Use of microbiological and patient data for choice of empirical antibiotic therapy in acute cholangitis

Shifting of Distribution and Changing of Antibiotic Resistance in Gram-Positive Bacteria from Bile of Patients with Acute Cholangitis

Background

Gram-negative bacteria are the predominant pathogens responsible for biliary infections; however, the prevalence of Gram-positive bacteria is currently increasing. Investigating the bacterial spectrum and evolving antibiotic resistance patterns of Gram-positive bacteria is crucial for optimizing the management of acute cholangitis, particularly in the context of the global rise in antibiotic resistance.

Methods

This retrospective analysis focused on Gram-positive bacteria isolated from the bile of patients undergoing biliary drainage with acute cholangitis at our hospital from January 1, 2018, to March 31, 2024. In total, 342 strains of Gram-positive bacteria were examined.

Results

The main Gram-positive bacteria detected included Enterococcus (57.23%), Staphylococcus (23.41%), and Streptococcus (13.01%). The most common species detected were Enterococcus faecium (36.42%), Enterococcus faecalis (14.16%), and Staphylococcus epidermidis (7.80%). Trend analysis revealed a decrease in the proportion of Enterococcus and an increase in Streptococcus. Additionally, the detection rate of methicillin-resistant Staphylococcus (MRS) showed a significant rise. Gram-positive bacteria exhibited high resistance to erythromycin and penicillin but remained highly susceptible to linezolid and vancomycin. Further, resistance to quinolones among Gram-positive bacteria was notably elevated.

Conclusion

The bacterial spectrum and antibiotic resistance patterns of Gram-positive bacteria in acute cholangitis have undergone significant changes. Penicillin is not recommended for the treatment of Gram-positive bacterial infections. Antibiotic resistance should be closely monitored when using quinolones. Particular attention is warranted regarding the markedly increasing antibiotic resistance of Enterococcus faecium.

Urgent Endoscopic Biliary Procedures: "Run Like the Wind"?

Emergency endoscopy is an activity that must be guaranteed 7 days a week and 24 h a day. The pathologies of endoscopic interest that require emergency intervention are mainly hemorrhages of the upper digestive tract, the removal of foreign bodies, and the ingestion of caustics. The emergency endoscopist must therefore be experienced in the management of these pathologies. Nowadays, however, we know that even some biliary tract pathologies must be managed within a variable period between 12 and 72 h, in particular acute cholangitis (Ach), acute biliary pancreatitis (ABP), biliary duct leaks (BDLs), and acute cholecystitis (AC). If, on one hand, there is little awareness among doctors about which pathologies of the biliary tract really deserve urgent treatment, on the other, the international guidelines, although not uniformly, have acquired the results of the studies and have clarified that only severe Ach should be treated within 12 h; in other cases, endoscopic treatment can be delayed up to 72 h according to the specific condition. This obviously has a significant organizational implication, as not all endoscopists have training in biliary tract endoscopy, and guaranteeing the availability of a biliary endoscopist 24/7 may be incompatible with respecting the working hours of individual professionals. This review aims to evaluate which pathologies of the biliary tract really require an endoscopic approach in emergency or urgency and the organizational consequences that this can determine. Based on the guidelines, we can conclude that a daytime availability for urgent biliary tract procedures 7 days a week should be provided for the management of severe ACh. Patients with ABP, AC unfit for surgery, and not responsive to medical therapy or BDLs can be treated over a longer period, allowing its scheduling on the first available day of the week.

A worrisome prevalence of extended-spectrum β-lactamase producers in patients with biliary obstruction and cholangitis: Phenotypic and molecular characterization of biliary Escherichia coli and Klebsiella pneumoniae isolates

BACKGROUND & AIMS

The alarming rise of antibiotic resistance presents a substantial and worrisome issue within the context of biliary obstruction, specifically in the treatment of cholangitis. This abovementioned scenario underscores the critical importance of addressing extended spectrum β-lactamase (ESBL) producers in the biliary system to adequately tackle cholangitis using third-generation cephalosporins. Hence, we aimed to determine the frequency of ESBL and carbapenemases among biliary Escherichia coli and Klebsiella pneumoniae isolated from patients with biliary obstruction.

METHODS

In this cross-sectional study, bile samples were collected via aspiration from patients diagnosed with biliary obstruction during the endoscopic retrograde cholangiopancreatography (ERCP) procedure. Subsequent culturing of these samples was performed, followed by phenotypic and molecular assessments for the detection of ESBL- and carbapenemase-producing strains of E. coli and K. pneumoniae.

RESULTS

Approximately 23.5 % of patients with biliary obstruction harbored biliary ESBL-producers, with the majority (70.2 %) being diagnosed with cholangitis. Moreover, 2.1 % of patients had biliary carbapenemase-producing K. pneumoniae strains. Molecular analysis confirmed the high prevalence of blaCTX-M and blaTEM in E. coli, and blaTEM and blaSHV in K. pneumoniae. Additionally, the presence of biliary K. pneumoniae harboring blaKPC, blaNDM, and blaIMP was observed.

CONCLUSION

Our study reveals a noteworthy observation that over half of patients experiencing biliary obstruction harbor ESBL-producing bacteria in their biliary tract. Notably, we discovered a significant link between ESBL producers and the risk of cholangitis. These findings raise important concerns regarding the suitability of employing third-generation cephalosporins as initial treatment for cholangitis and other similar biliary infections.

Clinical and biochemical factors for bacteria in bile among patients with acute cholangitis

BACKGROUND

Acute cholangitis is a clinical syndrome caused by a bacterial infection in the biliary system. The bacteria could exist in the bile before bile drainage despite empirical antibiotic treatment.

METHODS

Patients with acute cholangitis admitted to a tertiary hospital in Southeastern China from August 2011 to September 2021 were involved when bile cultures were performed. Patient information before bile cultures and during hospitalization was extracted from the clinical record database. The risk factors related to bacteria in bile were assessed by univariable and multivairable logistic regression analysis, respectively.

RESULTS

A total of 533 patients (66.05%) had bacterial growth in bile. Alanine aminotransferase concentration [odds ratio (OR) = 0.998, P < 0.001], absolute monocyte count (OR = 0.335, P = 0.001), and duration of antibiotic use (OR = 0.933, P = 0.026) were negatively correlated with bacteria in bile. In contrast, C-reactive protein (OR = 1.006, P = 0.003), thrombin time (OR = 1.213, P = 0.033), prothrombin time (OR = 1.210, P = 0.011), and age (OR = 1.025, P < 0.001) were positively correlated with bacteria in bile. Based on an area under the receiver operating characteristic curve of 0.737 (95% CI, 0.697-0.776, P < 0.001), combining these seven variables could efficiently predict the presence of bacteria in bile among patients with acute cholangitis.

CONCLUSION

The combination of clinical indicators before bile drainage could predict the risk of bacteria in bile for patients with acute cholangitis.

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.

Acute cholangitis: a state-of-the-art review

Acute cholangitis is a potentially life-threatening bacterial infection of the intra and/or extrahepatic bile ducts. It remains the second and third cause of community-acquired and hospital-acquired bacteremia, respectively, and is associated with mortality rates of up to 15%, despite advances in broad-spectrum antimicrobial therapy and improved access to emergency biliary tract decompression procedures. Even though not much has changed in recent years in terms of diagnosis or treatment, new data have emerged regarding multidrug-resistant bacteria that serve as etiologic agents of cholangitis. Moreover, different approaches in antibiotic regimes depending on severity grading and bile sample cultures as well as novel minimally invasive endoscopic procedures that can help when consecrated treatments such as endoscopic retrograde cholangiopancreatography (ERCP) fail, cannot be performed, or are unavailable have been proposed. This state-of-the-art review aims to offer a complete and updated assessment of the epidemiology, novel diagnostic and therapeutic methods, complications, and prognostic variables of acute cholangitis. The authors will review the prognostic implications of unusual complications, the relevance of regular bile samples and antibiograms, and their new role in guiding antibiotic therapy and limiting antibiotic resistance to present an organized and comprehensive approach to the care of acute cholangitis.

Guidelines for Antibiotics Prescription in Critically Ill Patients

How to cite this article: Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, et al. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024;28(S2):S104-S216.

Bile Culture May Guide Antibiotic Stewardship in Acute Bacterial Cholangitis

BACKGROUND

Bile cultures are often sent with blood cultures in patients with acute bacterial cholangitis.

AIMS

To assess the yield of blood and bile cultures in patients with cholangitis and the clinical utility of bile cultures in guiding therapy.

METHODS

All patients diagnosed with cholangitis, based on the Tokyo 2013/2018 guidelines were recruited retrospectively over ten years. The clinical and investigation details were recorded. The results of bile and blood cultures including antibiotic sensitivity patterns were noted. The concordance of microorganisms grown in blood and bile cultures and their sensitivity pattern were assessed.

RESULTS

A total of 1063 patients with cholangitis were included. Their mean age was 52.7 ± 14 years and 65.4% were males. Blood cultures were positive in 372 (35%) patients. Bile culture was performed in 384 patients with 84.4% being positive, which was significantly higher than the yield of blood culture (p < 0.001). Polymicrobial growth was more in bile (59.3%) than in blood cultures (13.5%, p < 0.001). E.coli, Klebsiella, Enterococcus and Pseudomonas were the four most common organisms isolated from both blood and bile. Extended spectrum betalactamase producing organisms were isolated in 57.7% and 58.8% of positive blood and bile cultures, respectively. Among 127 patients with both blood and bile cultures positive, complete or partial concordance of organisms was noted in about 90%.

CONCLUSION

Bile and blood cultures have a similar microbial profile in most patients with cholangitis. As bile cultures have a significantly higher yield than blood cultures, they could effectively guide antimicrobial therapy, especially in those with negative blood cultures.

Risk factors for cefmetazole-non-susceptible bacteremia in acute cholangitis

INTRODUCTION

Cefmetazole (CMZ), an antibiotic with limited international distribution, is recommended by the Tokyo Guidelines 2018 (TG18) for non-severe cases of acute cholangitis (AC). However, the risk factors for CMZ-non-susceptible (CMZ-NS) bacteremia in AC remain unclear. Here, we aimed to investigate the risk factors for CMZ-NS bacteremia and evaluate mortality in patients with AC.

METHODS

This single-center, retrospective, observational study included all patients diagnosed with definite bacteremic AC, based on TG18, from April 2019 to March 2023. Risk factors for CMZ-NS bacteremia were analyzed by univariate, and age- and sex-adjusted, logistic regression analyses. Mortality was compared by cause of obstruction, CMZ-susceptible/CMZ-NS bacteremia, and initial treatment.

RESULTS

In total, 165 patients were enrolled. CMZ-NS bacteremia was diagnosed in 46 (27.9 %) patients. Histories of diabetes mellitus, hepato-biliary-pancreatic cancer, malignant biliary obstruction, and endoscopic sphincterotomy were identified as significant factors associated with the risk of CMZ-NS bacteremia. Thirteen patients died within 30 days of hospital admission. The mortality of patients with AC and malignant biliary obstruction was statistically higher than that of patients with bile duct stones. No patients with AC and bile duct stones died in the group with CMZ-NS bacteremia and inappropriate initial antibiotics.

CONCLUSIONS

In AC, a history of diabetes mellitus, hepato-biliary-pancreatic cancer, malignant biliary obstruction, and endoscopic sphincterotomy are associated with an increased risk of CMZ-NS bacteremia. Therefore, the choice of empiric therapy for AC should be based on the etiology and patient background, rather than on the severity.

Extended-Spectrum Beta-Lactamase Escherichia coli-Associated Acute Cholangitis: Uncommon Patient Characteristics and Clinical Implications

Acute cholangitis is a potentially life-threatening condition caused by an infection of the biliary tract resulting from biliary obstruction. This case report highlights an unusual presentation of acute cholangitis in an elderly patient characterized by the presence of extended-spectrum beta-lactamase-producing Escherichia coli. We aim to emphasize the significance of recognizing diverse clinical manifestations in the elderly population to enhance timely diagnosis and appropriate management. The case highlights the importance of better understanding patient risk factors for potential causative organisms and their susceptibility to selecting proper antibiotics and improving clinical outcomes.

Comparative Analysis of Microbial Species and Multidrug Resistance Patterns in Acute Cholangitis Patients with Cholecystectomy: A Single-Center Study

This study aimed to compare microbial species and multidrug resistance patterns in acute cholangitis patients with and without a history of cholecystectomy, highlighting potential differences We hypothesized that post-cholecystectomy patients would exhibit distinct microbial spectra and resistance patterns. Conducted at a western Romanian hospital specializing in gastroenterology and hepatobiliary diseases from 2020 to 2023, this retrospective study included 488 acute cholangitis patients, divided into groups based on their cholecystectomy history. Bile and blood samples were analyzed for microbial identification and antibiotic susceptibility using VITEK®2. Positive biliary cultures were found in 66% of patients. The cholecystectomy group showed a higher prevalence of multidrug-resistant organisms, with 74.4% exhibiting resistance compared to 31.5% in the non-cholecystectomy group (p < 0.001). Notable microbial differences included higher occurrences of Escherichia coli (40.2%) and Enterococcus spp. (32.4%) in the cholecystectomy group. Resistance to Piperacillin/Tazobactam and Penems was significantly higher in this group, with odds ratios of 3.25 (p < 0.001) and 2.80 (p = 0.001), respectively, for the development of multidrug-resistant (MDR) bacterial species. The study confirmed our hypothesis, revealing distinct microbial profiles and a higher prevalence of multidrug resistance in acute cholangitis post-cholecystectomy patients. These findings underscore the need for tailored antibiotic strategies in managing acute cholangitis in this patient demographic.

The Predictive Value of Different Laboratory Indicators Based on the 2018 Tokyo Guidelines for the Severity of Acute Cholangitis

BACKGROUND

This study evaluated the predictive value of different laboratory indicators for the severity of acute cholangitis (AC) according to the 2018 Tokyo Guidelines.

OBJECTIVES

We enrolled consecutive patients with a diagnosis of AC from June 2016 to May 2021. Serum procalcitonin (PCT) and C-reactive protein (CRP) levels, white blood cell counts, the neutrophil-lymphocyte ratio, and the platelet-lymphocyte ratio (PLR) were compared according to the severity of AC.

RESULTS

In total, 293 patients were enrolled in this study (mild, n = 172; moderate, n = 68; severe, n = 53). In receiver operating characteristic analyses, CRP was the best biomarker for differentiating mild and moderate AC (area under the curve [AUC] 0.66, 95% confidence interval [CI] 0.58-0.74). PCT was the best biomarker for differentiating mild and severe AC (AUC 0.80, 95% CI 0.74-0.86). Blood culture was performed in 117 patients (39.93%), 53 of whom (45.30%) had positive results. Regarding blood culture positivity, PLR was most predictive (AUC 0.85, 95% CI 0.78-0.92).

CONCLUSIONS

PCT can be used as a reliable predictor of severe AC. CRP was most predictive of moderate AC, whereas PLR was most predictive of blood culture positivity.

Clinico-epidemiological characteristics of the biliary samples and their antibiotic susceptibility pattern at a teaching hospital in Northern India

Introduction

Bile is deemed a sterile fluid, with the presence of clinical conditions like cholelithiasis, cholecystitis, previous biliary interventions, biliary strictures, and so on, leading to bile stasis, and increases the chances of bacteriobilia. In this study, we recognize the bacterial spectrum of microorganisms isolated from bile samples, diagnostic parameters, and antibiotic sensitivity patterns.

Methods

A retrospective observational study was carried out by compiling data from the hospital information system of a tertiary care center from 2021 to 2022 to evaluate biliary infections in patients who underwent surgical procedures related to the biliary tract and associated organs.

Results

A total of 234 patients' bile samples were included in our study. The mean age of patients was 48.04 ± 14.74 years, with more patients below the age of 65 years among those with infected bile samples. One hundred and sixty-three (163/234, 69.66%) patients infected by 209 pathogenic microorganisms were recognized. The most common microorganism isolated was Escherichia coli (83/209, 39.71%), followed by Pseudomonas aeruginosa (37/209, 17.7%). Acinetobacter baumannii and Klebsiella pneumoniae isolate owed to more than 90% penicillin, extended-spectrum beta-lactamase, carbapenem, and fluoroquinolone resistance among all isolates. Length of hospital stay, malignant obstruction, and chronic kidney disease were identified as statistically significant risk factors that lead to the isolation of multi-drug-resistant isolates from bile culture.

Conclusion

We recognized the spectrum of pathogens causing biliary tract infections at our center along with the antibiotic resistance pattern to guide and facilitate prompt and appropriate treatment by primary health care professionals and family medicine practitioners.

The gut microbiota: A new perspective for tertiary prevention of hepatobiliary and gallbladder diseases

The gut microbiota is a complex ecosystem that has coevolved with the human body for hundreds of millions of years. In the past 30 years, with the progress of gene sequencing and omics technology, the research related to gut microbiota has developed rapidly especially in the field of digestive system diseases and systemic metabolic diseases. Mechanical, biological, immune, and other factors make the intestinal flora form a close bidirectional connection with the liver and gallbladder, which can be called the "gut-liver-biliary axis." Liver and gallbladder, as internal organs of the peritoneum, suffer from insidious onset, which are not easy to detect. The diagnosis is often made through laboratory chemical tests and imaging methods, and intervention measures are usually taken only when organic lesions have occurred. At this time, some people may have entered the irreversible stage of disease development. We reviewed the literature describing the role of intestinal flora in the pathogenesis and biotherapy of hepatobiliary diseases in the past 3-5 years, including the dynamic changes of intestinal flora at different stages of the disease, as well as the signaling pathways involved in intestinal flora and its metabolites, etc. After summarizing the above contents, we hope to highlight the potential of intestinal flora as a new clinical target for early prevention, early diagnosis, timely treatment and prognosis of hepatobiliary diseases. GRAPHICAL ABSTRACT.

Multifactorial Analysis of Biliary Infection in Patients with Hepato-pancreatico-biliary and Associated Intraabdominal Malignancies Admitted to a Teaching Hospital in Northern India

Background

Blockage of the biliary tract is commonly caused by malignant tumors leading to deranged liver function, responsible for poor prognosis and a high rate of bacteriobilia leading to mortality.

Material and methods

We collected retrospective data from the hospital information system and laboratory registers in our department from 2021 to 2022 to evaluate biliary infections in patients with hepato-pancreatico-biliary and associated intraabdominal malignancies.

Result

A total of 118 (118/234, 50.43%) patients' bile samples were estimated in this study. Patients' average age was 53.02 ± 13.49 years, with more patients below the age of 65 years among those with infected bile samples. Eight patients were infected by 102 pathogenic microorganisms. The most common pathogenic microorganism responsible for biliary infection in patients with abdominal malignancies was Escherichia coli (38/102, 37.25%) followed by Klebsiella pneumoniae (21/102, 20.59%) and Enterococcus spp. (18/102, 17.65%). Underlying comorbidities like diabetes mellitus, hypothyroidism, hypoproteinemia, chronic liver disease, immunosuppression, chronic kidney disease, increased hospital stay, admission to the intensive care unit (ICU), and presence of percutaneous transhepatic biliary drain were statistically significant risk factors for isolation of multidrug-resistant pathogenic bacteria.

Conclusion

Our study guided physicians in identifying the associated demographic characteristics, risk factors, and the spectrum of pathogens responsible for bacteriobilia in abdominal cancer patients along with the antibiotic resistance pattern among these isolates and better selection of antibiotics and antibiotic prophylaxis for patients at risk of developing biliary tract infections with multidrug-resistant pathogens.

How to cite this article

Kar M, Dubey A, Patel SS, et al. Multifactorial Analysis of Biliary Infection in Patients with Hepato-pancreatico-biliary and Associated Intraabdominal Malignancies Admitted to a Teaching Hospital in Northern India. Euroasian J Hepato-Gastroenterol 2023;13(1):10-17.

Antimicrobial Resistance Profile of Bacteria Causing Pediatric Infections at the University Teaching Hospital in Rwanda

Bacterial infections pose a global threat, especially in the pediatric population. Antimicrobials that are used to treat such infections continuously show reduced efficacy, and empirical therapy is a major treatment option in Rwanda. This study aimed to determine the resistance rate of commonly used antibiotics in pediatric patients. The study was conducted from June 1, 2018 to May 30, 2019, and microbiological samples were collected from 712 children with suspected bacterial infections. Antimicrobial sensitivity testing was performed on 177 positive cultures (24%) that were considered for data analysis. The findings show that the major bacterial isolates were Klebsiella pneumoniae (n = 50, 28.2%), Escherichia coli (n = 47, 26.5%), and Staphylococcus aureus (n = 38, 21.4%). In general, the greatest antibiotic resistance rate was observed in ampicillin (n = 125, 86.2%), amoxicillin-clavulanic acid (n = 84, 82.4%), amoxicillin (n = 64, 79%), cefadroxil (n = 83, 69.2%), tetracycline (n = 72, 59.7%), ceftazidime (n = 42, 55.3%), and cefuroxime (n = 14, 53.8%). More specifically, Klebsiella pneumoniae was 100% resistant to amoxicillin-clavulanic acid, cefuroxime, trimethoprim-sulfamethoxazole, ceftazidime, erythromycin, and clindamycin. Staphylococcus aureus was 86.7% resistant to ampicillin, and Escherichia coli was 91.7% resistant to tetracycline, 90.6% resistant to ampicillin, 83.3% resistant to amoxicillin-clavulanic acid, 79.3% resistant to cefadroxil, and 78.6% resistant to ceftazidime. Moreover, Klebsiella pneumoniae from blood and urine was 96.8% and 100% sensitive, respectively, to meropenem. Staphylococcus aureus from blood was 100% sensitive to vancomycin, whereas Escherichia coli from urine was sensitive to clindamycin (100%), nitrofurantoin (80.6%), and ciprofloxacin (72.7%). In conclusion, our findings show a high resistance rate to commonly used antibiotics, which suggests precaution in empirical therapy and continued surveillance of antimicrobial resistance.

Broad vs Narrow Spectrum Antibiotics in Common Bile Duct Stones: A Post Hoc Analysis of an Eastern Association for the Surgery of Trauma Multicenter Study

BACKGROUND

Antimicrobial guidance for common bile duct stones during the perioperative period is limited. We sought to examine the effect of broad-spectrum (BS) vs narrow-spectrum (NS) antibiotics on surgical site infections (SSIs) in patients with common bile duct stones undergoing same-admission cholecystectomy.

STUDY DESIGN

We performed a post hoc analysis of a prospective, observational, multicenter study of patients undergoing same-admission cholecystectomy for choledocholithiasis and/or acute biliary pancreatitis between 2016 and 2019. We excluded patients with cholangitis, perforated cholecystitis, and nonbiliary infections on admission. Patients were divided based on receipt of BS or NS antibiotics. Our primary outcome was the incidence of SSIs, and secondary outcomes included hospital length of stay, acute kidney injury (AKI), and 30-day readmission for SSI.

RESULTS

The cohort had 891 patients: 51.7% (n= 461) received BS antibiotics and 48.3% (n = 430) received NS antibiotics. Overall antibiotic duration was longer in the BS group than in the NS group (6 vs 4 d, p = 0.01); however, there was no difference in rates of SSI (0.9% vs 0.5%, p = 0.7) or 30-day readmission for SSI (1.1% vs 1.2%, p = 1.0). Hospital length of stay was significantly longer in the BS group (p < 0.001) as were rates of AKI (5% vs 1.4%, p = 0.001). On multivariable regression, BS antibiotic use was a risk factor for AKI (adjusted odds ratio 2.8, 95% CI 1.16 to 7.82, p = 0.02).

CONCLUSION

The incidence of SSI and 30-day readmission for SSI was similar between antibiotic groups. However, BS antibiotic use was associated with a longer hospitalization and greater likelihood of AKI.

A Retrospective Study on Bile Culture and Antibiotic Susceptibility Patterns of Patients with Biliary Tract Infections

Aim

This study aimed to provide profiles of microorganisms isolated from bile and antibiotic susceptibility patterns of biliary tract infections (BTIs) in our center.

Methods

A total of 277 patients diagnosed with BTIs at the Second Affiliated Hospital of Harbin Medical University from 2011 to 2018 were included in this study. Medical records were reviewed to obtain clinical and demographic data. Bile specimens were prepared through endoscopic retrograde cholangiopancreatography (ERCP), percutaneous transhepatic cholangiodrainage (PTCD), and percutaneous transhepatic gallbladder drainage (PTGD) under aseptic conditions. In those with positive bile culture results, blood cultures were concurrently conducted. The concordance of the results between bile culture and blood culture were also analysed.

Results

Two hundred and sixty-seven bile cultures were positive, while 280 strains of micro-organisms were isolated. Among these, 76.8% were Gram-negative, 22.5% were Gram-positive and 0.7% were fungi. The most common microorganisms were Escherichia coli, Klebsiella pneumoniae, and Enterococcus faecalis. Gram-negative bacteria we tested were highly sensitive to ertapenem, imipenem, tigecycline, and amikacin. Gram-positive bacteria we tested were highly sensitive to tigecycline, teicoplanin, linezolid, vancomycin, and chloramphenicol. For the 44 patients with positive bile cultures, a blood culture was also performed. Among them, 29 cases yielded positive blood culture results. Among those cases with positive blood culture, 48.3% showed complete agreement with bile culture, 3.4% showed partial agreement, and 48.3% showed disagreement. The most common microorganisms in blood culture were the same as in bile culture. Additionally, the proportion of Staphylococcus epidermidis was significantly higher in blood culture (P < 0.05).

Conclusion

Our study provided a comprehensive analysis of the bacteria distribution and drug resistance profiles in patients with BTIs in northern China. Further studies should be conducted to validate our findings.

ROLE OF CHANGE IN THE LEVELS OF INFLAMMATORY MARKERS POST DRAINAGE IN PREDICTING OUTCOME IN ACUTE CHOLANGITIS

BACKGROUND

Acute cholangitis (AC) is a gastro-intestinal emergency associated with significant mortality. Role of change in the levels of inflammatory markers post drainage in predicting outcome in acute cholangitis is uncertain.

OBJECTIVE

To evaluate the predictive value of changes in C-reactive protein (CRP) and procalcitonin levels after biliary drainage in relation to outcomes (survival or mortality) at 1 month.

METHODS

A prospective observational study of consecutive adults presenting with AC was performed. At admission and at 48 hours post biliary drainage, procalcitonin and CRP were sent.

RESULTS

Between August 2020 till December 2020 we recruited 72 consecutive patients of AC. The median age of the patients was 55 years (range 43-62 years) and 42 (58.33%) were females. Although the delta change in serum procalcitonin (P value<0.001) and CRP (P value<0.001) was significant, it had no bearing on the outcome. Altered sensorium and INR were independently associated with mortality at 1 month. The 30-day mortality prediction of day 0 procalcitonin was measured by receiver operating characteristic analysis which resulted in an area under the curve of 0.697 with a 95% confidence interval (95%CI) of 0.545-0.849. The optimal cut-off of procalcitonin would be 0.57ng/mL with a sensitivity and specificity of 80% and 60% respectively to predict mortality.

CONCLUSION

Change in serum procalcitonin and CRP levels at 48 hours post drainage although significant, had no impact on the outcome of acute cholangitis.

Clinical characteristics of Gram-negative and Gram-positive bacterial infection in acute cholangitis: a retrospective observational study

Background

To investigate the difference in the severity of illness, organ dysfunction, and prognosis of acute cholangitis due to different pathogenic bacterial infection types.

Methods

A retrospective observational study was performed. Patients who met the selection criteria according to blood culture and bile culture results of different pathogenic bacterial were divided into groups. The severity of illness, organ dysfunction, and prognosis of the groups were analyzed and compared comprehensively.

Results

A total of 424 patients were included, and no bacterial growth developed in 111 patients (26.2%). Among the 313 patients (73.8%) with bacterial growth, 155 patients had only Gram-negative bacteria cultured (49.5%), 48 patients had only Gram-positive bacteria cultured (15.3%), and 110 patients had both Gram-negative and Gram-positive bacteria cultured (35.1%). The proportion of Grade III patients and the APACHE II and SOFA scores of the mixed Gram-negative and positive group were the highest (p < 0.05); the intensive care unit admission day and hospital stay were longer, and the mortality rate were also higher 20/110 (18.2%) than the other two groups. Regression analysis showed that bacterial growth was an independent risk factor for organ dysfunction. The risks of an increased septic shock, neurological dysfunction, hepatic dysfunction, hematological dysfunction, and respiratory dysfunction in the mixed Gram-negative and positive group were higher than the Gram-negative group (P < 0.05). The Cox proportional hazards regression prompt showed that different culture results were independent risk factors for death. The mixed Gram-negative and positive group had increased hazard ratios and 95% CI of 7.30 (95% CI 1.55 to 34.38) compared with the Gram-negative group. There was no difference between the Gram-negative group and the Gram-positive group in the severity of illness, organ dysfunction, intensive care unit admission day, hospital stay, mortality rate, and risk of death (P > 0.05).

Conclusions

In acute cholangitis, mixed infection with Gram-negative and Gram-positive bacteria was more severe and was associated with a higher risk of death. There were no apparent differences between Gram-negative and Gram-positive bacterial infections.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06964-1.

[Bacterial hepatobiliary infections : Pathogen spectrum, antimicrobial resistance and current treatment concepts]

Ascending cholangitis and pyogenic liver abscesses are acute febrile bacterial hepatobiliary diseases. Nowadays they frequently occur in patients with structural changes of the biliary system and are usually treated by a combination of interventional drainage procedures and antimicrobial therapy. While Gram-negative Enterobacterales were identified as major causes in the past, biliary tract interventions and antibiotic exposure have contributed to an increase in enterococcal species and extended spectrum beta-lactamase (ESBL)-producing Enterobacterales. When selecting an appropriate empirical treatment the treating internist must consider local and individual risk factors for antimicrobial resistance in addition to pharmacokinetic aspects and disease severity to reduce the likelihood of treatment failure.

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.

Biliary infection; distribution of species and antibiogram study

Background

Biliary infections like cholecystitis and cholangitis are common and could be life threatening if treated inappropriate. Prescribing antibiotics is the key to control such infections. Occurrence of bacterial resistance to antibiotics is highly probable and should be continuously monitored. This study aimed to re-evaluate bacterial species distribution and their interaction to antibiotics in biliary infections.

Method

Total 2288 patients who were diagnosed as whether acute or chronic cholecystitis with/without concurrent cholangitis enrolled in this cohort study. All were candidate for cholecystectomy operation. In the theatre a sterile bile sample was aspirated from the gallbladder as early as the organ was exposed. Analysis was performed on culture and antibiogram results.

Results

Finally 492 (21.5%) microorganism growth was seen in all culture environments. Bacterial colonization was most common in cholangitis (63.8%) which followed by acute (26%) and chronic (10.9%) cholecystitis respectively (p = 0.001). Escherichia coli (58%) and Klebsiella species (12.2%) were mostly isolated pathogens. Antibiogram study illustrated bacterial sensitivity of gram-negative pathogens to imipenem (100%), amikacin (98.1%), and gentamicin (90.4%) which in gram-positive bacterial species was 100% to imipenem, vancomycin, rifampcin, and clindamycin.

Conclusion

Cephalosporins as an empirical treatment for biliary infections is not suitable. Aminoglycosides including amikacin and gentamycin are costly beneficial as the first line for empirical antibiotic therapy in selected patients because of their good bacterial sensitivity and low expenses. Imipenem should remain for multidrug resistance species.

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Distribution of bacterial species in biliary infection has not obviously changed in recent decades.

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Relative resistance of biliary germ to current advised antibiotic is flashed.

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Aminoglycoside more widely covers biliary germ than cephalosporin does in selected patient.

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Revision of current antibiotic guide for biliary infection to prevent antibiotic resistance is needed.

Acute Cholangitis: Causes, Diagnosis, and Management

Acute cholangitis, also referred to as ascending cholangitis, is an infection of the biliary tree characterized by fever, jaundice, and abdominal pain, which in most cases is the consequence of biliary obstruction. Diagnosis is commonly made by the presence of clinical features, laboratory tests, and imaging studies. The treatment modalities include administration of intravenous fluids, antimicrobial therapy, and prompt drainage of the bile duct. Early diagnosis and treatment of acute cholangitis are crucial to prevent unwanted clinical outcome of the disease. This article provides an update on early diagnosis and management of acute cholangitis.

The prevalence of the iutA and ibeA genes in Escherichia coli isolates from severe and non-severe patients with bacteremic acute biliary tract infection is significantly different

Background

Although Escherichia coli is the most frequently isolated microorganism in acute biliary tract infections with bacteremia, data regarding its virulence are limited.

Results

Information on cases of bacteremia in acute biliary tract infection in a retrospective study was collected from 2013 to 2015 at a tertiary care hospital in Japan. Factors related to the severity of infection were investigated, including patient background, phylogenetic typing, and virulence factors of E. coli, such as adhesion, invasion, toxins, and iron acquisition.

In total, 72 E. coli strains were identified in 71 cases, most of which primarily belonged to the B2 phylogroup (68.1%). The presence of the iutA gene (77.3% in the non-severe group, 46.4% in the severe group, P = 0.011) and the ibeA gene (9.1% in the non-severe group, and 35.7% in the severe group, P = 0.012) was significantly associated with the severity of infection. Among the patient characteristics, diabetes mellitus with organ involvement and alkaline phosphatase were different in the severe and non-severe groups.

Conclusions

We showed that bacteremic E. coli strains from acute biliary tract infections belonged to the virulent (B2) phylogroup. The prevalence of the iutA and ibeA genes between the two groups of bacteremia severity was significantly different.

Fibrocystic liver disease: novel concepts and translational perspectives

Fibrocystic liver diseases (FLDs) comprise a heterogeneous group of rare diseases of the biliary tree, having in common an abnormal development of the embryonic ductal plate caused by genetically-determined dysfunctions of proteins expressed in the primary cilia of cholangiocytes (and therefore grouped among the "ciliopathies"). The ductal dysgenesis may affect the biliary system at multiple levels, from the small intrahepatic bile ducts [congenital hepatic fibrosis (CHF)], to the larger intrahepatic bile ducts [Caroli disease (CD), or Caroli syndrome (CS), when CD coexists with CHF], leading to biliary microhamartomas and segmental bile duct dilations. Biliary changes are accompanied by progressive deposition of abundant peribiliary fibrosis. Peribiliary fibrosis and biliary cysts are the fundamental lesions of FLDs and are responsible for the main clinical manifestations, such as portal hypertension, recurrent cholangitis, cholestasis, sepsis and eventually cholangiocarcinoma. Furthermore, FLDs often associate with a spectrum of disorders affecting primarily the kidney. Among them, the autosomal recessive polycystic kidney disease (ARPKD) is the most frequent, and the renal function impairment is central in disease progression. CHF, CD/CS, and ARPKD are caused by a number of mutations in polycystic kidney hepatic disease 1 (PKHD1), a gene that encodes for fibrocystin/polyductin, a protein of unclear function, but supposedly involved in planar cell polarity and other fundamental cell functions. Targeted medical therapy is not available yet and thus the current treatment aims at controlling the complications. Interventional radiology or surgical treatments, including liver transplantation, are used in selected cases.

Bacterial bile duct colonization in perihilar cholangiocarcinoma and its clinical significance

Abdominal infections including cholangitis represent a major problem in patients with perihilar cholangiocarcinoma (pCCA). Thus, we investigated bacterial colonization of the bile ducts and determined its impact on postoperative outcome focusing on abdominal infections. A cohort of 95 pCCA patients who underwent surgery between 2010 and 2019 with available intraoperative microbial bile cultures were analyzed regarding bile duct colonization and postoperative abdominal infection by group comparisons and logistic regressions. 84.2% (80/95) showed bacterial colonization of the bile ducts and 54.7% (52/95) developed postoperative abdominal infections. Enterococcus faecalis (38.8%, 31/80), Enterococcus faecium (32.5%, 26/80), Enterobacter cloacae (16.3%, 13/80) and Escherichia coli (11.3%, 9/80) were the most common bacteria colonizing the bile ducts and Enterococcus faecium (71.2%, 37/52), Enterococcus faecalis (30.8%, 16/52), Enterobacter cloacae (25.0%, 13/52) and Escherichia coli (19.2%, 10/52) the most common causes of postoperative abdominal infection. Further, reduced susceptibility to perioperative antibiotic prophylaxis (OR = 10.10, p = .007) was identified as independent predictor of postoperative abdominal infection. Bacterial colonization is common in pCCA patients and reduced susceptibility of the bacteria to the intraoperative antibiotic prophylaxis is an independent predictor of postoperative abdominal infections. Adapting antibiotic prophylaxis might therefore have the potential to improve surgical outcome pCCA patients.