Antibiotic Therapy of 3 Days May Be Sufficient After Biliary Drainage for Acute Cholangitis: A Systematic Review

Abstract

Background The optimal antibiotic therapy duration for cholangitis is unclear. Guideline recommendations vary between 4 and 14 days after biliary drainage. Clinical observations and some evidence however suggest that shorter antibiotic therapy may be sufficient. Objective To compare the effectiveness and safety of short-course therapy of ≤ 3 days with long-course therapy of ≥ 4 days after biliary drainage in cholangitis patients. Methods We searched the databases PubMed, EMBASE, Cochrane Library, and trial registers for literature up to August 5, 2020. RCTs and observational studies including case series reporting on antibiotic therapy duration for acute cholangitis were eligible for inclusion. Two reviewers independently evaluated study eligibility, extracted data, assessed risk of bias and quality of evidence. A meta-analysis was planned if the included studies were comparable with regard to important study characteristics. Primary outcomes included recurrent cholangitis, subsequent other infection, and mortality. Results We included eight studies with 938 cholangitis patients. Four observational studies enrolled patients treated for ≤ 3 days. Recurrent cholangitis occurred in 0-26.8% of patients treated with short-course therapy, which did not differ from long-course therapy (range 0-21.1%). Subsequent other infection and mortality rates were also comparable. Quality of available evidence was very low. Conclusion There is no high-quality evidence available to draw a strong conclusion, but heterogeneous observational studies suggest that antibiotic therapy of ≤ 3 days is sufficient in cholangitis patients with common bile duct stones.

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

“…Our investigation suggests that the outcomes of patients with AC with multiple hilar biliary obstructions may be poor. Although it is challenging to fully align our definition of outcomes with those of previous reports, the clinical cure rate of Group 3 was 87.1%, which is inferior when compared with those of Groups 1 and 2 or previous reports 4–6 . Unlike the simple obstruction in the bile ducts outside the liver, in cases of multiple hilar biliary obstructions, it is sometimes difficult to achieve complete drainage of the entire bile duct.…”

“…19 We considered antimicrobial therapy duration as an important factor to investigate based on previous reports indicating that it can be shortened compared with the recommended duration in the TG18. [4][5][6] To assess the conditions of patients immediately before the discontinuation of antibiotics, we incorporated NEWS into our analysis. The United Kingdom's National Early Warning Score Development and Implementation Group developed the NEWS to assess deteriorating conditions in hospitalized patients and to predict inpatient death or intensive care unit (ICU) admission.…”

“…This evidence proposes that administering antimicrobials for a short duration after biliary drainage represents a viable and reasonable approach for the treatment of AC. [4][5][6] To our knowledge, no study has investigated whether AC resulting from multiple hilar biliary obstructions requires a similar duration of antimicrobial treatment as AC resulting from simple obstruction in the extrahepatic bile duct, which the TG18 guidelines treat equally. 3 Bismuth-IV obstruction (Figure S1, Supporting information) has been reported to have a higher clinical failure rate for bile duct drainage than other hilar obstruction.…”

“…Recent research findings suggest that the brief use of antimicrobials, lasting only 1–3 days following biliary drainage, is comparable in efficacy to the conventional treatment duration for AC. This evidence proposes that administering antimicrobials for a short duration after biliary drainage represents a viable and reasonable approach for the treatment of AC 4–6 …”

Early and Direct Endoscopic Stone Removal in the Moderate Grade of Acute Cholangitis with Choledocholithiasis Was Safe and Effective: A Prospective Study

“…In acute cholangitis, the Tokyo Guidelines 2018 (TG18) recommend 4-7 days of antibiotic treatment for patients with acute cholangitis once the source of infection is controlled, but evidence for this was graded as low (evidence level C) [36]. Most studies discussed the early ERCP for acute cholangitis regarding biliary drainage only [37]. Rare studies reported the duration of antibiotics after single-stage ERCP stone removal.…”