Spectrum of pathogens in acute cholangitis in patients with and without biliary endoprosthesis

Weber, Andreas; Schneider, Ján; Wagenpfeil, Stefan; Winkle, Philipp; Riedel, Jochen; Wantia, Nina; Feihl, Susanne; Römmler, Franziska; Baur, Dorothee M.; Schmid, Roland M.; Algül, Hana; Huber, Wolfgang

doi:10.1016/j.jinf.2013.04.008

Cited by 41 publications

(44 citation statements)

References 20 publications

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“…Anaerobes were detected in less than 10% of our patients. These results are consistent with other recent reports [7][8][9][10] and revise the classic view that both enterobacterales and anaerobes are the most important pathogens in biliary tract infections [11]. Bacteremia was detected in one third of cases with available blood culture results.…”

Section: Discussionsupporting

confidence: 92%

“…Reflecting their differing virulence, and in agreement with a recent large multicenter trial on biliary infections, enterobacterales comprised almost 60% and enterococci only 20% of blood culture isolates [2]. In line with previous studies, our multivariate analysis found the presence of a biliary prosthesis an independent predictor for enterococcal isolation from bile [3,9,12,13]. The Tokyo guideline recommends empirical treatment covering enterococci in severe community-acquired cholangitisand in health-care associated infections if patients are colonized or enterococci are otherwise of concern.…”

Section: Discussionsupporting

confidence: 88%

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Use of microbiological and patient data for choice of empirical antibiotic therapy in acute cholangitis

et al. 2020

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Background: Ineffective antibiotic therapy increases mortality of acute cholangitis. The choice of antibiotics should reflect local resistance patterns and avoid the overuse of broad-spectrum agents. In this study, we analysed how results of bile and blood cultures and patient data can be used for selection of empirical antibiotic therapy in acute cholangits. Methods: Pathogen frequencies and susceptibility rates were determined in 423 positive bile duct cultures and 197 corresponding blood cultures obtained from 348 consecutive patients with acute cholangitis. Patient data were retrieved from the medical records. Associations of patient and microbiological data were assessed using the Chi-2 test and multivariate binary logistic regression. Results: In bile cultures, enterobacterales and enterococci were isolated with equal frequencies of approximately 30% whereas in blood cultures, enterobacterales predominated (56% compared to 21% enterococci). Antibiotic resistance rates of enterobacterales were > 20% for fluorochinolones, cephalosporines and acylureidopenicillins but not for carbapenems (< 2%). The efficacy of empirical therapy was poor with a coverage of bacterial bile and blood culture isolates in 51 and 69%, respectively. By multivariate analysis, predictors for pathogen species, antibiotic susceptibility and expected antibiotic coverage were identified. Conclusions: In unselected patients treated for acute cholangitis in a large tertiary refferential center, use of carbapenems seems necessary to achieve a high antibiotic coverage. However, by analysis of patient and microbiological data, subgroups for highly effective carbapenem-sparing therapy can be defined. For patients with community-acquired cholangitis without biliary prosthesis who do not need intensive care, piperacillin/tazobactam represents a regimen with an expected excellent antibiotic coverage.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionsupporting

confidence: 88%

Use of microbiological and patient data for choice of empirical antibiotic therapy in acute cholangitis

et al. 2020

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“…were the biliary pathogens most frequently observed in a recent study from a German tertiary center, with an even higher proportion of Enterococcus spp. found in patients who had undergone BD stenting [10]. Bile from healthy individuals is sterile; however, in patients with BD pathologies, bacterial or fungal colonization of the bile without clinical signs of infection may occur [11,12] in up to 100% of patients with biliary stents [13], which can be difficult to discriminate from AC [14].…”

Section: Introductionmentioning

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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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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“…The authors concluded that the initiation of biliary sludge formation on biliary stents requires vital bacteria. Furthermore, any catheter embedded in the human organism constitutes a foreign matter, influencing the local bacterial flora [15] , [16] . In a previous retrospective study [16] , we could show that the incidences of Enterococcus spp.…”

Section: Introductionmentioning

confidence: 99%

“…Furthermore, any catheter embedded in the human organism constitutes a foreign matter, influencing the local bacterial flora [15] , [16] . In a previous retrospective study [16] , we could show that the incidences of Enterococcus spp. and non-fermenting bacteria were significantly higher in cholangitis episodes with biliary endoprosthesis compared to cholangitis episodes without biliary endoprosthesis.…”

Section: Introductionmentioning

confidence: 99%

Biliary Endoprosthesis: A Prospective Analysis of Bacterial Colonization and Risk Factors for Sludge Formation

et al. 2014

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Bacterial colonization of biliary stents is one of the driving forces behind sludge formation which may result in stent occlusion. Major focus of the study was to analyze the spectrum and number of microorganisms in relation to the indwelling time of stents and the risk factors for sludge formation. 343 stents were sonicated to optimize the bacterial release from the biofilm and identified by matrix-associated laser desorption/ionization-time of flight mass spectrometer (MALDI-TOF). 2283 bacteria were analyzed in total. The most prevalent microorganisms were Enterococcus species (spp.) (504;22%), followed by Klebsiella spp. (218;10%) and Candida spp. (188;8%). Colonization of the stents mainly began with aerobic gram-positive bacteria (43/49;88%) and Candida spp. (25/49;51%), whereas stents with an indwelling time>60 days(d) showed an almost equal colonization rate by aerobic gram-negative (176/184;96%) and aerobic gram-positive bacteria (183/184;99%) and a high proportion of anaerobes (127/184;69%). Compared to stents without sludge, more Clostridium spp. [(P = 0.02; Odds Ratio (OR): 2.4; 95% confidence interval (95%CI): (1.1–4.9)]) and Staphylococcus spp. [(P = 0.03; OR (95%CI): 4.3 (1.1–16.5)] were cultured from stents with sludge. Multivariate analysis revealed a significant relationship between the number of microorganisms [P<0.01; OR (95%CI): 1.3(1.1–1.5)], the indwelling time [P<0.01; 1–15 d vs. 20–59 d: OR (95%CI): 5.6(1.4–22), 1–15 d vs. 60–3087 d: OR (95% CI): 9.5(2.5–35.7)], the presence of sideholes [P<0.01; OR (95%CI): 3.5(1.6–7.9)] and the occurrence of sludge. Stent occlusion was found in 70/343(20%) stents. In 35% of cases, stent occlusion resulted in a cholangitis or cholestasis. In conclusion, microbial colonization of the stents changed with the indwelling time. Sludge was associated with an altered spectrum and an increasing number of microorganisms, a long indwelling time and the presence of sideholes. Interestingly, stent occlusion did not necessarily lead to a symptomatic biliary obstruction.

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Spectrum of pathogens in acute cholangitis in patients with and without biliary endoprosthesis

Cited by 41 publications

References 20 publications

Use of microbiological and patient data for choice of empirical antibiotic therapy in acute cholangitis

Use of microbiological and patient data for choice of empirical antibiotic therapy in acute cholangitis

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

Biliary Endoprosthesis: A Prospective Analysis of Bacterial Colonization and Risk Factors for Sludge Formation

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