2.60). A prediction model was built to predict polymicrobial BSI with moderate predictability (c statistic = 0.78). Significant predictors included biliary tract infection, nosocomial infection, nursing home residence, stroke, and afebrile presentation.

CONCLUSIONS

Polymicrobial BSI occurred in approximately 1 in 10 episodes of community-onset BSI and was independently associated with excess mortality. Clinical predictors identified in this study may help guide the prescription of empiric broad-spectrum antibiotics.

Clinical epidemiology and outcomes of biliary tract infections caused by Klebsiella pneumoniae

Background

Biliary tract infection (BTI) is a common cause of bacteremia, and is associated with high morbidity and mortality. The clinical epidemiology and outcomes of BTI caused by Klebsiella pneumoniae (KP) have not been well investigated.

Methods

This was a retrospective study performed at a university teaching hospital in China from May 2012 to June 2017 that analyzed data for 119 patients with BTI caused by KP. We identified KP from bile cultures obtained before endoscopic or surgical treatment. Patients' demographic characteristics and clinical outcomes were also recorded.

Results

Forty-seven KP strains (39.5%) were positive for the extended spectrum beta-lactamase (ESBL) phenotype. The ESBL-positive group had a higher rate of stay in ICU [12.8% vs. 1.4% (ESBL-negative group); P=0.015] and a significantly longer hospital stay (30.79±31.512 vs. 20.06±23.945 days, respectively; P=0.037). There were no significant differences for 30-day mortality between the two groups; 112 (94.1%) patients survived and 7 (5.9%) died within 30-days of onset. Univariate analysis showed that nonsurvivors were significantly more likely to be older (66.46±22.34 vs. 46±14.84 years, respectively; P=0.001), and have hypoproteinemia (5/7, 71.4% vs. 21/112, 18.8%; P=0.006), immunosuppression (3/7, 42.9% vs. 4/112, 3.6%; P=0.004), solid tumors (5/7, 71.4% vs. 20/112, 17.9%; P=0.004), bloodstream infections (6/7, 85.7% vs. 22/112, 19.6%; P=0.001), and lower surgery rates (1/7, 14.3% vs. 66/112, 58.9%; P=0.042) compared with survivors, respectively. However, we found no significant independent risk factor for mortality. The malignant biliary obstruction group was significantly more likely to have chronic liver disease (P=0.035) than the benign biliary obstruction group, and mortality was higher for the malignant biliary obstruction group (5/25, 20% vs. 2/94, 2.1%, respectively; P=0.05). The malignant biliary group also had higher alkaline phosphatase, and direct and total bilirubin direct levels. Multivariate analysis showed that chronic liver disease was an independent risk factor in patients with malignant biliary disease [odds ratio (OR), 2.431; 95% confidence interval, 1.834-4.031; P=0.001].

Conclusions

Patients with BTI caused by KP were more likely to have the ESBL phenotype, and antibiotic resistance was not associated with overall survival. Patients with malignant biliary obstruction had higher mortality, and chronic liver disease was an independent risk factor.

Changes in Microbial Profiles and Antibiotic Resistance Patterns in Patients with Biliary Tract Infection over a Six-Year Period

Background: Biliary tract infection (BTI) is a common complication in patients with biliary obstruction caused by various biliary tract disorders. To improve the management of patients with BTI, microbial profiles from bile cultures and antibiotic resistance patterns were evaluated in this six-year retrospective study. Methods: A total of 709 patients with various biliary tract disorders from January 2012 to December 2017 were enrolled in this study. Bile specimens were taken from intra-operative puncture or post-operative drainage for microbial culture under sterile conditions. Microbial culture, identification, and antibiotic resistance test were performed according to a standard routine. Results: Cultures were positive in 574 of 789 bile specimens (73%). Of all isolates, 386 were gram-negative bacilli (67%), 170 were gram-positive cocci (30%), and 18 were fungi (3%). The two most common micro-organisms were Escherichia coli (29%) and Klebsiella pneumoniae (16%), the extended-spectrum β-lactamases (ESBL) positivity rates of which were 52% and 21%, respectively. Both bacteria were highly resistant to commonly used antibiotic agents (penicillins, cephalosporins, and quinolones), and highly susceptible to carbapenems, amikacin, and piperacillin-tazobactam. Enterococcus (19%) was the next most common bacteria isolated from bile samples, mainly including Enterococcus faecium (8%) and Enterococcus faecalis (6%). These two bacteria were resistant to cefazolin and clindamycin but sensitive to teicoplanin, tigecycline, and vancomycin. Enterococcus faecium was more resistant than Enterococcus faecalis to most of the tested antibiotic agents. Annual statistical analysis showed that the frequency of gram-negative enteric bacteria was decreasing slowly, but that of gram-positive enterococci was increasing slowly. Moreover, the overall antibiotic resistance rates of the most common strains have been decreasing slowly over the past six years. Conclusions: Enterobacteriaceae (Enterococcus coli and Klebsiella pneumoniae) and Enterococcus (Enterococcus faecium and Enterococcus faecalis) were the common pathogenic bacteria causing BTI, which exhibited high resistance to routinely used antibiotic agents and were highly sensitive to piperacillin-tazobactam, carbapenem, amikacin, and vancomycin. The microbial profiles from bile and its antibiotic resistance patterns have changed, which will help in the empirical treatment of BTI.

Unchanged mortality in patients with acute cholangitis despite an increase in malignant etiologies - a 25-year epidemiological study

Background and aims: Acute cholangitis (AC) is a rare but serious condition, with an incidence of 7.0 per 10,000 people and mortality rates up to 10%. The aim of this study was to describe changes in obstruction etiology, comorbidities, clinical factors, and mortality among AC patients during a 25-year period. Methods: Using a database of 11,563 consecutive ERCP-procedures performed from 1990-2015 at Odense University Hospital, we identified all AC cases during that period. Clinical and epidemiological data were collected from the database and the Danish Patient Registry. Association with 30-day mortality was investigated using multiple logistic regression analysis with adjustment for confounding factors. Results: In total, 775 consecutive and individual cases of AC were included. Among cases, 42% (n = 326) were of malignant etiology, with an increasing incidence over time (regression coefficient [95% CI]: 0.03 [0.01-0.04] per year; p = .01). Mean Charlson Comorbidity Index was 1.4, with an increase over time (regression coefficient [95% CI]: 0.04 [0.03-0.05] per year; p < .01). Malignant obstruction etiology was associated with 30-day mortality (OR [95% CI]: 1.11 [1.04-1.18]; p < .01). Overall 30-day mortality was 12% (n = 91). After adjustment for confounding factors, no significant changes in 30-day mortality were observed over time (OR [95% CI]: 1 [1-1.00]; p = .91 per year). Conclusion: Significant increases in the incidence of malignant obstruction etiology and severity of comorbidities among AC patients were observed during the study period. Despite those findings, 30-day mortality remained unchanged, potentially reflecting a general improvement in the management of AC.

Anaerobic coverage as definitive therapy does not affect clinical outcomes in community-onset bacteremic biliary tract infection without anaerobic bacteremia

Background

Antibiotics with anaerobic coverage are widely used for the treatment of biliary tract infection (BTI), even in the absence of isolated anaerobes. The current study aimed to investigate the differences in clinical outcomes in patients with community-onset bacteremic BTIs without anaerobic bacteremia, treated with vs. without anti-anaerobic coverage.

Methods

A retrospective analysis was conducted at a medical center in Taiwan from September 2014 to March 2016. Patients with community-onset bacteremic BTIs without anaerobic bacteremia and who were treated with appropriate antibiotics were analyzed. The clinical outcomes were compared between patients treated with and without anti-anaerobic coverage as definitive therapy after the blood culture reports were available. Multivariable and propensity score-adjusted analysis were used to identify the risk factors associated with treatment failure.

Results

Among the enrolled 87 patients, 63 and 24 patients were treated with and without anaerobic coverage, respectively. Escherichia coli (55.2%) and Klebsiella pneumoniae (23.0%) were the most common organisms isolated from the blood cultures. The rate of treatment failure (relapse and 28-day mortality) was similar between the groups with and without anaerobic coverage (20.6% vs. 16.7%, p = 0.677). Propensity score-adjusted multivariable analysis revealed that definitive therapy without anaerobic coverage was not a predisposing factor for treatment failure (OR = 0.92, 95% CI 0.18–4.67, p = 0.916).

Conclusions

Definitive therapy without anaerobic coverage does not affect the outcomes of patients with community-onset bacteremic BTIs without anaerobes isolated from blood. Our results might provide a possible target for antibiotic stewardship interventions in BTIs.

Shorter duration of antibiotic treatment for acute bacteraemic cholangitis with successful biliary drainage: a retrospective cohort study

OBJECTIVES

To assess the effectiveness of short duration antimicrobial therapy for acute cholangitis with bacteraemia.

METHODS

We conducted a retrospective cohort study of patients with acute bacteraemic cholangitis with successful biliary duct drainage at a single centre in Japan. We compared short-course antimicrobial therapy (SCT, ≤7 days) and long-course therapy (LCT, ≥8 days), with a primary outcome of 30-day mortality. We constructed logistic regression models for mortality and a composite outcome, including mortality, recurrence, recrudescence, new bacteraemia, liver abscess or other complications related to cholangitis. We also developed a propensity score for SCT with inverse probability weighting for both the primary outcome and the composite outcome.

RESULTS

We identified 263 patients in our cohort; 86 (32.7%) patients received SCT and the remaining 177 (67.3%) received LCT. The median durations of SCT and LCT were 6 days (range 2-7 days) and 12 days (range 8-46 days), respectively. The 30-day mortalities of SCT and LCT were 4.7% (4/85) and 5.7% (10/176), respectively (p 1.00). Logistic regression analysis showed that the odds ratio of SCT for 30-day mortality and the composite outcome were 1.07 (95% CI 0.25-4.52, p 0.93) and 1.08 (95% CI 0.48-2.45, p 0.85), respectively. Propensity score analyses for both 30-day mortality and the composite outcome did not demonstrate a difference between SCT and LCT (p 0.65 and p 0.95, respectively).

CONCLUSIONS

SCT with a median duration of 6 days did not have worse outcomes than LCT with a median duration of 12 days. Shortening the duration of antimicrobial therapy may be a reasonable option when treating acute bacteraemic cholangitis following successful biliary drainage.

Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis

Antimicrobial therapy is a mainstay of the management for patients with acute cholangitis and/or cholecystitis. The Tokyo Guidelines 2018 (TG18) provides recommendations for the appropriate use of antimicrobials for community-acquired and healthcare-associated infections. The listed agents are for empirical therapy provided before the infecting isolates are identified. Antimicrobial agents are listed by class-definitions and TG18 severity grade I, II, and III subcategorized by clinical settings. In the era of emerging and increasing antimicrobial resistance, monitoring and updating local antibiograms is underscored. Prudent antimicrobial usage and early de-escalation or termination of antimicrobial therapy are now important parts of decision-making. What is new in TG18 is that the duration of antimicrobial therapy for both acute cholangitis and cholecystitis is systematically reviewed. Prophylactic antimicrobial usage for elective endoscopic retrograde cholangiopancreatography is no longer recommended and the section was deleted in TG18. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

IL-7 and procalcitonin are useful biomarkers in the comprehensive evaluation of the severity of acute cholangitis

BACKGROUND

The incidence of biliary tract infection (BTI), especially healthcare-associated cholangitis, is increasing. However, there are few reports concerning biomarkers of acute cholangitis. We therefore performed an exhaustive investigation of several biomarkers.

METHODS

We retrospectively measured 11 cytokines, six chemokines and procalcitonin (PCT), and endotoxin activity assay (EAA) values (IRB: 110512019) of 61 samples with acute cholangitis.

RESULT

The 28-day mortality rate was 9.8%. The levels of most cytokines and chemokines were significantly correlated with each other. A low IL-7 level was found to predict blood culture positivity. Low IL-7 level was also found to predict disseminated intravascular coagulation. Low IL-7 levels and a high PCT level were found to be predictors of severe cholangitis. The 28-day mortality in the group of patients with an IL-7 level of ≤6.0 and a PCT level of >0.5 was 18.2%. It was significantly higher than in the other group.

CONCLUSION

The combined use of IL-7 and PCT may be useful for evaluating severe acute cholangitis; these results may suggest that severe acute cholangitis is affected by immunosuppressive changes.

Acute Cholangitis After Bilioenteric Anastomosis for Bile Duct Injuries

BACKGROUND/PURPOSE

The study aims to describe the clinical features, microbiology, and associated factors of acute cholangitis (AC) after bilioenteric anastomosis (BEA) for biliary duct injury (BDI). Additionally, we assessed the performance of the Tokyo Guidelines 2013 (TG13) recommendations in these patients.

METHODS

We conducted a case-control study of 524 adults with a history of BEA for BDI from January 2000 to January 2014. A propensity score adjustment was performed for the analysis of the independent role of the main factors identified during the univariate logistic regression procedure.

RESULTS

We identified 117 episodes of AC in 70 patients; 51.3% were definitive AC according to the TG13 diagnostic criteria, and 39.3% did not fulfill the imaging criteria of AC. A history of post-operative biliary complications (OR 2.55, 95% CI 1.38-4.70) and the bile duct confluence preservation (OR 0.46, 95% CI 0.24-0.87) were associated with AC. Eighty-nine percent of the microorganisms were Enterobacteriaceae; of them, 28% were extended spectrum β-lactamase (ESBL) producers.

CONCLUSIONS

AC is a common complication after BEA and must be suspected even in the absence of imaging findings, particulary in patients with a history of post-operative biliary complications, and/or without bile duct confluence preserved. An empirical treatment for ESBL-producing Enterobacteriaceae may be appropriate in patients living in countries with a high rate of bacterial drug resistance.

Optimal Timing of Endoscopic Retrograde Cholangiopancreatography in Acute Cholangitis

OBJECTIVES

Acute cholangitis mandates resuscitation, antibiotic therapy, and biliary decompression. Our aim was to define the optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) for patients with acute cholangitis.

METHODS

Clinical data on all cases of cholangitis managed by ERCP were prospectively collected from September 2010 to July 2013. The clinical impact of the time to ERCP, defined as the time from presentation in the emergency department to the commencement of the ERCP, was determined. The primary outcome was length of hospitalization. Secondary outcomes included vasopressor use, endotracheal intubation, intensive care unit admission, and death.

RESULTS

ERCP was successful in 182 (92%) of 199 patients with cholangitis. Length of hospitalization was significantly longer for patients undergoing ERCP at ≥48 versus <48 hours (median 9.1 vs. 6.5 d, P=0.004) even though patients having ERCP at ≥48 hours were less sick as indicated by less frequent intensive care unit admission [odds ratio,0.3; 95% confidence interval (CI), 0.2-0.6]. Multivariate analysis revealed that hospitalization increased by 1.44 days for every day ERCP was delayed (P<0.001). Comparison of ERCP≥72 versus <72 hours revealed odds ratios of 2.6 (95% CI, 1.0-7.0) for vasopressor requirement and 3.6 (95% CI, 0.8-15.9) for mortality. Time to ERCP did not impact technical success or procedural adverse events.

CONCLUSIONS

ERCP should be performed within 2 days of presentation as a delay of 48 or more hours is associated with disproportionate increase in hospital stay. Delay>72 hours is associated with additional adverse outcomes including hypotension requiring vasopressor support.

Updated comprehensive epidemiology, microbiology, and outcomes among patients with acute cholangitis

BACKGROUND

The international practice guidelines for patients with acute cholangitis and cholecystitis were released in 2007 (TG07) and revised in 2013 (TG13). This study investigated updated epidemiology and outcomes among patients with acute cholangitis on a larger scale for the first time.

METHODS

This is an international multi-center retrospective observational study in Japan and Taiwan. All consecutive patients older than 18 years of age and given a clinical diagnosis of acute cholangitis by clinicians between 1 January 2011 and 31 December 2012 were enrolled. Those who met the diagnostic criteria of acute cholangitis by TG13 were statistically analyzed.

RESULTS

A total of 7,294 patients were enrolled and 6,433 patients met the TG13 diagnostic criteria. The severity distribution was Grade I (37.5%), Grade II (36.2%), and Grade III (26.2%). The 30-day all-cause mortality was 2.4%, 4.7%, and 8.4% in Grade I, II, III severity, respectively (P < 0.001). The incidence of liver abscess and endocarditis as complications of acute cholangitis was 2.0% and 0.26%, respectively.

CONCLUSIONS

This is the first large scale study to investigate patients with acute cholangitis. This study provides the basis to define the best practices to manage patients with acute cholangitis in future studies.

Comparison of acute cholangitis with or without common bile duct dilatation

To improve the management of patients with acute cholangitis, the present study compared laboratory test variables between acute cholangitis patients with or without common bile duct (CBD) dilatation [CBDdil(+) and CBDdil(-), respectively]. The medical records of patients diagnosed with acute cholangitis and subjected to endoscopic retrograde cholangiopancreatography between February 2008 and May 2015 were retrospectively analyzed. The present study consisted of 40 men (aged 69.4±8.8 years) and 37 women (aged 68.8±11.6 years). It was observed that CBDdil(-) patients were slightly younger than CBDdil(+) patients (P=0.0976), and levels of C-reactive protein (CRP) were significantly higher in CBDdil(-) patients than in CBDdil(+) patients (P=0.0392). In addition, logistic regression analysis indicated that CRP levels were associated with the presence of CBD dilatation (P=0.0392). These data indicate that patients with acute cholangitis without CBD dilatation tend to be younger and have higher levels of CRP. Thus, in acute cholangitis patients without CBD dilatation, diagnosis should be determined using clinical symptoms and laboratory data.

Randomized clinical trial of extended versus single-dose perioperative antibiotic prophylaxis for acute calculous cholecystitis

Background

Many patients who have surgery for acute cholecystitis receive postoperative antibiotic prophylaxis, with the intent to reduce infectious complications. There is, however, no evidence that extending antibiotics beyond a single perioperative dose is advantageous. This study aimed to determine the effect of extended antibiotic prophylaxis on infectious complications in patients with mild acute cholecystitis undergoing cholecystectomy.

Methods

For this randomized controlled non-inferiority trial, adult patients with mild acute calculous cholecystitis undergoing cholecystectomy at six major teaching hospitals in the Netherlands, between April 2012 and September 2014, were assessed for eligibility. Patients were randomized to either a single preoperative dose of cefazolin (2000 mg), or antibiotic prophylaxis for 3 days after surgery (intravenous cefuroxime 750 mg plus metronidazole 500 mg, three times daily), in addition to the single dose. The primary endpoint was rate of infectious complications within 30 days after operation.

Results

In the intention-to-treat analysis, three of 77 patients (4 per cent) in the extended antibiotic group and three of 73 (4 per cent) in the standard prophylaxis group developed postoperative infectious complications (absolute difference 0·2 (95 per cent c.i. –8·2 to 8·9) per cent). Based on a margin of 5 per cent, non-inferiority of standard prophylaxis compared with extended prophylaxis was not proven. Median length of hospital stay was 3 days in the extended antibiotic group and 1 day in the standard prophylaxis group.

Conclusion

Standard single-dose antibiotic prophylaxis did not lead to an increase in postoperative infectious complications in patients with mild acute cholecystitis undergoing cholecystectomy. Registration number: NTR3089 (www.trialregister.nl).

Characteristics, aetiology, antimicrobial resistance and outcomes of bacteraemic cholangitis in patients with solid tumours: A prospective cohort study

OBJECTIVES

To asses the clinical features, aetiology, antimicrobial resistance and outcomes of bacteraemic cholangitis in patients with solid tumours (ST).

METHODS

All consecutive episodes of bacteraemia in hospitalized patients were prospectively analysed (2006-2015).

RESULTS

Of 1852 episodes of bacteraemia, 750 involved patients with ST. Among them, 173 episodes (23%) were due to cholangitis. The most frequent neoplasms were hepato-biliary-pancreatic tumours (68.2%) and gastrointestinal cancer (18.5%); 57.2% of patients had a biliary stent in place. The most frequent causative agents were Escherichia coli (39.3%) followed by Klebsiella pneumoniae (15.1%) and Enterococcus faecium (7.8%). Forty-one episodes (18.7%) were caused by multidrug-resistant (MDR) microorganisms. Patients with a second episode of cholangitis were more likely to have an MDR isolate and to had received inadequate empirical antibiotic therapy. 7-day and 30-day case-fatality rates were 7.6% and 26%, respectively. The only risk factors independently associated with 30-day case-fatality rate were corticosteroids and malignancy-related complications.

CONCLUSIONS

Bacteraemic cholangitis is frequent in patients with ST, and is mainly caused by Enterobacteriaceae and E. faecium. The emergence of MDR is of special concern, particularly in patients with a second episode of bacteraemia. Case-fatality rates are high, especially among patients receiving corticosteroids and presenting malignancy-related complications.

The impact of delayed biliary decompression and anti-microbial therapy in 260 patients with cholangitis-associated septic shock

BACKGROUND

Cholangitis-associated septic shock carries significant mortality. There is uncertainty regarding the most appropriate time to achieve biliary decompression.

AIM

To determine whether the timing of biliary decompression and anti-microbial therapy affect the survival in cholangitis patients with septic shock.

METHODS

Nested retrospective cohort study of all cholangitis-associated septic shock patients (hypotension requiring vasopressors) from an international, multi-centre database between 1996 and 2011.

RESULTS

Among 260 patients (mean age 69 years, 57% male), overall mortality was 37%. Compared to nonsurvivors (n = 96), survivors (n = 164) had lower mean admission Acute Physiology And Chronic Health Evaluation (APACHE) II (22 vs. 28, P < 0.001) and lower median serum lactate on admission (3.4 vs. 4.6 mmol/L, P < 0.001). Survivors were more likely to receive appropriate anti-microbial therapy earlier (median 2.6 vs. 6.8 h from shock, P < 0.001). Survivors were also more likely to undergo successful biliary decompression earlier (median 8.8 vs. 22 h, P < 0.001). After adjusting for co-variates, APACHE II (odds ratio, OR 1.21 per increment (1.11-1.32), time delay to appropriate anti-microbial therapy [OR 1.15 per hour (1.07-1.25)] and delayed biliary decompression >12 h [OR 3.40 (1.12-10.31)] were all significantly associated with increased mortality (P < 0.04 for all; c-statistic 0.896).

CONCLUSIONS

Patients with septic shock secondary to acute cholangitis have significant mortality. Endoscopic biliary decompression >12 h after the onset of shock and delayed receipt of appropriate anti-microbial therapy were both significantly associated with adverse hospital outcome. This might suggest that early initiation of anti-microbial therapy and urgent biliary decompression (within 12 h) could potentially improve outcomes in this high-risk patient population.

The association between biliary tract inflammation and risk of digestive system cancers: A population-based cohort study

The relationship between biliary tract inflammation (BTI) and digestive system cancers is unclear. This study aimed to evaluate the association between BTI and the risks of digestive system cancers.Using the Taiwan National Health Insurance claims data, information on a cohort of patients diagnosed with BTI (n = 4398) between 2000 and 2009 was collected. A comparison cohort of sex-, age-, and index year-matched persons without BTI (n = 17,592) was selected from the same database. The disease was defined by the ICD-9-CM. Both cohorts were followed until the end of 2010 and incidences of digestive system cancers were calculated.The results revealed an increase in adjusted hazard ratio (aHR) of biliary tract cancer (24.45; 95% confidence interval [CI]: 9.20-65.02), primary liver cancer (1.53; 95% CI: 1.07-2.18), and pancreatic cancer (3.10; 95% CI: 1.20-8.03) in patients with both gallbladder and BTI. The aHR of stomach cancer was also found to be increased (2.73; 95% CI: 1.28-5.81) in patients with gallbladder inflammation only. There were no differences in esophageal cancer (aHR: 0.82; 95% CI: 0.23-2.87) and colorectal cancer (aHR: 0.92; 95% CI: 0.59-1.45). The aHR for digestive system cancers increased by 3.66 times (95% CI: 2.50-5.35) and 12.20 times (95% CI: 8.66-17.17) in BTI visits frequency averaged 2 to 4 visits per year and frequency averaged ≥5 visits per year, respectively.Patients with BTI have significantly higher risk of digestive system cancers, particularly biliary tract, pancreatic, and primary liver cancers, compared with those who are without it.

Clinical evaluation of the Tokyo Guidelines 2013 for severity assessment of acute cholangitis

BACKGROUND

We evaluated the severity assessment criteria for acute cholangitis (AC) of the Tokyo Guidelines 2013 (TG13) and developed a scoring system for predicting the need for urgent/early biliary drainage.

METHODS

We retrospectively reviewed 66 AC cases prospectively managed based on the TG07 and divided into an urgent/early biliary drainage group (n = 30) and elective biliary drainage group (n = 36).

RESULTS

There were 26 mild, 27 moderate, and 13 severe cases based on the TG13. The TG13 assessment in 12 of the 17 cases requiring early biliary drainage based on the TG07 was moderate, but underestimated the other five cases as mild AC. When five predictors (blood urea nitrogen >20 mg/dL, SIRS presence, platelet count <120 000/μL, serum albumin level <3.0 g/dL, age ≥75 years old) were used to devise a scoring system, the receiver-operator characteristic curve of the scores showed good test performance for predicting the need for urgent/early biliary drainage. The area under the curve (AUC) was 0.95 and higher than the TG13 AUC (0.80).

CONCLUSIONS

The TG13 is practical, but some AC cases requiring urgent/early biliary drainage were underestimated as mild AC. The scoring system allows identification of high-risk AC patients and will improve the TG13.

Delayed endoscopic retrograde cholangiopancreatography is associated with persistent organ failure in hospitalised patients with acute cholangitis

BACKGROUND

Predictors of organ failure and the impact of early endoscopic retrograde cholangiopancreatography (ERCP) on outcomes in patients with acute cholangitis are unclear.

AIM

To identify factors associated with persistent organ failure and assess the impact of early ERCP on outcomes in hospitalised patients with cholangitis.

METHODS

Consecutive hospitalised patients who received ERCP at two centres for cholangitis from 4/2005-3/2013 were retrospectively reviewed. Delayed ERCP was defined as ERCP ≥ 48 h after hospitalisation. Primary outcome was persistent organ failure at >48 h after hospitalisation (≥ 1.5 times rise in creatinine levels from baseline values to ≥ 1.5 mg/dL or need for dialysis, mechanical ventilation and/or hypotension requiring vasopressor).

RESULTS

203 patients (mean age 59 ± 19 years) had ERCP for cholangitis: 115 with choledocholithiasis, 48 with other benign obstructions and 40 with malignant strictures. Forty-five (22%) patients had persistent organ failure at >48 h and 11 (5%) died. On multivariate analysis, Charlson Comorbidity Index >2 (OR = 4.6, 95% CI = 1.5-13.8), systemic inflammatory response syndrome (SIRS; OR = 3.2, 95% CI = 1.1-9.8), hypoalbuminemia (OR = 3.3, 95% CI = 1.4-7.9), bacteremia (OR = 2.8, 95% CI 1.3-6.2) and delayed ERCP(OR = 3.1, 95% CI: 1.4-7.0) were associated with persistent organ failure. Every 1-day delay in ERCP was associated with a 17% (95% CI = 5-29%) relative risk increase in persistent organ failure after adjusting for significant factors.

CONCLUSIONS

Delay in ERCP beyond 48 h was associated with persistent organ failure in hospitalised patients with acute cholangitis. Other factors included increased comorbidities, SIRS, hypoalbuminemia and bacteremia. Early ERCP performed within 48 h after presentation in patients with cholangitis may improve outcomes.

Risk factors of organ failure in cholangitis with bacteriobilia

AIM: To identify the risk factors for organ failure (OF) in cholangitis with bacteriobilia.

METHODS: This study included 182 patients with acute cholangitis who underwent percutaneous transhepatic biliary drainage between January 2005 and April 2013. We conducted a retrospective analysis of comprehensive clinical and laboratory data.

RESULTS: There were 24 cases (13.2%) of OF and five deaths (2.7%). Bile culture was positive for microbial growth in 130 out of 138 (94.2%) patients. In multivariate analysis of 130 patients with positive bile cultures, significant predictive factors for OF were the presence of extended-spectrum beta-lactamase (ESBL) organisms in blood cultures, pre-existing renal dysfunction, and choledocholithiasis as an etiology, with odds ratios of 15.376, 6.319, and 3.573, respectively. We developed a scoring system with a regression coefficient of each significant variable. The OF score was calculated using the following equation: (2.7 × ESBL organisms in blood cultures) + (1.8 × pre-existing renal dysfunction) + (1.3 × choledocholithiasis). This scoring system for predicting OF was highly specific (99.1%) and had a positive predictive value of 86.2%.

CONCLUSION: ESBL organisms in blood cultures, pre-existing renal dysfunction, and choledocholithiasis are risk factors for OF in cholangitis with bacteriobilia. The OF scoring system may aid clinicians to identify a poor prognosis group.

Early oral antibiotic switch compared with conventional intravenous antibiotic therapy for acute cholangitis with bacteremia

BACKGROUND

Biliary decompression with antibiotic therapy is the mainstay treatment for acute cholangitis with bacteremia. A few studies have been conducted to investigate the optimal duration and route of antibiotic therapy in biliary tract infection with bacteremia.

METHODS

Patients with acute cholangitis with bacteremia who achieved successful biliary drainage were randomly assigned to an early oral antibiotic switch group (group A, n = 29) and a conventional intravenous antibiotics group (group B, n = 30). Patients were discharged when they were afebrile over 2 days after oral antibiotic switch and showed consecutive improvement in the laboratory index. They were followed up and assessed at 30 days after diagnosis to evaluate the eradication of bacteria, recurrence of acute cholangitis, and 30-day mortality rate.

RESULTS

There were no statistically significant differences between the two groups in baseline characteristics, clinical and laboratory index, severity of acute cholangitis, bacteria isolated from blood cultures, and clinical outcomes. The rate of eradication of bacteria was 93.1 % in group A and 93.3 % in group B, respectively (p = 0.97). Using non-inferiority tests, the rate of eradication of bacteria in group A was not inferior to that in group B (95 % CI -0.13 to 0.14, p = 0.97). There was no statistically significant difference in the recurrence of acute cholangitis and a 30-day mortality rate between the two groups.

CONCLUSIONS

Early switch to oral antibiotic therapy following adequate biliary drainage for treatment of acute cholangitis with bacteremia was not inferior to conventional 10-day intravenous antibiotic therapy.

Identification of risk factors for intraoperative hemobilia and its correlation with early postoperative complications in patients with hepatolithiasis

BACKGROUND

This study intends to determine the risk factor(s) for intraoperative hemobilia in patients with hepatolithiasis and examine whether the occurrence of intraoperative hemobilia influences the rate of early postoperative complications.

METHODS

A retrospective analysis of 867 eligible patients was performed. Patients were divided into 2 groups: group A (hemobilia, n = 76) and group B (nonhemobilia, n = 791).

RESULTS

The incidence of intraoperative hemobilia was 8.8% (76/867). Independent risk factors of intraoperative hemobilia for patients with hepatolithiasis were interval between surgery and latest attack of acute cholangitis less than or equal to 38.8 days; preoperative attack of acute severe cholangitis; and intrahepatic duct stricture. Group A had a higher incidence of early postoperative complications than group B. Shorter interval between surgery and latest attack of acute cholangitis correlated with intraoperative hemobilia and postoperative complications.

CONCLUSION

The severity and time of onset of preoperative acute cholangitis influence the risk of intraoperative hemobilia, which is positively correlated with early postoperative complications.