Antimicrobial therapy of 3 days or less is sufficient after successful ERCP for acute cholangitis

Abstract

Background Recommendations for the duration of antimicrobial therapy in cholangitis after successful endoscopic biliary drainage vary. The aim of this study was to compare the occurrence of local infectious complications in patients with acute cholangitis treated with antibiotics for 3 days or less compared with 4 days or more. Methods We performed a retrospective multicentre study in seven hospitals in the Netherlands. Patients who received a successful biliary drainage by endoscopic retrograde cholangio-pancreatography because of cholangitis due to common bile duct stones between 2012 and 2017 were included. The primary outcome was the occurrence of a local infectious complication within 3 months of endoscopic retrograde cholangio-pancreatography. Secondary outcomes included Clostridioides difficile infection, total length of hospital stay and all-cause mortality. Results A total of 426 patients with cholangitis were identified and 296 patients met all inclusion criteria. Therapy duration was ≤3 days in 137 patients (46.3%). During follow-up, 41 patients (13.9%) developed a local infectious complication. Occurrence of infectious complications did not differ between the two groups ( p = 0.32). No patient developed Clostridioides difficile infection. Median hospital stay was 6 days (interquartile range 4–8 days) in the short antibiotic group compared with 7 days (interquartile range 5–9 days) in the long group ( p = 0.03). Four (1.4%) patients died during follow-up, all were treated for ≥4 days ( p = 0.13 ). Conclusions Antimicrobial therapy of 3 days or less seems to be sufficient after successful biliary drainage in patients with acute cholangitis. Randomized trials should confirm our findings.

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

“…We retrieved 41 full-text articles, of which eight met all inclusion criteria ( Fig. 1) [11,[25][26][27][28][29][30][31].…”

“…Patients with different etiologies were enrolled in 5 out of 8 studies [25,26,[28][29][30]. Haal et al and Satake et al compared SCT (≤ 3 days) with LCT (≥ 4 days) [11,31]. In the single-arm study of Kogure et al ABT was stopped after temperature was < 37 °C for 24 h. [26] Van Lent et al compared SCT (≤ 3 days) with mediumcourse therapy (MCT; 4/5 days) and LCT (> 5 days) [30].…”

“…Types of ABT prescribed were penicillins, a combination of a penicillin with a aminoglycoside or fluoroquinolone, cephalosporins, a combination of a cephalosporin with a aminoglycoside or metronidazole, a fluoroquinolone or a carbapenem. The ERCP was performed as soon as possible in the study of Kogure et al [26] In the other studies, the time between admission and the ERCP ranged from within 24 h, [11,25,[27][28][29]] to a maximum of 4.5 days [30,31]. The timing of the drainage differed significantly between the study groups in the studies of Haal et al, Satake et al, and Doi et al [11,25,31].…”

“…The two RCTs were at low risk of bias in three out of five domains, while two out of five domains raised some concerns [27,28]. We considered the observational intervention study of Doi et al to be at moderate risk of bias [25], and the four other observational intervention studies to be at serious risk of bias, especially due to a high risk of confounding [11,[29][30][31]. We judged the prospective single-arm study of Kogure et al to be at moderate risk of bias [26].…”

“…Six studies assessed mortality [11,25,[28][29][30][31]. The studies of Kogure et al and Netinatsunton et al did not report mortality as outcome but we assessed rates of 0%, because all patients visited the outpatient clinic or were contacted by telephone [26,27].…”