Review of the Tokyo Guidelines 2018: Antimicrobial Therapy for Acute Cholangitis and Cholecystitis

Buckman, Sara; Mazuski, John E.

doi:10.1001/jamasurg.2019.2169

Cited by 12 publications

(13 citation statements)

References 9 publications

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“…Given the development of an increasing amount of antimicrobial resistance ( Buckman and Mazuski, 2019 ), sample cultures and susceptibility tests should be performed as soon as possible for patients with choledocholithiasis, especially those with acute cholangitis. In addition to the decision for antimicrobial usage, this study demonstrated the predictive value of specific microorganisms from bile for patient conditions.…”

Section: Discussionmentioning

confidence: 99%

Biliary Microbiota in Choledocholithiasis and Correlation With Duodenal Microbiota

Han

Fan

et al. 2021

Front. Cell. Infect. Microbiol.

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BackgroundThe pathogenesis of choledocholithiasis is closely related to the role of bacteria. However, little is known about the predictive role of bile bacteria in clinical conditions of patients and the compositional and functional characteristics of biliary microbiota in choledocholithiasis.MethodsTo investigate the predictive value of biliary bacteria, clinical data of 488 patients with choledocholithiasis were collected. The predictive value of common bile bacteria to patients’ clinical conditions was analyzed by logistic regression. Samples of bile and corresponding duodenal juice from 10 selected patients with choledocholithiasis were obtained, and the composition and function of microbial communities were analyzed based on 16S rRNA sequencing and Tax4Fun.ResultsThe clinical conditions of patients with choledocholithiasis, such as recurrence, the severity of acute cholangitis, and duration of hospital stay were closely related to different species of bile bacteria as well as antimicrobial-resistant bacteria. Employing 16S rRNA sequencing, the dominant phyla of biliary and duodenal microbiota were Proteobacteria and Firmicutes. The top three core microbiota at the genus level were Escherichia–Shigella, Fusobacterium, and Enterococcus. Escherichia coli accounted for the most abundant annotated species in both. Differences in composition between biliary and duodenal microbiota were not significant according to the alpha and beta diversities. Differential abundant features were not found in biliary microbiota indicated by A linear discriminant analysis effective size algorithm. The major pathways identified in biliary and duodenal microbiota were related to membrane transport, translation, replication and repair, carbohydrate and amino acid metabolism. However, no significant difference in those major pathways, as well as antimicrobial-resistance patterns, was observed between biliary and duodenal microbiota.ConclusionOur study first demonstrates the predictive contribution of biliary bacteria to the clinical conditions of patients with choledocholithiasis, and then it offers new insights into the compositional and functional features of biliary and duodenal microbiota. Similarities between biliary and duodenal microbiota support the theory of bacterial duodenal–biliary reflux in patients with choledocholithiasis. Meanwhile, when it is impracticable to obtain a bile sample, duodenal juice may be used as an alternative for bacterial culture and susceptibility tests.

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Section: Discussionmentioning

confidence: 99%

Biliary Microbiota in Choledocholithiasis and Correlation With Duodenal Microbiota

Han

Fan

et al. 2021

Front. Cell. Infect. Microbiol.

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“…The emergency admission to the hospital has not shown to be significant in the decision to place surgical drain. Probably, the correct selection of the patient undergoing surgery, in accordance with the 2018 Tokyo Guidelines (28,29), plays a key role. For example, in the case of fragile patients with emergency admission, it is preferable to adopt a conservative treatment with percutaneous drainage and antimicrobial therapy scheduling elective surgery subsequently, reducing the risk to place a drain (30)(31)(32)(33)(34).…”

Section: Discussionmentioning

confidence: 99%

Predictive Factors for Drain Placement After Laparoscopic Cholecystectomy

et al. 2022

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PurposeCurrently, surgical drainage during a laparoscopic cholecystectomy (LC) is still placed in selected patients. Evidence of the non-beneficial effect of the surgical drain comes from studies with a heterogeneous population. This preliminary study aims to identify any clinical, demographic, or intraoperative predictive factors for a surgical drain placement during LC as the first step to identify population for a prospective randomized study.MethodThe study was conducted in a single referral center and academic hospital between 2014 and 2018. Patients who underwent unconverted LC were divided into two groups: Group A (drain) and Group B (no drain). We explored baseline, preoperative, intraoperative characteristics, and postoperative outcomes.ResultsBetween 409 patients who underwent LC: 90 (22%) patients were in Group A (drain). Age >64 years, male sex, cholecystitis, Charlson comorbidity index (CCI) ≥ 1, experienced surgeon, intraoperative technical difficulties, need for an additional trocar, operative time >60 min, and estimated blood loss >10 ml were predictive factors at univariate analysis. While at multivariate analysis, cholecystitis (odds ratio [OR]: 2.8, 95% CI:1.5–5.1; p < 0.001), CCI ≥ 1 (OR:1.9, 95% CI:1.0–3.5; p = 0.05), intraoperative technical difficulties (OR: 3.6, 95% CI:1.8–6.2; p < 0.001), need of an additional trocar (OR: 2.5, 95% CI: 1.4–4.4; p < 0.005), and estimated blood loss >10 ml (OR: 3.0, 95% CI:1.7–5.3; p < 0.0001) were predictive factors for a surgical drain placement during LC.ConclusionsThis study identified predictive factors that currently drive the surgeons to a surgical drain placement after LC. Randomized prospective studies are needed to define the use of drain placement in these selected patients.

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“…Recognizing that prompt diagnosis of biliary sepsis and initiation of appropriate antimicrobial therapy and source control are cornerstones in the treatment of acute cholecystitis and biliary pancreatitis, TG18 recommends obtaining blood cultures on admission 14 . However, just 24 per cent of respondents reported following this guideline for cholecystitis and 32 per cent for pancreatitis.…”

Section: Discussionmentioning

confidence: 99%

“…The TG18 expert group 2 proposed a management bundle emphasizing the prompt diagnosis of acute cholecystitis, biliary pancreatitis and cholangitic choledocholithiasis, and early evaluation of surgical risk, with the commencement of appropriate resuscitation and antimicrobial administration. To guide appropriate antimicrobial management based on local antimicrobial susceptibility data, blood and/or bile cultures are strongly recommended in TG18 14 . For definitive treatment of moderate or severe disease presentation, TG18 advocates early cholecystectomy (within 7 days, but preferably within 72 h) and/or biliary drainage where patient factors allow, reserving delayed cholecystectomy for cases in which delayed presentation, negative physiological factors or patient co‐morbidity favoured non‐operative management 2,11,12 .…”

Section: Introductionmentioning

confidence: 99%

Self-reported and actual adherence to the Tokyo guidelines in the European snapshot audit of complicated calculous biliary disease

et al. 2020

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Background: Complicated acute biliary calculous disease poses clinical challenges. The European Society of Trauma and Emergency Surgery (ESTES) snapshot audit of complicated biliary calculous disease aims to make novel comparisons between self-reported institutional adherence to the Tokyo guidelines (TG18) and 'real-world' contemporary practice across Europe. Methods: A preplanned analysis of a prospective observational multicentre audit that captured patients undergoing emergency admission for complicated biliary calculous disease (complicated cholecystitis, biliary pancreatitis, or choledocholithiasis with or without cholangitis) between 1 and 31 October 2018 was performed. An anonymized survey was administered to participating sites. Results: Following an open call for participation, 25 centres from nine countries enrolled 338 patients. All centres completed the anonymized survey. Fifteen centres (60 per cent) self-reported that a minority of patients were treated surgically on index admission, favouring interval cholecystectomy. This was replicated in the snapshot audit, in which 152 of 338 patients (45⋅0 per cent) underwent index admission cholecystectomy, 17 (5⋅0 per cent) had interval cholecystectomy, and the remaining 169 (50⋅0 per cent) had not undergone surgery by the end of the 60-day follow-up. Centres that employed a dedicated acute care surgery model of care were more likely to perform index admission cholecystectomy compared with a traditional general surgery 'on call' service (57 versus 38 per cent respectively; odds ratio 2⋅14 (95 per cent c.i. 1⋅37 to 3⋅35), P < 0⋅001). Six centres (24 per cent) self-reported routinely performing blood cultures in acute cholecystitis; patient-level audit data revealed that blood cultures were done in 47 of 154 patients (30⋅5 per cent). No centre self-reported omitting antibiotics in the management of acute cholecystitis, and 144 of 154 (93⋅5 per cent) of patients in the snapshot audit received antibiotics during their index admission. Conclusion: Awareness of TG18 recommendations was high, but self-reported adherence and objective snapshot audit data showed low compliance with TG18 in patients with complicated acute biliary calculous disease. Funding information No funding * Members of the ESTES Cohort Studies Group are co-authors of this study and may be found under the heading Collaborators.

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Review of the Tokyo Guidelines 2018: Antimicrobial Therapy for Acute Cholangitis and Cholecystitis

Cited by 12 publications

References 9 publications

Biliary Microbiota in Choledocholithiasis and Correlation With Duodenal Microbiota

Biliary Microbiota in Choledocholithiasis and Correlation With Duodenal Microbiota

Predictive Factors for Drain Placement After Laparoscopic Cholecystectomy

Self-reported and actual adherence to the Tokyo guidelines in the European snapshot audit of complicated calculous biliary disease

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