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

Abstract

Background Little is known on the outcome and risk factors for mortality of patients admitted in Intensive Care units (ICUs) for Acute cholangitis (AC). Methods Retrospective multicenter study included adults admitted in eleven intensive care units for a proven AC from 2005 to 2018. Risk factors for in-hospital mortality were identified using multivariate analysis. Results Overall, 382 patients were included, in-hospital mortality was 29%. SOFA score at admission was 8 [5–11]. Biliary obstruction was mainly related to gallstone (53%) and cancer (22%). Median total bilirubin and PCT were respectively 83 µmol/L [50–147] and 19.1 µg/L [5.3–54.8]. Sixty-three percent of patients (n = 252) had positive blood culture, mainly Gram-negative bacilli (86%) and 14% produced extended spectrum beta lactamase bacteria. At ICU admission, persisting obstruction was frequent (79%) and biliary decompression was performed using therapeutic endoscopic retrograde cholangiopancreatography (76%) and percutaneous transhepatic biliary drainage (21%). Adjusted mortality significantly decreased overtime, adjusted OR for mortality per year was 0.72 [0.54–0.96] (p = 0.02). In a multivariate analysis, factors at admission associated with in-hospital mortality were: SOFA score (OR 1.14 [95% CI 1.05–1.24] by point, p = 0.001), lactate (OR 1.21 [95% CI 1.08–1.36], by 1 mmol/L, p < 0.001), total serum bilirubin (OR 1.26 [95% CI 1.12–1.41], by 50 μmol/L, p < 0.001), obstruction non-related to gallstones (p < 0.05) and AC complications (OR 2.74 [95% CI 1.45–5.17], p = 0.002). Time between ICU admission and biliary decompression > 48 h was associated with in-hospital mortality (adjusted OR 2.73 [95% CI 1.30–6.22], p = 0.02). Conclusions In this large retrospective multicenter study, we found that AC-associated mortality significantly decreased overtime. Severity of organ failure, cause of obstruction and local complications of AC are risk factors for mortality, as well as delayed biliary drainage > 48 h.

Changing Patterns of Causative Pathogens over Time and Efficacy of Empirical Antibiotic Therapies in Acute Cholangitis with Bacteremia

“…3 The previous studies on microbial profile in BTIs with bacteremia were summarized in Table 7. 10,11,[17][18][19] The proportion of causative pathogens varied between studies, but their distribution was similar. The most common Gramnegative bacteria were E. coli (20.5% to 52.3%), followed by Klebsiella spp.…”

Critically-Ill Patients with Biliary Obstruction and Cholangitis: Bedside Fluoroscopic-Free Endoscopic Drainage versus Percutaneous Drainage

“…Risk factors of 30-day mortality were underlying malignancies and acute renal failure requiring emergent hemodialysis other than the APACHEII score. Delayed biliary decompression >12–48 h in acute severe cholangitis patients is a risk factor for mortality [ 2 , 23 ]. Early biliary drainage occurring within 24 h shortens the length of ICU stay but does not improve survival [ 24 , 25 ].…”

“…We found no statistical differences in mortality rate between the EBD and PTBD groups. This indicated that infection control with adequate biliary drainage is more critical than which drainage method is implemented [ 23 , 26 ].…”

Exploring the Association Between Paralytic Ileus and Endoscopic Retrograde Cholangiopancreatography Complications Using the National Inpatient Sample Database

“…Patients who need procedures done at the bedside require extensive coordination and preparation to move equipment quickly. Since timing can be a priority in an acutely sick patient, the endoscopist may not have all the tools necessary to complete the procedure safely and promptly outside of the gastroenterology suite [ 24 - 26 ]. These can contribute to more complications, subsequently causing the increased lengths of stay and higher total charges seen in our study.…”