Bloodstream infections after interventional procedures in the biliary tract

Evaluation of Blood Stream and Biliary Tract Infections Related to Percutaneous Transhepatic Cholangiography and Prophylaxis Given in Patients with Malignancy

Objective

Percutaneous transhepatic cholangiography (PTC) is an invasive procedure used in patients with obstructive jaundice in the progress of some malignancies, and its most common complication is infection. We aimed to evaluate the patients who underwent PTC regarding their cultures, prophylaxis, and antibiotics used for treatment.

Materials and Methods

In this cross-sectional study, patients who underwent PTC and were followed up in a medical oncology outpatient clinic between 2010-2017 were evaluated retrospectively. Patients' data were obtained from the hospital record system (FONET), epicrisis forms, and patient progress files.

Results

A total of 93 patients were included in the study. Prophylaxis was given in 50% of the cases. Complications developed in 68% of the cases after the intervention, and the infectious disease clinic consulted all. Blood cultures were obtained from 89% of the febrile patients; however, bile cultures were obtained only from 29%. The rate of resistant Gram-negative enteric bacteria in growing microorganisms was 52% (n=13). It was determined that 65% of the initiated empirical treatments were appropriate for the growth of microorganisms.

Conclusion

The growth rate was significantly higher in blood cultures than in bile cultures. The lower growth rate in bile culture was attributed to the low number of bile cultures. There was no significant difference regarding the growth rate and drug resistance of the microorganisms. Therefore, we think giving antibiotics as treatment rather than prophylaxis is more appropriate. Taking cultures will ensure that patients receive appropriate antibiotic therapy for the causative agent.

EUS-guided hepaticoenterostomy as a portal to allow definitive antegrade treatment of benign biliary diseases in patients with surgically altered anatomy

BACKGROUND AND AIMS

EUS-guided hepaticoenterostomy (EUS-HE) usually is reserved for palliation of malignant biliary obstruction after failed endoscopic retrograde cholangiography (ERC) or inaccessible biliary tree in surgically altered anatomy (SAA). We describe the outcome of EUS-HE and antegrade therapy for benign biliary disease in patients with SAA.

METHODS

Retrospective review of 20 consecutive patients with surgically altered anatomy and benign biliary obstruction who underwent EUS-HE performed by 1 endoscopist at a tertiary-care center over a 3-year period.

RESULTS

During the study period, 37 patients underwent EUS-HE; 24 for benign disease. Of these, 20 patients had SAA and were analyzed (15 women, mean age, 62 years). SAA consisted of 9 Roux-en-Y gastric bypasses, 6 Roux-en-Y hepaticojejunostomy, 2 Billroth II procedures, and 3 Whipple procedures. Indications for ERC were common bile duct stones (n = 8), benign postoperative strictures (n = 7), chronic pancreatitis (n = 3), inflammatory stricture (n = 1), and treatment of a bile leak (n = 1). Five patients had previously failed balloon enteroscopy-assisted ERCs. The approach was transgastric in 15 and transjejunal in 5. In all cases, a branch of the left hepatic duct with a mean diameter of 7.8 mm was accessed. Median stent length was 80 mm, with diameters of 8 or 10 mm. Antegrade, definitive endoscopic therapy via the HE was performed in 18 patients, with an average of 2.7 procedures performed for resolution of stones and/or downstream strictures. HE stents were removed in 17 patients after a mean of 91 days without adverse events. Three patients experienced mild adverse events (1 with postprocedural pancreatitis after placement of a 10F transpapillary stent, 1 with postprocedural abdominal pain, and 1 with postprocedural cholangitis) requiring hospitalization for fewer than 3 nights; no severe adverse events occurred. The average postprocedural hospital stay was 1.3 days. No deaths occurred during follow-up.

CONCLUSIONS

EUS-HE is safe and effective in the management of benign biliary obstruction in patients with surgically altered anatomy. It creates a portal to allow definitive, antegrade therapy and is a viable alternative to other endoscopic methods in this patient population.

Risk factors and outcomes of pyogenic liver abscess in adult liver recipients: a matched case-control study

BACKGROUND

Adult liver recipients (ALR) differ from the general population with pyogenic liver abscess (PLA) as they exhibit: reconstructed biliary anatomy, recurrent hospitalizations, poor clinical condition and are subjected to immunosuppression. The aim of this study was to identify risk factors associated with PLA in ALR and to analyze the management experience of these patients.

METHODS

Between 1996 and 2016, 879 adult patients underwent liver transplantation (LT), 26 of whom developed PLA. Patients and controls were matched according to the time from transplant to abscess in a 1 to 5 relation. A logistic regression model was performed to establish PLA risk factors considering clusters for matched cases and controls. Risk factors were identified and a multivariate regression analysis performed.

RESULTS

Patients with post-LT PLA were more likely to have lower BMI (p = 0.006), renal failure (p = 0.031) and to have undergone retransplantation (p = 0.002). A history of hepatic artery thrombosis (p = 0.010), the presence of Roux en-Y hepatojejunostomy (p < 0.001) and longer organ ischemia time (p = 0.009) were independent predictors for the development of post-LT PLA. Five-year survival was 49% (95%CI 28-67%) and 89% (95%CI 78%-94%) for post-LT PLA and no post-LT PLA, respectively (p < 0.001).

CONCLUSION

history of hepatic artery thrombosis, the presence of hepatojejunostomy and a longer ischemia time represent independent predictors for the development of post-LT PLA. There was a significantly poorer survival in patients who developed post-LT PLA compared with those who did not.

Antibiotic prophylaxis in transarterial chemoembolization of hepatocellular carcinoma

BACKGROUND AND STUDY AIMS

Transarterial chemoembolization remains a common treatment option in unresectable hepatocellular carcinoma. However, protocols for pre- and post-procedure care and the role of antibiotic prophylaxis have not been evaluated. The aim of this work was to compare 3 different groups of prophylactic antibiotics in patients undergoing chemoembolization and to compare the efficacy of intravenous versus oral route.

PATIENTS AND METHODS

180 hepatocellular carcinoma patients undergoing transarterial chemoembolization were selected. Patients were classified into 3 groups; Group 1: 60 patients; 30 received intravenous ceftriaxone, and 30 received oral cefixime. Group 2: 60 patients; 30 patients received intravenous levofloxacin and 30 received oral levofloxacin. Group 3: 60 patients; 30 received intravenous ciprofloxacin and 30 received oral ciprofloxacin. All antibiotics were given one day before intervention and for 4 days afterwards. Complete blood count, C-reactive protein, liver and renal function tests were assessed 1 and 5 days and then 1 month after the procedure.

RESULTS

The ciprofloxacin group gave better results than the other 2 groups regarding total and differential leucocytic count and C-reactive protein level. No significant difference was found between oral and intravenous routes among the 3 groups. None of the studied patients developed infections or liver abscess after chemoembolization.

CONCLUSION

Third generation cephalosporin, levofloxacin or ciprofloxacin all are effective as prophylaxis against post-chemoembolization infections. No significant difference between oral and intravenous administration among the 3 groups. Oral ciprofloxacin is an effective, safe and relatively inexpensive prophylaxis regimen.

Prevention and management of infectious complications of percutaneous interventions

Infectious complications following interventional radiology (IR) procedures can cause significant patient morbidity and, potentially, mortality. As the number and breadth of IR procedures grow, it becomes increasingly evident that interventional radiologists must possess a thorough understanding of these potential infectious complications. Furthermore, given the increasing incidence of antibiotic-resistant bacteria, emphasis on cost containment, and attention to quality of care, it is critical to have infection control strategies to maximize patient safety. This article reviews infectious complications associated with percutaneous ablation of liver tumors, transarterial embolization of liver tumors, uterine fibroid embolization, percutaneous nephrostomy, percutaneous biliary interventions, central venous catheters, and intravascular stents. Emphasis is placed on incidence, risk factors, prevention, and management. With the use of these strategies, IR procedures can be performed with reduced risk of infectious complications.

Relationship of Gallbladder Perforation and Bacteriobilia with Occurrence of Surgical Site Infections following Laparoscopic Cholecystectomy

Aim. To assess the occurrence of SSIs in patients with spillage of gallbladder contents and bacteriobilia during laparoscopic cholecystectomy. Methods. We evaluated 113 patients who underwent laparoscopic cholecystectomy between September 2013 and April 2015. The SSIs and their relationship with gallbladder rupture and bacteriobilia were assessed. Results. The mean age of patients developing SSIs was 45.57 ± 8.89 years. 18 patients (16%) had spillage of bile from the gallbladder. Percentage of SSIs overall was 6%, while percentage of SSIs in gallbladder content spillage was 5.5%. Organism profile of the culture from surgical site showed monomicrobial infection: 58% Staphylococcus aureus, 14% Pseudomonas, and 14% E. coli. The occurrence of SSIs in patients with bacteriobilia was 16% as compared to 2% in patients without bacteriobilia. Conclusions. Gallbladder content spillage is not a significant risk factor leading to increase in SSIs. The occurrence of SSIs is significantly higher in patients with bacteriobilia.

Clinical outcomes and prediction of survival following percutaneous biliary drainage for malignant obstructive jaundice

The present study aimed to investigate the clinical outcomes of percutaneous transhepatic biliary drainage in patients with obstructive jaundice and identify potential predictors of patient survival. Clinical data from 102 patients (66 males and 36 females; median age, 63.50 years; range, 29–84 years) with a mean (± standard deviation) pre-drainage serum bilirubin level of 285.4 (±136.7 μmol/l), were retrospectively studied. Technical and clinical success, complications and survival time were recorded and their relationship with clinical factors, including age, obstruction level, liver metastases, serum bilirubin level and subsequent treatments following drainage, were analyzed by Fisher’s exact test. Patient survival rate and other predictors were analyzed by Kaplan-Meier survival curves and Cox’s proportional hazard model. The technical and clinical success rates were 100 and 76.5%, respectively. The presence of liver metastases was associated with reduced successful drainage. The overall complication rate was 7.8% and the overall median survival time was 185 days [95% confidence interval (CI), 159–211 days]. A log-rank test showed that age (χ², 4.003; P=0.04), bilirubin levels following procedure (χ², 5.139; P=0.02) and subsequent therapy (χ², 15.459; P=0.00) affected survival time. However, Cox’s regression analysis revealed no administration of additional treatments to be a risk factor of survival (odds ratio, 2.323; 95% CI, 1.465–3.685; P=0.000). Percutaneous transhepatic biliary drainage for malignant biliary obstruction was found to be a safe and effective method to relieve jaundice caused by progressive neoplasms. Subsequent radical therapy following drainage, including surgery, chemotherapy and other local treatment types, are likely to increase patient survival.

Primary epiploic appendagitis and successful outpatient management

Background

Primary epiploic appendagitis (PEA) is a rare cause of abdominal acute or subacute complaints. Diagnosis of PEA is made with ultrasonography (US) or when computed tomography (CT) reveals a characteristic lesion.

Case Report

We report on two patients with PEA. In one patient PEA was first seen with US and confirmed with contrast enhanced CT, and in the second patient CT without contrast enhancement demonstrated PEA. In both patients an outpatient recovery with conservative non-surgical treatment is described.

Conclusions

Medical personnel should be aware of this rare disease, which mimics many other intra-abdominal acute and subacute conditions. A correct diagnosis of PEA with imaging procedures enables conservative and successful outpatient management avoiding unnecessary surgical intervention and additional costs.

Prophylactic antibiotic guidelines in modern interventional radiology practice

Modern interventional radiology practice is continuously evolving. Developments include increases in the number of central venous catheter placements and tumor treatments (uterine fibroid therapy, radio- and chemoembolization of liver tumor, percutaneous radiofrequency and cryoablation), and new procedures such as abdominal aortic aneurysm stent-graft repair, vertebroplasty, kyphoplasty, and varicose vein therapies. There have also been recent advancements in standard biliary and urinary drainage procedures, percutaneous gastrointestinal feeding tube placement, and transjugular intrahepatic portosystemic shunts. Prophylactic antibiotics have become the standard of care in many departments, with little clinical data to support its wide acceptance. The rise in antibiotic-resistant strains of organisms in all hospitals worldwide have forced every department to question the use of prophylactic antibiotics. The authors review the evidence behind use of prophylactic antibiotics in standard interventional radiology procedures, as well as in newer procedures that have only recently been incorporated into interventional radiology practice.

A guide to antibiotics for the interventional radiologist

Antibiotics are among the most common pharmaceutical agents used by the interventional radiologist. This article updates some of the practical aspects of the use of antibiotics in interventional radiological practice and provides some general guidelines with respect to indications for and selection of antibiotics. In particular, the objectives of this article are to review the basic pharmacology of the common antibiotic agents, the interventional radiological procedures in which prophylactic antibiotics are usually administered, the specific antimicrobial agents recommended for prophylaxis before common interventional radiological procedures, the appropriate antibiotics for patients allergic to penicillins, and the indications for antibiotic prophylaxis to prevent bacterial endocarditis.

Complications of percutaneous transhepatic biliary drainage in patients with dilated and nondilated intrahepatic bile ducts

Percutaneous transhepatic biliary drainage (PTBD) have been described as an effective technique to obtain biliary access. Between January 1996 and December 2006, a total of 419 consecutive patients with endoscopically inaccessible bile ducts underwent PTBD. The current retrospective study evaluated success and complication rates of this invasive technique. PTBD was successful in 410/419 patients (97%). The success rate was equal in patients with dilated and nondilated bile ducts (p=0.820). In 39/419 patients (9%) procedure related complications could be observed. Major complications occurred in 17/419 patients (4%). Patients with nondilated intrahepatic bile ducts had significantly higher complication rates compared to patients with dilated intrahepatic bile ducts (14.5% vs. 6.9%, respectively [p=0.022]). Procedure related deaths were observed in 3 patients (0.7%). In conclusion, percutaneous transhepatic biliary drainage is an effective procedure in patients with dilated and nondilated intrahepatic bile ducts. However, patients with nondilated intrahepatic bile ducts showed a higher risk for procedure related complications.

Role of ciprofloxacin in patients with cholestasis after endoscopic retrograde cholangiopancreatography

AIM: To determine the role of ciprofloxacin in reducing cholangitis in cholestatic patients with adequate biliary drainage after endoscopic retrograde cholangiopancreatography (ERCP).

METHODS: A randomized, controlled trial was performed in 48 cholestatic patients at Rajavithi Hospital (Tertiary Referral Center for ERCP: 600 cases per year). All the 48 patients received 200 mg ciprofloxacin intravenous injection for 30 min before starting any procedures, and then were randomly divided in two groups. Twenty-two patients in study group continually received ciprofloxacin until 48 h after ERCP. Causes of biliary obstruction, bacteriology of bile and blood (in cholangitis) and clinical cholangitis were recorded.

RESULTS: Forty-eight patients were enrolled and divided into continuous ciprofloxacin treatment group (n = 22) and discontinuous ciprofloxacin treatment group (n = 26). During ERCP, stones were found in 22 patients, malignant diseases in 24 patients and other pathologic lesions in 5 patients. One (4.5%) of the 22 patients who received ciprofloxacin and 2 (6.3%) of the 26 patients who discontinued ciprofloxacin after ERCP developed cholangitis (relative risk = 0.71; 95% CI = 0.14-3.65; p = 0.88). Bacterobilia was found in 27 (56.3%) out of 48 patients. E. coli and Streptococcus viridans were the most common organisms.

CONCLUSION: Continual use of ciprofloxacin in patients with cholestasis after adequate biliary drainage procedures plays no role in reducing cholangitis.

Antibiotic prophylaxis in interventional radiology

Despite several decades of advances in both minimally invasive techniques and antibiotic therapy, infection remains one of the more common complications of invasive procedures. Interventional radiology (IR) has traditionally been believed to be associated with lower infection rates than surgery. However, new interventional techniques, as well as more aggressive therapeutic interventions, have presented new challenges in relation to pharmacological management of postprocedural infection and pain. The risk of infection associated with IR procedures can never be completely eliminated, and the reasons for this are manifold, including more virulent organisms, ongoing and newly emerging antibiotic resistance, increased numbers of immunocompromised patients, and the adoption into everyday interventional practice of more aggressive interventional techniques such as chemoembolization, uterine fibroid embolization, and complex biliary intervention. Despite the widespread use of prophylactic antibiotics in IR, and the widely held belief that they are beneficial and are the standard of care, randomized controlled clinical trials have never validated the use of antibiotics in this setting. As such, an argument could be made not to use antibiotics at all for prophylaxis in IR. The purpose of this article is to discuss some of the issues relating to the use of prophylactic antibiotics, and what choice of antibiotics physicians make when they decide to use prophylaxis for IR procedures.

Hepatic abscess after liver transplantation: 1990-2000

BACKGROUND

Infections following solid-organ transplants are a major cause of morbidity and mortality. Few studies have reported the complications of hepatic abscesses.

METHODS

This investigation consisted of a retrospective chart review of all solid-organ transplant recipients from 1990 to 2000. Criteria for diagnosis included parenchymal hepatic lesions, positive cultures from liver aspirates or blood cultures, or both, and a compatible clinical presentation.

RESULTS

Of 2,175 recipients of all organ transplants (heart, lung, kidney, liver, pancreas), we identified 12 patients who had experienced 14 episodes of hepatic abscess, all in liver transplant recipients. Median time from transplant to hepatic abscess was 386 days (range 25-4,198). The most common predisposing factor was hepatic artery thrombosis (HAT), which occurred in eight patients, and was diagnosed at an average of 249 days (range 33-3,215) after transplantation. Clinical presentation of hepatic abscess was similar to that described in non-immunosuppressed patients. All but one patient showed hypoalbuminemia (<3.5 g/dL); those with HAT also had significantly elevated lactate dehydrogenase. Liver aspirates grew gram-positive aerobic bacteria (50% of isolates), gram-negative aerobic bacteria (30%), and anaerobes and yeasts (10% each). Patients received an average of 6 weeks of intravenous antibiotic therapy. Catheter drainage was successful in 70% of cases; and five patients required retransplantation. Altogether, five of the patients died, yielding a mortality rate of 42%.

CONCLUSIONS

Hepatic abscess, a rare complication after liver transplantation, was frequently associated with hepatic artery thrombosis. Mortality was higher than in patients who had not undergone transplantation. Prolonged antibiotic therapy, drainage, and even retransplantation may be required to improve the outcome in these patients.

Complications of percutaneous transhepatic biliary interventions

Complications of percutaneous transhepatic biliary drainage procedures range from skin discomfort to life-threatening arterial hemobilia. A thorough understanding of biliary anatomy and postprocedure care is essential if such procedures are to be performed. This article summarizes the anatomic, technical, and clinical issues related to biliary interventions and assists the interventional radiologist in the management of complications encountered in patients undergoing biliary interventions.

Clinical factors associated with positive bile cultures during primary percutaneous biliary drainage

PURPOSE

To evaluate the utility of routine bile cultures and to determine the risk factors for bacterial colonization of the bile as well as the biliary flora in patients with biliary obstruction undergoing primary percutaneous biliary drainage.

MATERIALS AND METHODS

Between October 1995 and January 1997, bile cultures were prospectively obtained in all patients undergoing percutaneous biliary drainage. Seventy-six patients underwent 86 procedures. Culture results were correlated with clinical, laboratory, and demographic variables. The antibiotic sensitivities of cultured organisms were examined.

RESULTS

Fever, previous endoscopic or percutaneous biliary instrumentation, and bilioenteric anastomosis were significant predictors of a positive bile culture. In the absence of any of these indicators, bile cultures were unlikely to be positive. Enterococcus species was the organism isolated most commonly. Yeast, gram-negative aerobic bacilli, and Streptococcus viridans followed in frequency.

CONCLUSION

Bile cultures provide valuable information that was useful for planning antibiotic prophylaxis and treatment. The likelihood of positive bile cultures can be predicted based on certain clinical variables. Continued investigation is needed to better predict bacterial flora in individual patients. Given the association between previous instrumentation and biliary colonization, noninvasive imaging modalities should be exhausted before invasive procedures are performed for solely diagnostic purposes in patients with biliary obstruction.

Investigation of antibiotic prophylaxis usage for vascular and nonvascular interventional procedures

PURPOSE

To investigate current antibiotic prophylactic usage for arteriography, angioplasty, vascular stent placement, transjugular intrahepatic portosystemic shunt placement (TIPS), tunneled-port placement, inferior vena cava (IVC) filter placement, biliary drainage, genitourinary drainage, abdominal drainage, and enteral tube placement with an aim to better clarify indications and regimens for prophylaxis.

METHODS

A questionnaire regarding antibiotic prophylactic usage was sent to 2,039 members of the Society of Cardiovascular and Interventional Radiology (SCVIR). There were 401 respondents. Replies were evaluated for frequency and indications of prophylaxis, specific prophylaxis used, and clarity of indications for prophylaxis.

RESULTS

A majority of responders never used prophylaxis for arteriography, angioplasty, vascular stent placement, IVC filter placement, abdominal drainage, and enteral tube placement. Infective complication rates from nonusage ranged between 1% and 15%. Approximately 45% always used prophylaxis for tunneled-port placement and TIPS with a 13%-16% infective complication rate among nonusers. In contrast, a majority of responders always used prophylaxis for biliary and genitourinary drainage, with a 40%-58% infective complication rate in nonusers. More than 70% of responders believed that the indications for prophylaxis were not clear for arteriography, angioplasty, vascular stent placement, tunneled-port placement, TIPS, IVC filter placement, and enteral tube placement, and in contrast, that the indications for prophylaxis for biliary and genitourinary drainage were clear. Fifty-one percent of responders believed that indications for prophylaxis for abdominal drainage were clear.

CONCLUSIONS

Indications for antibiotic prophylaxis are not clear to interventionalists for a large number of vascular and nonvascular interventional procedures. Prophylaxis appears unnecessary for routine arteriography, angioplasty, IVC filter placement, vascular stent placement, or enterostomy tube placement. Antibiotic prophylaxis is warranted for TIPS and tunneled-port placement. Conversely, indications for antibiotic prophylaxis are clear to interventionalists for biliary and genitourinary drainage procedures. Routine prophylaxis remains warranted for both.

Relevance and risk factors of enterococcal bacteremia following liver transplantation

To analyze the clinical characteristics of and identify specific risk factors for enterococcal bacteremia following liver transplantation, we performed a study in 405 consecutive liver transplantation recipients prophylaxed with a selective bowel decontamination regimen. Seventy enterococcal bacteremias in 52 patients were identified. Enterococcus faecalis (50) outnumbered Enterococcus faecium isolates (18), and 49% of enterococcal bacteremias were polymicrobial. Biliary tree complications were present in 34% of enterococcal bacteremias. Of the 15 deaths (29%) among the patients with enterococcal bacteremia, 4 were directly associated with enterococcal bacteremia. In a multivariate analysis, Roux-en-Y choledochojejunostomy (P=0.005), a cytomegalovirus-seropositive donor (P=0.013), prolonged transplantation time (P=0.02), and biliary stricturing (P=0.016) were identified as significant risk factors. Other risk factors identified in a univariate analysis included primary sclerosing cholangitis (P=0.009) and symptomatic cytomegalovirus infection (P=0.008). Enterococcal bacteremia is a frequent infectious complication in liver transplantation recipients receiving selective bowel decontamination. Its association with cytomegalovirus and biliary tree abnormalities suggest specific areas for prophylactic intervention.

Anaerobic culture yield in interventional radiologic drainage procedures

PURPOSE

This study was designed to determine the yield of anaerobic cultures from percutaneous radiologic drainage procedures.

PATIENTS AND METHODS

Anaerobic culture results in 317 patients from June 1992 to May 1994 were retrospectively examined. Anaerobic specimens were placed in specially designed anaerobic culture tubes and not blood culture media. Patients had undergone the following procedures: percutaneous nephrostomy (105 patients), biliary drainage (65 patients), and abdominal abscess drainage (147 patients). Aerobic culture results were tabulated in those patients with positive anaerobic cultures.

RESULTS

Overall, 10% of patients (n = 32) had positive anaerobic cultures (Bacteroides species, n = 25; Clostridium, n = 6; other organisms, n = 4). Anaerobes were isolated in 13% (n = 19) of abdominal abscess drainages, 8% (n = 8) of nephrostomy drainages, and 8% (n = 5) of biliary drainages. Aerobic isolates were present in 78% (n = 25) of patients with anaerobic infection.

CONCLUSION

The yield for anaerobic cultures varies for different types of percutaneous drainage procedures from 8% to 13%. When isolated, anaerobic bacteria are frequently mixed with aerobic bacteria. Anaerobic culture usage is recommended with abdominal abscess and biliary drainages. Anaerobic bacterial cultures are not recommended for percutaneous nephrostomy unless the patient has a urinary tract malignancy or has undergone urinary instrumentation.