Risk factors and outcome in patients with primary sclerosing cholangitis with persistent biliary candidiasis

Rupp, Christian; Bode, Konrad A.; Chahoud, Fadi; Wannhoff, Andreas; Friedrich, Kilian; Weiss, Karl-Heinz; Sauer, Peter; Stremmel, Wolfgang; Gotthardt, Daniel

doi:10.1186/s12879-014-0562-8

Cited by 31 publications

(16 citation statements)

References 37 publications

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“…Second, the bile samples were obtained primarily by ERCP and may have been contaminated by the autologous oral and duodenal microflora. Although routine bile sampling during ERCP is not generally recommended by current guidelines, it is widely performed in clinical practice in Germany as it allows the identification of pathogens and their antibiotic susceptibility providing a rationale for antibiotic therapy in patients at risk for MDR pathogens [30,31]. This approach is justified by the arguments that the highest bacterial burden during AC is suspected to be in the biliary system, that blood cultures show a lower sensitivity than bile cultures in AC but–if positive–are in high concordance with the corresponding bile cultures, and that even if duodenal contamination may play a role–the presence of MDR gut bacteria may itself impose a risk factor for ascending AC by MDR.…”

Section: Discussionmentioning

confidence: 99%

“…Fourth, because no significant short-term mortality occurred after AC in our study–even in the absence of antibiotic therapy—there were no hard end-points to prove the failure of antibiotic therapy. Recent studies that could show an association between the microbial bile profile and survival were performed retrospectively and identified MDR bacteria or fungi as risk factors for mortality in patients with malignant biliary obstruction [32], primary sclerosing cholangitis [30] or a liver transplant [28,33]. Whether this association was causative and how it can be addressed by appropriate treatment is unknown.…”

Section: Discussionmentioning

confidence: 99%

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Risk Factors for Multi-Drug Resistant Pathogens and Failure of Empiric First-Line Therapy in Acute Cholangitis

et al. 2017

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BackgroundAcute cholangitis (AC) requires the immediate initiation of antibiotic therapy in addition to treatment for biliary obstruction. Against a background of an increasing prevalence of multi-drug resistant (MDR) bacteria, the risk factors for the failure of empiric therapy must be defined.MethodsUsing a pathogen-based approach, 1764 isolates from positive bile duct cultures were retrospectively analyzed to characterize the respective pathogen spectra in two German tertiary centers. Using a patient-based approach, the clinical and laboratory data for 83 patients with AC were assessed to identify risk factors for AC with pathogens resistant to the applied empiric therapy.ResultsBile cultures were predominantly polymicrobial, and empiric antibiotic therapies did not cover the full biliary pathogen spectrum in 78% of cases. MDR bacteria were isolated from the bile of 24/83 (29%) patients. The univariate risk factors for biliary MDR bacteria were male sex, nosocomial AC, prior antibiotic exposure and prior biliary stenting, of which biliary stenting was the only independent risk factor according to multivariate analysis (OR = 3.8; 95% CI 1.3–11.0, P = 0.013). Although there were no significant differences in survival or hospital stay in AC patients with and without detected biliary MDR pathogens, the former more often had a concomitant bloodstream infection (58% vs. 24%; P = 0.019), including those involving MDR pathogens or fungi (21% vs. 2%; P = 0.007).ConclusionPatients with biliary stents who develop AC should receive empiric therapy covering enterococci and extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae. These patients are at an increased risk for bloodstream infections by MDR pathogens or fungi.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Risk Factors for Multi-Drug Resistant Pathogens and Failure of Empiric First-Line Therapy in Acute Cholangitis

et al. 2017

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“…Worse prognosis in the late‐onset cohort may be in part explained by an increased frequency of infectious complications that could aggravate disease progression 20 . This may be explained by mechanisms of immunosenescence and a subsequently impaired immune response 21 .…”

Section: Discussionmentioning

confidence: 99%

Impact of age at diagnosis on disease progression in patients with primary sclerosing cholangitis

et al. 2018

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Background: The median age of diagnosis of primary sclerosing cholangitis (PSC) is $30-40 years. Objective: We aimed to analyse disease progression and liver-dependent survival in patients diagnosed with PSC after 50 years of age. Methods: Patients with PSC were analysed with regard to their age at diagnosis. Patients with a first diagnosis of PSC after the age of 50 years were considered as the late-onset group. Results: A total of 32/215 (14.9%) patients were diagnosed with PSC after 50 years of age. The proportion of females was significantly higher among patients with late-onset PSC (48.4 vs. 27.3%; p ¼ 0.02). Patients with later diagnosis required dilatation therapy more often due to dominant stenosis (84.2 vs. 53.1%; p ¼ 0.01) and suffered from recurrent cholangitis more often (48.3 vs. 21.0%; p ¼ 0.003). Patients with late-onset PSC had reduced transplantation-free survival (10.5 AE 0.6 years vs. 20.8 AE 1.7 years, p < 0.0001), with progredient liver failure and cholangiocarcinoma as the leading causes of death. Conclusions: Patients with later age at diagnosis of PSC displayed a different clinical phenotype with a different sex ratio, immune status and an increased risk for progressive liver failure and biliary malignancies.

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“…Thus, existing data on biliary stent microbial communities may be biased and incomplete [ 1 ]. Notably, even available information on culturable bacteria is not static and shows a recent trend toward pathogens such as extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae , enterococci, and Candida species [ 10 , 23 – 28 ]. Thus, standard antimicrobial therapy concepts for patients with cholangitis, which mainly target sensitive Enterobacteriaceae and anaerobes, need to be reevaluated [ 25 – 28 ].…”

Section: Introductionmentioning

confidence: 99%

Epidemiology and Resistance Patterns of Bacterial and Fungal Colonization of Biliary Plastic Stents: A Prospective Cohort Study

et al. 2016

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BackgroundPlastic stents used for the treatment of biliary obstruction will become occluded over time due to microbial colonization and formation of biofilms. Treatment of stent-associated cholangitis is often not effective because of inappropriate use of antimicrobial agents or antimicrobial resistance. We aimed to assess the current bacterial and fungal etiology of stent-associated biofilms, with particular emphasis on antimicrobial resistance.MethodsPatients with biliary strictures requiring endoscopic stent placement were prospectively enrolled. After the retrieval of stents, biofilms were disrupted by sonication, microorganisms were cultured, and isolates were identified by matrix-associated laser desorption/ionization time-of-flight (MALDI-TOF) mass spectrometry and/or biochemical typing. Finally, minimum inhibitory concentrations (MICs) were determined for various antimicrobial agents. Selected stents were further analyzed by fluorescence in situ hybridization (FISH).ResultsAmong 120 patients (62.5% males, median age 64 years) with biliary strictures (35% malignant, 65% benign), 113 double pigtail polyurethane and 100 straight polyethylene stents were analyzed after a median indwelling time of 63 days (range, 1–1274 days). The stent occlusion rate was 11.5% and 13%, respectively, being associated with a significantly increased risk of cholangitis (38.5% vs. 9.1%, P<0.001). Ninety-five different bacterial and 13 fungal species were detected; polymicrobial colonization predominated (95.8% vs. 4.2%, P<0.001). Enterococci (79.3%), Enterobacteriaceae (73.7%), and Candida spp. (55.9%) were the leading pathogens. Candida species were more frequent in patients previously receiving prolonged antibiotic therapy (63% vs. 46.7%, P = 0.023). Vancomycin-resistant enterococci accounted for 13.7%, extended-spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae with co-resistance to ciprofloxacin accounted for 13.9%, and azole-resistant Candida spp. accounted for 32.9% of the respective isolates.ConclusionsEnterococci and Candida species play an important role in the microbial colonization of biliary stents. Therefore, empirical antimicrobial treatment of stent-associated cholangitis should be guided toward enterococci, Enterobacteriaceae, streptococci, anaerobes, and Candida. To determine causative pathogens, an accurate microbiological analysis of the extracted stent(s) may be helpful.

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Risk factors and outcome in patients with primary sclerosing cholangitis with persistent biliary candidiasis

Cited by 31 publications

References 37 publications

Risk Factors for Multi-Drug Resistant Pathogens and Failure of Empiric First-Line Therapy in Acute Cholangitis

Risk Factors for Multi-Drug Resistant Pathogens and Failure of Empiric First-Line Therapy in Acute Cholangitis

Impact of age at diagnosis on disease progression in patients with primary sclerosing cholangitis

Epidemiology and Resistance Patterns of Bacterial and Fungal Colonization of Biliary Plastic Stents: A Prospective Cohort Study

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