Microbial profile and antibiotic sensitivity pattern in bile cultures from endoscopic retrograde cholangiography patients

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.

Internal versus external biliary drainage in malignant biliary obstructions: is there a difference in the rate of infection?

BACKGROUND

Percutaneous biliary drainage is a frequently used method to provide biliary decompression in patients with biliary obstruction.

PURPOSE

To investigate the between drainage type and infection risk in patients treated with internal-external and external biliary drainage catheterization for malignant biliary obstruction.

MATERIAL AND METHODS

A total of 410 patients with malignant biliary obstruction who underwent internal-external or external biliary drainage catheterization between January 2012 and October 2016 were retrospectively evaluated. We investigated the correlation between percutaneous biliary drainage technique and infection frequency by evaluating patients with clinical findings, bile and blood cultures, complete blood counts, and blood biochemistry.

RESULTS

There was no statistically significant difference between the selected patient groups (internal-external or external biliary drainage catheter placed) in terms of age, sex, primary diagnosis, receiving chemotherapy, catheter sizes, and outpatient-patient status. After catheterization, catheter-related infection was observed in 49 of 216 (22.7%) patients with internal-external and 18 of 127 (14.2%) patients with external biliary drainage catheters, according to the defined criteria. There was no difference in infection rate after the biliary drainage in the two groups (P > 0.05). There was also no difference concerning frequently proliferating microorganisms in bile cultures.

CONCLUSION

Internal-external biliary drainage catheter placement does not bring an additional infection risk for uninfected cholestatic patients whose obstruction could be passed easily in the initial drainage.

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.

Pattern of bile cultures and antibiotic sensitivity tests in Sudanese patients diagnosed with obstructive jaundice: A single-center prospective study

Background and Aim

Biliary obstruction causes bacteriobilia and significant morbidity and high mortality, which necessitates prompt and effective treatment for a good clinical outcome. Hence, the aim of this study was to determine updated knowledge of biliary microbial spectrum, antibiotic sensitivity pattern, and key clinical factors of bacteriobilia.

Methods

This is a prospective study conducted during the period between November 2021 and December 2022 at Ibn Sina specialized hospital, Khartoum, Sudan, on 50 patients diagnosed with obstructive jaundice and symptomatic bacteriobilia who underwent open biliary surgeries electively. Bile samples were aspirated intra-operatively and cultured, and antibiotic sensitivity tests were performed.

Results

Fifty-four percent of patients diagnosed with obstructive jaundice who underwent elective open biliary surgeries were males with the ratio (2:1). Forty-six percent of patients were between 61 and 75 years (elderly). The most frequent cause of obstructive jaundice was migrating biliary stones (48% of cases). Thirty-two percent of patients were diabetic with bacteriobilia. The predominant isolated bacterial pathogen in this study was Escherichia coli (36% of cases). These biliary pathogens were sensitive to meropenem in 54% of cases and ciprofloxacin in 46%. Eventually, in all patients in this study, biliary bacterial pathogens were found to be resistant to a broad spectrum of antibiotics.

Conclusion

Careful selection of empirical antibiotic therapy based on surveillance of routine bile cultures during biliary tree procedures in patients with high risk of bacteriobilia will potentially help in improving the surgical outcomes and optimizing treatment of acute cholangitis, which is associated with high mortality.

Effectiveness of a new approach to minimally invasive surgery in palliative treatment of patients with distal malignant biliary obstruction

BACKGROUND

Palliative endoscopic biliary drainage is the primary treatment option for the management of patients with jaundice which results from distal malignant biliary obstruction (DMBO). In this group of patients, decompression of the bile duct (BD) allows for pain reduction, symptom relief, chemotherapy administration, improved quality of life, and increased survival rate. To reduce the unfavorable effects of BD decompression, minimally invasive surgical techniques require continuous improvement.

AIM

To develop a technique for internal-external biliary-jejunal drainage (IEBJD) and assess its effectiveness in comparison to other minimally invasive procedures in the palliative treatment of patients with DMBO.

METHODS

A retrospective analysis of prospectively collected data was performed, which included 134 patients with DMBO who underwent palliative BD decompression. Biliary-jejunal drainage was developed to divert bile from the BD directly into the initial loops of the small intestine to prevent duodeno-biliary reflux. IEBJD was carried out using percutaneous transhepatic access. Percutaneous transhepatic biliary drainage (PTBD), endoscopic retrograde biliary stenting (ERBS), and internal-external transpapillary biliary drainage (IETBD) were used for the treatment of study patients. Endpoints of the study were the clinical success of the procedure, the frequency and nature of complications, and the cumulative survival rate.

RESULTS

There were no significant differences in the frequency of minor complications between the study groups. Significant complications occurred in 5 (17.2%) patients in the IEBJD group, in 16 (64.0%) in the ERBS group, in 9 (47.4%) in the IETBD group, and in 12 (17.4%) in the PTBD group. Cholangitis was the most common severe complication. In the IEBJD group, the course of cholangitis was characterized by a delayed onset and shorter duration as compared to other study groups. The cumulative survival rate of patients who underwent IEBJD was 2.6 times higher in comparison to those of the PTBD and IETBD groups and 20% higher in comparison to that of the ERBS group.

CONCLUSION

IEBJD has advantages over other minimally invasive BD decompression techniques and can be recommended for the palliative treatment of patients with DMBO.

Nanogap traps for passive bacteria concentration and single-point confocal Raman spectroscopy

A microfluidic device enabling the isolation and concentration of bacteria for analysis by confocal Raman spectroscopy is presented. The glass-on-silicon device employs a tapered chamber surrounded by a 500 nm gap that serves to concentrate cells at the chamber apex during sample perfusion. The sub-micrometer gap retains bacteria by size exclusion while allowing smaller contaminants to pass unimpeded. Concentrating bacteria within the fixed volume enables the use of single-point confocal Raman detection for the rapid acquisition of spectral signatures for bacteria identification. The technology is evaluated for the analysis of E. cloacae, K. pneumoniae, and C. diphtheriae, with automated peak extraction yielding distinct spectral fingerprints for each pathogen at a concentration of 103 CFU/ml that compare favorably with spectra obtained from significantly higher concentration reference samples evaluated by conventional confocal Raman analysis. The nanogap technology offers a simple, robust, and passive approach to concentrating bacteria from dilute samples into well-defined optical detection volumes, enabling rapid and sensitive confocal Raman detection for label-free identification of focused cells.

Influence of bacteriobilia on postoperative complications in patients with periampullary tumors

BACKGROUND

Periampullary tumours (PAT) may cause obstruction of distal choledochus. The bile stasis is a risk factor for microbial colonisation of bile (bacteriobilia), cholangitis, hepatic insufficiency and coagulopathy. PAT obstruction can be managed surgically or non-operatively - by inserting a biliary drain or stent (BDS). Although BDS allows for adequate bile drainage, liver function restitution and coagulopathy, increased bacteriobilia has been reported and this is associated with an increased incidence of postoperative complications.

METHODS

A monocentric, prospective, comparative study including 100 patients operated with PAT. The effects of bacteriobilia and the presence of a drain in the biliary tract on the development of postoperative complications were evaluated.

RESULTS

Positive microbial findings in bile were found in 67% of patients. It was 98% in the biliary drain group vs. 36% in non-drained patients (p = 0.0001). In 68% 2 or more different bacterial strains were simultaneously present (p = 0.0001). Patients with a positive microbial finding in bile had more frequent incidence of infectious complications 40.2% (27) vs. 9.1% (3); p = 0.0011. The most frequent infectious complication was wound infection 29.8% (20) vs. 3.03% (1); p = 0.0014. Similarly, a higher incidence of postoperative infectious complications occurred in patients with BDS - 36% (18) vs. 24% (12); p = 0.2752.

CONCLUSION

The presence of a drain or stent in the biliary tract significantly increases the microbial colonisation of bile. It is associated with a significant increase in infectious complications, especially infections in the wound.

Incidence of bactibilia and related factors in patients who undergo cholecystectomy

Purpose

In general, bile is normally sterile. However, there are reports bactibilia may occur in certain instances, though the causal factors are unclear. We analyzed possible preoperative predictors of bactibilia upon cholecystectomy.

Methods

Bile samples were collected during cholecystectomies from November 2018 to November 2019. A total of 428 open or laparoscopic cholecystectomies were performed. Preoperative, intraoperative, and postoperative variables were compared between the culture-positive and culture-negative groups.

Results

One hundred fifty-seven patients (36.7%) were culture-positive. Gram-negative bacteria (95 [61.0%]) were more common. Escherichia coli (38 [40.0%]) and Enterobacter (22 [23.2%]) were the most common species. In univariate analysis, age of ≥70 years (P < 0.001), male sex (P < 0.001), high American Society of Anesthesiologists physical status grades (P = 0.001), diabetes mellitus (P = 0.002), jaundice (P = 0.007), high Tokyo Guideline grades (P = 0.008), percutaneous transhepatic gallbladder drainage (PTGBD; P < 0.001), endoscopic retrograde cholangiopancreatography (ERCP; P < 0.001) were identified as a risk factors for bactibilia. In multivariate analysis, age of ≥70 years (hazard ratio [HR], 2.874; 95% confidence interval [CI], 1.769-4.670; P = 0.001), ERCP (HR, 9.001; 95% CI, 4.833-16.75; P < 0.001), and PTGBD (HR, 2.866; 95% CI, 1.440-4.901; P = 0.002) were independent risk factors for bactibilia.

Conclusion

Among patients who underwent cholecystectomy, those who were elderly, symptomatic, and underwent preoperative drainage were more likely to have bactibilia. In such cases, surgeons should take care to prevent bile leakage during surgery and consider administering appropriate antibiotics.

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.

Microbial spectrum and drug resistance of pathogens cultured from gallbladder bile specimens of patients with cholelithiasis: A single-center retrospective study

BACKGROUND

Bacterial infection is an important cause of cholelithiasis or gallstones and interferes with its treatment. There is no consensus on bile microbial culture profiles in previous studies, and identified microbial spectrum and drug resistance is helpful for targeted preventive and therapeutic drugs in the perioperative period.

AIM

To analyze the bile microbial spectrum of patients with cholelithiasis and the drug susceptibility patterns in order to establish an empirical antibiotic treatment for cholelithiasis-associated infection.

METHODS

A retrospective single-center study was conducted on patients diagnosed with cholelithiasis between May 2013 and December 2018.

RESULTS

This study included 185 patients, of whom 163 (88.1%) were diagnosed with gallstones and 22 (11.9%) were diagnosed with gallstones and common bile duct stones (CBDSs). Bile culture in 38 cases (20.5%) was positive. The presence of CBDSs (OR = 5.4, 95%CI: 1.3-21.9, P = 0.03) and longer operation time (> 80 min) (OR = 4.3, 95%CI: 1.4-13.1, P = 0.01) were identified as independent risk factors for positive bile culture. Gram-negative bacteria were detected in 28 positive bile specimens, and Escherichia coli (E. coli) (19/28) and Klebsiella pneumoniae (5/28) were the most frequently identified species. Gram-positive bacteria were present in 10 specimens. The resistance rate to cephalosporin in E. coli was above 42% and varied across generations. All the isolated E. coli strains were sensitive to carbapenems, with the exception of one imipenem-resistant strain. K. pneumoniae showed a similar resistance spectrum to E. coli. Enterococcus spp. was largely sensitive to glycopeptides and penicillin, except for a few strains of E. faecium.

CONCLUSION

The presence of common bile duct stones and longer operation time were identified as independent risk factors for positive bile culture in patients with cholelithiasis. The most commonly detected bacterium was E. coli. The combination of β-lactam antibiotics and β-lactamase inhibitors prescribed perioperatively appears to be effective against bile pathogens and is recommended. Additionally, regular monitoring of emerging resistance patterns is required in the future.

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.

Infectious complications of non-surgical biliary tract manipulation in paediatric patients. Role of antibiotic prophylaxis

BACKGROUND

Infections related to non-surgical manipulation of the biliary tract (NSMBT) are common events despite periprocedural antibiotic prophylaxis (PAP). Since June 2017, our local protocol has indicated a 24-h regimen of intravenous piperacillin-tazobactam for this purpose.

OBJECTIVE

We aimed to describe the incidence and characteristics of NSMBT-related paediatric infections, define risk factors for their development, and analyse adherence to our PAP protocol.

MATERIALS AND METHODS

Epidemiological, clinical, and microbiological data were collected in consecutive NSMBT procedures performed in paediatric patients (<18 years) in our centre (2010-2019).

RESULTS

113 procedures in 37 patients, median age 4 years (IQR 1-8), were included. Main underlying diseases were biliary atresia (32%) and cancer (14%). Sixty-eight percent had undergone liver transplant and 70% hepaticojejunostomy. In 44 procedures (39%), the intervention was performed during the course of infection and previously prescribed antibiotic treatment was maintained. In the other 69, PAP was specifically indicated for NSMBT; antibiotic adequacy increased from 35% to 100% after June 2017. In total, 32 NSMBT-related infections (28%) occurred, mainly in the first 24h post-procedure (72%); no deaths happened. Causative pathogens were Gram-negative rods (64%), Gram-positive cocci (28%), and Candida spp. (8%). Main related risk factors were hepaticojejunostomy, biliary obstruction, and liver transplant.

CONCLUSIONS

NSMBT in children entails a significant infection risk, even under antibiotic prophylaxis, being hepaticojejunostomy the main risk factor. Infectious complications mainly occurred immediately after the procedure. After establishing a PAP protocol, 100% of interventions received appropriate prophylaxis, decreasing antibiotic exposure time and potentially, the length of hospital stay.

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.

EASL Clinical Practice Guidelines on sclerosing cholangitis

Management of primary or secondary sclerosing cholangitis is challenging. These Clinical Practice Guidelines have been developed to provide practical guidance on debated topics including diagnostic methods, prognostic assessment, early detection of complications, optimal care pathways and therapeutic (pharmacological, endoscopic or surgical) options both in adults and children.

Microbiology of bile aspirates obtained at ERCP in patients with suspected acute cholangitis

BACKGROUND

The cornerstone of treatment for acute cholangitis is source control with biliary drainage and early antibiotics. The primary aim of this study was to describe the microbiology of bile aspirate pathogens obtained at the time of endoscopic retrograde cholangiopancreatography (ERCP) in patients suspected of having acute cholangitis.

METHODS

In this single-center retrospective study, patients were included if a bile aspirate was collected at ERCP for suspicion of acute cholangitis, from 1 January 2010 to 31 December 2016.

RESULTS

There were 721 ERCP procedures for suspected acute cholangitis with bile culture results, with 662 positive bile cultures (91.8 %). Pathogens included: Enterococcus species (spp.) 448 (67.7 %); Klebsiella spp. 295 (44.6 %); Escherichia coli 269 (40.6 %); Pseudomonas spp. 52 (7.9 %); and anaerobes 64 (9.7 %). Susceptibility of Klebsiella pneumoniae and E.coli isolates to ciprofloxacin was 88 % and 64 %, respectively. Extended-spectrum beta-lactamases and carbapenem resistance were found in 7.9 % and 3.6 % of Enterobacteriaceae, respectively. There were 437 concurrent blood cultures, of which 174 were positive (39.8 % of cultures drawn). Prior biliary endoscopic sphincterotomy (ES) was evident in 459 ERCP cases (63.7 %), and was associated with increased frequency of Klebsiella spp., Pseudomonas aeruginosa, Enterobacter spp., and Enterococcus spp. Prior biliary ES significantly increased the probability of vancomycin-resistant Enterococcus (VRE).

CONCLUSIONS

The vast majority of bile cultures (91.8 %) were positive. The susceptibilities of E.coli and K.pneumoniae to ciprofloxacin are lower than historically noted. A notable portion of cultures contained pathogenic drug-resistant organisms. Prior biliary ES is associated with a higher frequency of certain organisms and higher frequency of VRE.

Which Suture to Choose in Hepato-Pancreatic-Biliary Surgery? Assessment of the Influence of Pancreatic Juice and Bile on the Resistance of Suturing Materials—In Vitro Research

(1) Background: The choice of appropriate surgical suture during operation is of great significance. Currently, there are no objective studies regarding the resistance of commonly used sutures in biliary tract surgery. (2) Methods: This fact leads one to conduct research concerning the resistance of the sutures (Polydioxanone, Poliglecaprone, Poliglactin 910, and their analogues coated with antibacterial triclosan) in the environment of sterile and contaminated bile and pancreatic juice. Tensile strength was tested at days 0, 7, 14, 21, and 28 of research. The study was performed in in vitro conditions for 28 days. (3) Results: Pancreatic juice and bile has a significant influence on the tensile strength of each suture. (4) Conclusions: The study indicated that sutures made of polydioxanone had the best qualities during the entire experiment.

Bacterial profile and antimicrobial susceptibility patterns in cancer patients

Background

Bloodstream infections have been the leading complications in cancer patients because they are at high risk for antibiotic-resistant bacterial infections. There is increasing evidence from different parts of the world of the high prevalence of antimicrobial-resistant bacterial strains in cancer patients. The burden of the infection is high in developing countries, especially in Ethiopia. Data on bacterial profile and antimicrobial susceptibility patterns among cancer patients in Ethiopia is limited. Thus, this study aimed to determine the predominant bacterial species causing bacteremia and their antibiotic resistance pattern among cancer patients at University of Gondar comprehensive specialized hospital.

Methods

A hospital-based, cross-sectional study was conducted on 200 study participants from March to July 2021. All cancer patients who developed a fever at the time of hospital visit were included in this study, and their socio-demographic and clinical data were collected using a structured questionnaire. Blood samples (10 mL for adults and 4 mL for children) were collected from each patient, and the collected blood samples were transferred into sterile tryptic soy broth, then incubated at 37°C for 7 days. Tryptic soy broth which showed signs of growth were Gram-stained and sub-cultured on blood agar, chocolate agar, MacConkey agar, and mannitol salt agar. The inoculated plates were then aerobically incubated at 37°C for 18–24 hours and the isolates obtained were identified using standard microbiological methods. Antimicrobial susceptibility tests were done using a modified Kirby-Bauer disk diffusion technique following CLSI 2021 guidelines. Data were entered using EPI data version 4.6 and analyzed with SPSS version 20.

Results

In this study, out of 200 cancer patients included and 67.5% (135/200) of them were males. The majorities of study participants, 56% (113/200) of cancer patients were pediatrics and 26.5% (53/200) of them belong under five years of age. Out of 200 patient samples that had undergone culture, 27% (54/200) samples had bacterial growth. Gram-positive bacterial isolates were predominant, 61.1%, and S. aureus was the predominant Gram-positive isolate, (51.5.6%), followed by coagulase-negative staphylococci (48.5%). Moreover, K. pneumoniae (47%) and P. aeruginosa (29.5%) were the most common Gram-negative bacterial isolates. Among patients who had BSIs, the highest prevalence of BSIs was observed among males (66.7%), and in pediatrics cancer patients (44.2%). Pediatric study participants were more venerable to bloodstream infection (P = 0.000) compared to adult participants. Meropenem (100%), amikacin (100%), piperacillin/tazobactam (72.3%), and ceftazidime (73.5%) were effective against for Gram-negative isolates while cefoxitin (81.2%) and penicillin (70.5%) were effective for Gram-positive isolates. Additionally, most Gram-negative and Gram-positive bacterial isolates were sensitive for gentamycin (75.9%). Multidrug resistance was seen among 17.1% bacterial isolates, and MDR in Gram-negative and Gram-positive bacteria were 83.3% and 16.7%, respectively. Gram-negative bacterial isolates showed a high prevalence of MDR than Gram-positive isolates.

Conclusions and recommendation

BSI’s remains an important health problem in cancer patients, and Gram-positive bacteria were more common as etiologic agents of BSIs in cancer patients. S. aureus was the dominant bacteria followed by CoNS, K. pneumoniae, and P. aeruginosa. Multidrug-resistant isolates found in cancer patients and routine bacterial surveillance and study of their resistance patterns may guide successful antimicrobial therapy and improve the quality of care. Therefore, strict regulation of antibiotic stewardship and infection control programs should be considered in the study area.

The complete genome sequence of a bile-isolated Stenotrophomonas maltophilia ZT1

Background

Stenotrophomonas maltophilia is one of the most frequently isolated opportunistic pathogens that can cause infections in humans. Many researches concerned the mechanism of antibiotic resistance displayed by S. maltophilia, however, the mechanism of its pathogenesis and its adaptation to special niches, such as bile, remain unclear.

Results

In this study, the S. maltophilia strain ZT1 was isolated from human bile. Its genome was sequenced and a circular chromosome of 4,391,471 bp was obtained with a GC content of 66.51%. There were 3962 protein-coding sequences, 7 rRNAs and 74 tRNAs in the chromosome. Compared with Virulence Factor Database, we identified more than 500 candidate virulence genes including genes encoding fimbrial assembly protein, enterobactin synthesis pathway proteins, efflux pumps, and the DNA and/or proteins secretion system in the genome of strain ZT1. Additionally, there were at least 22 genes related to bile adaption, including emrAB, acrRAB, galU, rfbC, tolC and mdtABC.

Conclusions

This is the first study to reveal the whole genome sequence of the ZT1 strain of S. maltophilia isolated from human bile. We identified hundreds virulence factors and 22 bile adaptation-related genes in the genome of the S. maltophilia strain ZT1. Further comparative genomic analysis and functional verification would aid in understanding the pathogenesis and bile adaptation of S. maltophilia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13099-021-00456-y.

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.

•

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

•

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

•

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

•

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

BACTERIAL ISOLATES AND ANTIBIOTIC SENSITIVITY PATTERNS IN CHOLEDOCHAL BILE COLLECTED DURING ERCP: A REPORT FROM CENTRAL INDIA

Temporal shifts have been known to occur in antibiotic sensitivity patterns of organisms causing cholangitis.The aim of this prospective study conducted on 100 patients of extra hepatic biliary obstruction (EHBO) was to identify the common microorganisms cultured from bile obtained during Endoscopic retrograde cholangiography and to study their local sensitivity pattern.Sixty six patients had growth in bile culture,the maximum growths amongst all micro-organisms were of Escherichia coli (40.9%) and Pseudomonas aeruginosa (40.9%). Growth rates were significantly higher in patients with non- malignant causes of biliary obstruction than those with malignant causes. Polymixins had the highest sensitivity to cultured bacteria followed by aminoglycosides and Imipenem.Study of culture & sensitivity pattern helps in deciding empirical antibiotic therapy in patients with cholangitis and it should be based on local sensitivity patterns

Infectious complications of non-surgical biliary tract manipulation in paediatric patients. Role of antibiotic prophylaxis

BACKGROUND

Infections related to non-surgical manipulation of the biliary tract (NSMBT) are common events despite periprocedural antibiotic prophylaxis (PAP). Since June 2017, our local protocol has indicated a 24-h regimen of intravenous piperacillin-tazobactam for this purpose.

OBJECTIVE

We aimed to describe the incidence and characteristics of NSMBT-related paediatric infections, define risk factors for their development, and analyse adherence to our PAP protocol.

MATERIALS AND METHODS

Epidemiological, clinical, and microbiological data were collected in consecutive NSMBT procedures performed in paediatric patients (<18 years) in our centre (2010-2019).

RESULTS

113 procedures in 37 patients, median age 4 years (IQR 1-8), were included. Main underlying diseases were biliary atresia (32%) and cancer (14%). Sixty-eight percent had undergone liver transplant and 70% hepaticojejunostomy. In 44 procedures (39%), the intervention was performed during the course of infection and previously prescribed antibiotic treatment was maintained. In the other 69, PAP was specifically indicated for NSMBT; antibiotic adequacy increased from 35% to 100% after June 2017. In total, 32 NSMBT-related infections (28%) occurred, mainly in the first 24h post-procedure (72%); no deaths happened. Causative pathogens were Gram-negative rods (64%), Gram-positive cocci (28%), and Candida spp. (8%). Main related risk factors were hepaticojejunostomy, biliary obstruction, and liver transplant.

CONCLUSIONS

NSMBT in children entails a significant infection risk, even under antibiotic prophylaxis, being hepaticojejunostomy the main risk factor. Infectious complications mainly occurred immediately after the procedure. After establishing a PAP protocol, 100% of interventions received appropriate prophylaxis, decreasing antibiotic exposure time and potentially, the length of hospital stay.

Antibiotic selection based on microbiology and resistance profiles of bile from gallbladder of patients with acute cholecystitis

With the progression of acute cholecystitis, antimicrobial therapy becomes important for infection control. Current antibiotic recommendations were mostly based on reports of patients with acute cholangitis whose bile specimens were sampled from the biliary tract. However, as most infections of acute cholecystitis are limited to the gallbladder, direct sampling from the site increases the probability of identifying the causative pathogen. We investigated 321 positive bile cultures from 931 patients with acute cholecystitis who underwent laparoscopic cholecystectomy between January 2003 and December 2017. The frequency of enterococci declined (P = 0.041), whereas that of Enterobacteriales (P = 0.005), particularly Escherichia (P = 0.008), increased over time. The incidence of ciprofloxacin-resistant Enterobacteriales showed a significant increasing trend (P = 0.031). Vancomycin-resistant E.faecium, carbapenem-resistant Enterobacteriales, and extended-spectrum beta-lactamase-producing Enterobacteriales were recently observed. In grade I and II acute cholecystitis, there were no significant differences in perioperative outcomes in patients with and without early appropriate antimicrobial therapy. In conclusion, the changing incidence of frequently isolated microorganisms and their antibiotic resistance over time would be considered before selecting antibiotics for the treatment of acute cholecystitis. Surgery might be a crucial component of infection control in grade I and II acute cholecystitis.

Microbiology of bile in extrahepatic biliary obstruction: A tropical experience

PURPOSE

Bile is considered sterile, but in obstructed biliary system, growth of micro-organisms results in bacteraemia and toxaemia. We analysed bacterial profile of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and evaluated antibiotic resistance patterns to formulate strategy for antibiotics in patients undergoing ERCP.

MATERIALS AND METHODS

Patients with cholestasis who underwent ERCP were enrolled. Bile, collected aseptically, was cultured. Positive cultures were processed for isolate identification and antibiotic susceptibility.

RESULTS

One hundred and sixty-three patients (78 females; mean age - 55.1 ± 15.8 years) were enrolled and divided into two groups: Group I (n = 99) were naïve and Group II (n = 64) had undergone ERCP and stenting previously. Positive culture was seen in 68.1% (n = 111) with monomicrobial growth in 74.8% (n = 83) and poly-microbial growth in 25.2% (n = 28). Culture positivity was common in Group II vis-a-vis Group I (84.4% vs. 57.5%). Poly-microbial growth was significantly more common in Group II (35.2% vs. 15.8%, P = 0.028). Gram-negative bacilli were the predominant organisms isolated with Escherichia coli, Pseudomonas aeruginosa and Klebsiella pneumoniae comprising 70% of the isolates. The most sensitive antibiotics were piperacillin-tazobactam and imipenem. The sensitivity of vancomycin, against Enterococcus spp. was in the range of 60%-70%.

CONCLUSION

Cholestasis leads to bacterial colonisation in most cases, regardless of the presence of a biliary stent. Biliary stent however predisposes to a polymicrobial growth. Most of the commonly used antibiotics continue to have significant sensitivity and may be used empirically. However, previously stented patients may have a higher incidence of infection with Enterococcus spp. and may require specific therapy.

Bacterial flora in the bile: Clinical implications and sensitivity pattern from a tertiary care centre

BACKGROUND

Though preoperative biliary drainage (PBD) has been suggested to be linked with increased perioperative morbidity it is still practiced commonly. We studied the association of PBD and positive biliary culture with surgical site infection and also analysed the common pathogens and their antibiotic sensitivity spectrum.

METHODS

Prospectively maintained data of patients who underwent various pancreatobiliary surgeries from 2017 to 2019 was analysed. Patients whose intraoperative bile culture reports were available were included in the study. Various factors associated with surgical site infection (SSI), microbial spectrum of bile culture and their sensitivity pattern were analysed.

RESULTS

Out of 68 patients whose bile culture report were available, PBD was done in 65% (n = 44). Among patients with infected bile (n = 51), biliary stent was present in 78.4% (n = 40). On univariate analysis, the factors associated with SSI were low albumin level (<3.5 mg%), long operative time (>6 h), duration of abdominal drain (>4 days), length of hospital stay, intraoperative bile spillage and infected bile. However, on multivariate analysis, only presence of drain for >4 days (p = 0.04) and positive bile culture (p = 0.02) was linked with increased risk of SSI. Most common organism isolated was E coli (73.2%), with 100% sensitivity to Colistin and Tigecycline shown by gram negative isolates.

CONCLUSION

Preoperative biliary stenting alone did not increase the risk of SSI, but the positive bile culture correlated with SSI irrespective of PBD. Most biliary pathogens were resistant to commonly used antibiotics and intraoperative bile culture will aid in providing appropriate antibiotic coverage.

Helicobacter pylori is not a contributing factor in gallbladder polyps or gallstones: a case-control matching study of Chinese individuals

OBJECTIVE

To investigate the relationship between Helicobacter pylori (H. pylori) infection and gallstones or gallbladder polyps.

METHODS

This retrospective analysis included 27,881 individuals who underwent health examinations that included a H. pylori test and an abdominal ultrasound scan. Patients were divided into four groups: gallbladder polyp (P group), gallstone (S group), gallstone and gallbladder polyp (SP group), and no gallbladder disease (N group). Case-control matching was used to select the participants in the control group.

RESULTS

The mean ages of participants in the P, S, and SP groups were all significantly higher than the mean age of participants in the N group. The proportions of participants with each type of body mass index significantly differed between the N and P groups, and between the N and S groups. In total 45.7% of participants exhibited H. pylori infection. After case-control matching, the proportion of participants with H. pylori infection did not significantly differ according to the presence or absence of gallbladder polyps. Similar results were observed regarding gallstones, as well as gallstones and gallbladder polyps.

CONCLUSION

H. pylori infection might not be related to gallbladder polyps or gallstones.

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 and microbiological characteristics of patients with biliary disease

BACKGROUND

Biliary diseases are common digestive system disorders which may combine with biliary tract infection such as cholecystitis or cholangitis. Thus, rapid identification of the bacteria and their antibiotic susceptibility profiles are crucial for reducing the mortality of patients with biliary tract infection.

AIM

To identify bacterial species and antibiotic susceptibility for antibacterial therapy and analyze bile cultivation risk factors for increasing detection rates.

METHODS

This retrospective study was conducted from July 2008 to July 2017. In total, 1339 bile samples which were collected during therapeutic endoscopic retrograde cholangiopan-creatography or percutaneous transhepatic cholangiodrainage or other biliary surgeries or biliary drainage were obtained to characterize pathogen spectra, antibiotic susceptibility, and clinical features. Clinical data including age, sex, comorbidities, clinical symptoms, protopathies, and history of biliary tract diseases and surgeries were collated from hospital medical records. Species identification and initial drug susceptibility were further identified by biochemical characterization using the VITEK 2 Compact test.

RESULTS

Positive microbiological findings were observed in 738 samples. The most frequently encountered strains were gram-negative bacteria (74.94%), including Escherichia coli (37.78%), Pseudomonas aeruginosa (8.96%), and Klebsiella pneumoniae (10.29%). Bile bacteria were largely sensitive to carbapenems, piperacillin/tazobactam, and gentamicin. Gram-negative strains had low susceptibility to ceftriaxone, quinolones and ampicillin. Almost the same micro-organisms were present in patients with malignant and benign diseases. The number of samples with Klebsiella pneumoniae in the bile culture were significantly different between patients with malignant and benign diseases (55 vs 30; P = 0.019). Age (P < 0.001), fever (P < 0.001), history of biliary tract diseases and surgeries (both P < 0.001), benign disease (P = 0.002), and the comorbidity chronic renal insufficiency (P = 0.007) affected the positive rates of the bile samples.

CONCLUSION

Gram-negative bacteria were the most commonly isolated biliary bacteria. We determined the major factors associated with positive detection rates. Microbiological analysis of bile samples allowed accurate antibiotic treatments.

Bacterobilia in pancreatic surgery-conclusions for perioperative antibiotic prophylaxis

BACKGROUND

Jaundice or preoperative cholestasis (PC) are typical symptoms of pancreatic masses. Approximately 50% of patients undergo preoperative biliary drainage (PBD) placement. PBD is a common cause of bacterobilia (BB) and is a known surgical site infection risk factor. An adjustment of preoperative antibiotic prophylaxis (PAP) may be reasonable according to the profile of BB. For this, we examined the microbiological findings in routine series of patients.

AIM

To investigate the incidence and profile of biliary bacterial colonization in patients undergoing pancreatic head resections.

METHODS

In the period from January 2009 to December 2015, 285 consecutive pancreatic head resections were performed. Indications for surgery were malignancy (71%), chronic pancreatitis (18%), and others (11%). A PBD was in 51% and PC was in 42%. The standard PAP was ampicillin/sulbactam. Intraoperatively, a smear was taken from the hepatic duct. An analysis of the isolated species and resistograms was performed. Patients were categorized according to the presence or absence of PC (PC+/PC-) and PBD (PBD+/PBD-) into four groups. Antibiotic efficiency was analyzed for standard PAP and possible alternatives.

RESULTS

BB was present in 150 patients (53%). BB was significantly more frequent in PBD+ (n =120) than in PBD- (n = 30), P < 0.01. BB was present both in patients with PC and without PC: (PBD-/PC-: 18%, PBD-/PC+: 30%, PBD+/PC-: 88%, PBD+/PC+: 80%). BB was more frequent in malignancy (56%) than in chronic pancreatitis (45%). PBD, however, was the only independent risk factor in multivariate analysis. In total, 357 pathogens (342 bacteria and 15 fungi) were detected. The five most common groups (n = 256, 74.8%) were Enterococcus spp. (28.4%), Streptococcus spp. (16.9%), Klebsiella spp. (12.6%), Escherichia coli (10.5%), and Enterobacter spp. (6.4%). A polymicrobial BB (PBD+: 77% vs PBD-: 40%, P < 0.01) and a more frequent detection of Enterococcus (P < 0.05) was significantly associated with PBD+. In PBD+, the efficiency of imipenem and piperacillin/tazobactam was significantly higher than that of the standard PAP (P < 0.01).

CONCLUSION

PBD-/PC- and PBD-/PC+ were associated with a low rate of BB, while PBD+ was always associated with a high rate of BB. In PBD+ patients, BB was polymicrobial and more often associated with Enterococcus. In PBD+, the spectrum of potential bacteria may not be covered by standard PAP. A more potent alternative for prophylactic application, however, was not found.

Pathophysiologic Characterization of a Novel Rabbit Model of Biliary Tract Infection-Derived Sepsis

Biliary tract infection (BTI)-derived sepsis remains a serious problem with significant morbidity and mortality in the modern era of critical care management. Current animal models of BTI have relied mostly on injecting purified bacteria or their toxins into the biliary tract. These models do not fully reflect pathophysiology or disease processes of clinical cholangitis or cholecystitis. In the current study, we developed a novel model of BTI by performing cholecystocolonic anastomosis (CCA) in rabbits and characterized pathophysiologic changes in this model. This model is intended to mimic the clinical process of cholecystocolonic fistula with reflux cholangitis, a severe form of BTI. Adult male rabbits were subjected to BTI-derived sepsis through an anastomosis of the gall bladder to the colon (i.e., CCA). The animals were monitored for 7 days to record survival. In additional groups of animals, various bacterial, hemodynamic, histological and biochemical parameters were measured at 12, 24, 48 and 72 h after CCA. The anastomosis between the gallbladder and the colon required about 5–8 min to finish. The median survival time for rabbits after CCA was 96 h. The positive rates of bacterial culture at 72 h after CCA were 83.3% and 100% in the blood and liver, respectively. The most common microorganism was Escherichia coli followed by Enterococcus. Plasma Tumor Necrosis Factor-α (TNF-α), Lnterleukin-10 (IL-10), Lnterleukin-6 (IL-6), and High-mobility group box 1 protein (HMGB-1) levels were greatly elevated after CCA. The cardiac index and heart rate increased slightly at 12 h after CCA and then continued to decrease. Systemic hypotension developed 48 h after CCA. Histological studies showed reflux cholangitis with acute lung and kidney injury. Cholecystocolonic anastomosis produces polymicrobial sepsis in rabbits, which mimics many aspects of human BTI-derived sepsis. It is reproducible and easy to perform and may serve as an excellent model for future sepsis research.

Microbial Profiles and Risk Factors of Preexisting Biliary Infection in Patients with Therapeutic Endoscopy

Background

The bile infection may already exist before the administration of an interventional procedure, despite no clinical manifestations of cholangitis detected. Blood cultures remained negative even in more than half of the febrile cases with cholangitis. Risk factors associated with bacterial growth in bile before the intervention are not well defined. To establish the bacterial profiles isolated from the bile samples and to identify risk factors for bacterial colonization in the bile system.

Methods

Individuals who underwent endoscopic retrograde cholangiopancreatography (ERCP) interventions were enrolled. Bile samples were aspirated and were immediately transferred into a sterile tube for storage.

Results

Positive bile cultures were detected in 363 (38.0%) of 956 patients, including 322 benign diseases and 41 malignances. Of 363 positive cases, 351 (96.7%) were monoinfection and 12 (3.3%) multi-infection. Escherichia coli were the most common Gram-negative bacteria (210, 56.0%), followed by Klebsiella pneumoniae (45, 12.0%). Enterococcus faecalis represented the most common Gram-positive microorganism (19, 5.07%), while Candida albicans (11, 2.93%) were the dominant fungi. Klebsiella pneumoniae were more frequently detected in malignant diseases (P = 0.046). Age, previous ERCP history or OLT history, and CBD diameter were independent risk factors for positive cultures (P < 0.05) while preoperative jaundice drug therapy was the protective factor for bile infection (P < 0.05).

Conclusion

Monomicrobial infection was dominant among all infections, and Klebsiella pneumoniae strains were more frequently isolated from patients with malignant diseases. To effectively manage patients who are at a high risk for bile infection, a detailed diagnosis and treatment plan for each case should be prepared.

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.

Colonization, resistance to bile, and virulence properties of Escherichia coli strains: Unusual characteristics associated with biliary tract diseases

Escherichia coli is the species that is most frequently isolated from bile of patients with biliary tract diseases. This study was aimed to investigate any association between resistance and virulence properties of these isolates with occurrence of the diseases. A total of 102 bile samples were obtained from patients subjected to endoscopic retrograde cholangiopancreatography for different biliary diseases. Clinical data were collected and culture of the bile samples was done on selective media. Resistance of characterized Escherichia coli isolates to deoxycholate sodium (0-7%) and nineteen antibiotics was determined and PCR using 16 pairs of primers targeting stx1, stx2, exhA, eae, bfp, agg, pcvd432, lt, st, ipaH, pic, pet, ast, set, sen, and cdtB genes was done. Our results showed a statistically significant association between E. coli colonization and existence of common bile duct and gallbladder stones (p value 0.028). Out of the 22 E. coli strains (22/102) multidrug resistance phenotype was present in 95.45%. None of the strains belonged to common E. coli pathotypes. However, bfp + EhxA-hly, bfp + astA, bfp + EhxA-hly + pic, and EhxA-hly + pic + astA, bfp, and astA genotypes were detected in these strains. bfp (7/22, 31.8%) and astA (5/22, 22.7%) were among most frequent virulence factors in these strains. Results of this study showed significant association between colonization of E. coli and choledocholithiasis. Unusual existence of virulence gene combinations in these strains and their resistance to DOC and multiple classes of antibiotics could be considered as possible causes of their persistence in this harsh microenvironment.

Nlrp3 Activation Induces Il-18 Synthesis and Affects the Epithelial Barrier Function in Reactive Cholangiocytes

Microbial products are thought to influence the progression of cholangiopathies, in particular primary sclerosing cholangitis (PSC). Inflammasomes are molecular platforms that respond to microbial products through the synthesis of proinflammatory cytokines. We investigated the role of inflammasome activation in cholangiocyte response to injury. Nucleotide-binding oligomerization domain (NOD)-like receptor family, pyrin domain-containing protein 3 (Nlrp3) expression was tested in cholangiocytes of normal and cholestatic livers. Effects of Nlrp3 activation induced by incubation with lipopolysaccharide and ATP was studied in vitro in normal and siRNA-Nlrp3 knocked-down cholangiocytes. Wild-type and Nlrp3 knockout (Nlrp3^-/-) mice were fed 3,5-diethoxycarbonyl-1,4-dihydrocollidine (DDC; a model of sclerosing cholangitis) for 4 weeks. Nlrp3 and its components were overexpressed in cholangiocytes of mice subjected to DDC and in patients affected by PSC. In vitro, Nlrp3 activation stimulated expression of Il-18 but not of Il-1β and Il-6. Nlrp3 activation had no effect on cholangiocyte proliferation but significantly decreased the expression of Zonulin-1 and E-cadherin, whereas Nlrp3 knockdown increased the permeability of cholangiocyte monolayers. In vivo, the DDC-stimulated number of cytokeratin-19-positive cells in the liver of wild-type animals was slightly reduced in Nlrp3^-/- mice, and expression of E-cadherin was reestablished. In conclusion, Nlrp3 is expressed in reactive cholangiocytes, in both murine models and patients with PSC. Activation of Nlrp3 leads to synthesis of proinflammatory cytokines and influences epithelial integrity of cholangiocytes.

Immune dysfunction in patients with obstructive jaundice before and after endoscopic retrograde cholangiopancreatography

This prospective observational study investigated monocyte cytokine responses to lipopolysaccharide (LPS) in patients with obstructive jaundice (OJ) before and after endoscopic biliary drainage. Dendritic cell (DC) subsets and their expression of co-stimulatory molecules were also studied. Forty patients with OJ and ten non-jaundiced patients with normal gastroscopy findings were recruited. Ten healthy volunteers provided control blood samples for immunological assays. Patients with OJ had blood and duodenal mucosa sampled at the time of endoscopic retrograde cholangiopancreatography (ERCP) and further blood sampled during the recovery phase. Monocyte cytokine responses to LPS, DC subsets and co-stimulatory molecule expression were compared with controls. Duodenal morphology and occludin expression were also assessed. Monocytes obtained before ERCP from jaundiced patients demonstrated reduced cytokine responses to endotoxin compared with controls (IL-1β: 2678 compared with 4631 pg/ml, P=0.04 and IL-6: 3442 compared with 6157 pg/ml, P=0.002). Monocytes from patients with malignancy had poorer responses to endotoxin than from those with benign OJ (IL-1β: 2025 compared with 3332 pg/ml, P=0.001). After ERCP, the secretion of inflammatory cytokines by monocytes obtained from jaundiced patients increased (IL-1β: 2150 compared with 2520 pg/ml, P=0.03 and IL-6: 2488 compared with 3250 pg/ml, P=0.01). Occludin expression (85 compared with 95%, P=0.004) and mean duodenal villus height (334 compared with 404 μm, P=0.03) were lower in jaundiced patients. Before biliary drainage, patients with OJ had a higher percentage of myeloid dendritic cells (mDCs) and greater mDC expression of CD40 (P=0.04) and CD86 (P=0.04). Monocytes from patients with OJ had lower proinflammatory cytokine secretion in response to LPS, an effect reversed following biliary drainage.

Evaluation of Streptococcus pneumoniae in bile samples: A case series review

Although Streptococcus pneumoniae is an important pathogen of humans, pneumococcal cholangitis is rare because of the rapid autolysis of S. pneumoniae. The aim of this case series was to review patients with bile cultures positive for S. pneumoniae. This study was a single center retrospective case series review of patients with S. pneumoniae in their bile at a tertiary-care cancer center between September 2002 and August 2015. Subjects consisted of all patients in whom S. pneumoniae was isolated in their bile during the study period. Bile specimens for culture were obtained from biliary drainage procedures such as endoscopic retrograde biliary drainage, endoscopic nasobiliary drainage, and percutaneous transhepatic biliary drainage. There were 20 patients with bile cultures positive for S. pneumoniae during the study period. All patients presented with extrahepatic obstructive jaundice due to hepatopancreatobiliary tumors. Nineteen of 20 patients underwent the placement of plastic intrabiliary tubes. The mean time between the first-time drainage and the positive culture was 26 days (range 0-313 days). Although 12 of 20 patients met our definition of cholangitis, 5 were clinically treated with antibiotics based on a physician's assessment of whether there was a true infection. The present study is the largest case series of patients with S. pneumoniae in their bile. Based on our findings, the isolation of S. pneumoniae from bile may be attributed to the placement of biliary drainage devices.

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.

Antibiotic Prophylaxis Prior to Elective ERCP Does Not Alter Cholangitis Rates or Shorten Hospital Stay: Results of an Observational Prospective Study of 138 Consecutive ERCPS

OBJECTIVES

The role of prophylactic antibiotherapy prior to elective endoscopic retrograde cholangiopancreatography (ERCP) is unclear. We aimed to determine whether patients receiving systemic antibiotics prior to ERCP had lower morbidity and mortality rates as well as shorter hospitalization compared to patients who did not receive antibiotic prophylaxis.

MATERIALS AND METHODS

We conducted a prospective study of all patients undergoing ERCP in our unit. Antibiotic use, postERCP cholangitis rates, 30-day mortality and hospital stay were studied. Also, bacteriological examination of bile aspirates from these patients was conducted and antibiotic susceptibility was determined for the isolated pathogens.

OUTCOMES

One hundred-thirty eight consecutive ERCPs conducted in our unit in a 9 month period were included. Cholangitis developed in 3 (4.6%) cases in the antibiotics groups and 3 (4%) cases in the control group (p=0.8). Hospital stay did not differ significantly between the two study groups (p=0.58). There was only one procedure-related death which was the result of postERCP pancreatitis in a patient with severe associated illnesses. Bile aspirates showed bacterial growth in 75% of the cases where bile was obtained, with E. coli being the most frequently isolated microorganism. No differences in bacteriological profiles were noted between the two study groups.

CONCLUSION

There seems to be no influence on patient-related outcome of antibiotic prophylaxis prior to elective ERCP.

Internal-external percutaneous transhepatic biliary drainage for patients with malignant obstructive jaundice

PURPOSE

To evaluate the effect of internal-external percutaneous transhepatic biliary drainage (IEPTBD) for patients with malignant obstructive jaundice.

METHODS

During the period of January 2008 and July 2013, internal-external drainage was performed in 42 patients with malignant obstructive jaundice. During the procedure, if the guide wire could pass through the occlusion and into the duodenum, IEPTBD was performed. External drainage biliary catheter was placed if the occlusion was not crossed. Newly onset of infection, degree of bilirubin decrease and the survival time of patients were selected as parameters to evaluate the effect of IEPTBD.

RESULTS

Twenty newly onset of infection were recorded after procedure and new infectious rate was 47.6%. Sixteen patients with infection (3 before, 13 after drainage) were uncontrolled after procedure, 12 of them (3 before, 9 after drainage) died within 1 month. The mean TBIL levels declined from 299.53 umol/L before drainage to 257.62 umol/L after drainage, while uninfected group decline from 274.86 umol/L to 132.34 umol/Lp (P < 0.5). The median survival time for uninfected group was 107 days, and for infection group was 43 days (P < 0.05).

CONCLUSIONS

The IEPTBD drainage may increase the chance of biliary infection, reduce bile drainage efficiency and decrease the long-term prognosis, and the external drainage is a better choice for patients with malignant obstructive jaundice need to biliary drainage.

Prospective observational multicenter study to define a diagnostic algorithm for biliary candidiasis

AIM: To develop an algorithm to improve the diagnosis and treatment of patients with biliary candidiasis.

METHODS: We performed a prospective study of 127 patients who underwent endoscopic retrograde cholangiopancreatography, for various biliary disorders, at 3 tertiary referral centers in Germany from July 2011 through July 2012 (ClinicalTrials.gov: NCT01109550). Bile, buccal, and stool samples were collected. When indicated, endoscopic transpapillary bile duct biopsies were performed to clarify the etiology of bile duct strictures and to prove invasive fungal infections.

RESULTS: Candida species were detected in 38 of the 127 bile samples (29.9%). By multivariate analysis patients’ age and previous endoscopic sphincterotomy were independent risk factors for biliary candidiasis (P < 0.05). Patients with immunosuppression (P = 0.058) and recent long-term antibiotic therapy (> 7 d) (P = 0.089) tend to be at risk for biliary candidiasis. One patient was negative in mycological culture of bile fluid but invasive biliary candidiasis was diagnosed histologically. Of Candida subspecies detected, 36.7% were azole-resistant, such as C glabrata. Eight patients received anti-mycotic therapy, based on our algorithm. Of these, 3 had cancer with biliary tract involvement, 2 had secondary sclerosing cholangitis, 1 had retroperitoneal fibrosis, and 5 had septicemia. In all patients contamination was ruled out by smears of the endoscope channel.

CONCLUSION: Gastroenterologists should be aware of frequent candida colonization in patients with cholangitis and biliary disorders. Our suggested algorithm facilitates the further clinical management.

The use of proton pump inhibitors and the spectrum and number of biliary pathogens in patients with acute cholangitis

BACKGROUND

Knowledge of the bacterial spectrum for acute cholangitis is essential for adequate empiric antibiotic treatment.

AIM

To analyse the relation of proton pump inhibitors (PPI) with biliary pathogens in patients with acute cholangitis.

METHODS

This retrospective study identified 278 patients with 318 acute cholangitis episodes using an endoscopic database. The relationship between PPI and microbiological outcomes was assessed by logistic and poisson regression analysis for binary and count data.

RESULTS

In total, 882 pathogens were isolated, of which, 120 cholangitis episodes occurred with PPI; 198 cholangitis episodes without PPI. Multivariate poisson regression analysis showed that PPI use resulted in a 23% increase in the number of biliary pathogens [3.14 vs. 2.55 (Δ = 0.59), P < 0.01], whereas stent therapy, previous interventional procedures (endoscopic retrograde cholangiography/percutaneous transhepatic cholangiography), genesis, age and sex showed no significant association with the number of biliary pathogens. Significantly, more cholangitis episodes with more than one pathogen isolated occurred during PPI treatment [103/120 (86%) vs. 151/198 (76%), P = 0.04]. Analysis of intrinsic anti-microbial resistance patterns was performed: Anti-microbial combination therapies were significantly more required to cover all isolated pathogens in cholangitis episodes with PPI than in cholangitis episodes without PPI (44/120 vs. 46/198, P = 0.01). Additionally, PPI use was associated with a significantly higher incidence of oropharyngeal flora in the biliary tract (53/120 vs. 61/198, P = 0.02).

CONCLUSIONS

Proton pump inhibitors seem to influence biliary pathogens by increasing the number and broadening the spectrum of biliary pathogens. However, the findings of this hypothesis-generating study need to be tested by confirmatory studies.

Microbial profile and antibiotic sensitivity pattern in bile cultures from patients with acute mild biliary pancreatitis

AIM: To study the profile of pathogen strains from bile of patients with acute mild biliary pancreatitis and their resistance to antimicrobial agents.

METHODS: Bile samples from 96 patients with acute mild biliary pancreatitis were cultured and tested for antibiotic susceptibility.

RESULTS: The most common organism was enterococci (27%), followed by Escherichia coli (19.2%), Pseudomonas aeruginosa (11.5%), and Klebsiella pneumoniae (10.3%). None of Gram-positive strains were resistant to telicoplanin and vancomycin. The percentage of Gram-negative strains that were sensitive to amikacin was highest (85.7%), followed by imipenem (81%), piperacillin and tazobactam (57.1%), cefepime hydrochloride (28.6%), and levofloxacin (19.0%). The percentage of ESBLs-producing bacteria in Gram-negative strains was 66.7%.

CONCLUSION: Enterococci have been found more commonly in patients with acute mild biliary pancreatitis. Combined antibiotic treatment with biliary decompression as early as possible is suggested for biliary obstructive infection. After biliary decompression, antibiotics will be selected according to the results of susceptibility test.