eMedicine Specialties > Emergency Medicine > Gastrointestinal

Cholangitis: Treatment & Medication

Author: Adam J Rosh, MD, MS, Assistant Professor, Department of Emergency Medicine, Wayne State University/Detroit Receiving Hospital
Coauthor(s): Jeffrey A Manko, MD, Assistant Professor of Clinical Surgery/Emergency Medicine, Director, Emergency Medicine Residency Program, Consulting Staff, Emergency Medicine Services, New York University/Bellevue Medical Center; Sally Santen, MD, Program Director, Assistant Professor, Department of Emergency Medicine, Vanderbilt University
Contributor Information and Disclosures

Updated: Sep 29, 2009

Treatment

Prehospital Care

• Diagnosis of cholangitis is not a prehospital diagnosis. Mild cholangitis may present with abdominal pain, jaundice, and fever. When transporting these patients to the hospital, place the patient on a monitor and insert an intravenous (IV) line.
• In unstable patients with cholangitis, prehospital care should include the following:
  • Immediate assessment of ABCs
  • Monitoring (eg, pulse oximetry, cardiac monitor, frequent blood pressure measurements, blood glucose measurement)
  • Stabilization (eg, oxygen, placement of 2 large-bore IVs, administration of IV fluids to unstable patients)
  • Rapid transport

Emergency Department Care

• Suspect mild cholangitis in patients with jaundice and a fever; consider cholangitis in all patients with sepsis.
• Degree of urgency of treatment depends on severity of illness. Important points are resuscitation, diagnosis, and treatment.
• After assessment of the ABCs, place the patient on a monitor with pulse oximetry, provide oxygen via nasal canula, and obtain an ECG. Draw and send laboratory studies (including blood cultures) when the intravenous line is placed.
• Provide fluid resuscitation with IV crystalloid solution (eg, 0.9% normal saline).
• Administer parenteral antibiotics empirically after blood cultures are drawn. Do not delay administration of antibiotics if blood cultures cannot be drawn.
• Correct any electrolyte abnormalities or coagulopathies.
• For management of patients in septic shock, see Shock, Septic.
• Standard therapy for cholangitis consists of broad-spectrum antibiotics with close observation to determine the need for emergency decompression of the biliary tree.
• A nasogastric tube may be helpful for patients who are vomiting.
• Patients should be nothing by mouth (NPO). Place a Foley catheter in ill patients to monitor urine output.
• The surgical literature states that, in patients with mild cholangitis, 80-90% respond to medical therapy.³ Approximately 15% do not respond and subsequently require immediate surgical or endoscopic decompression. Mortality rates approach 100% for patients who fail medical therapy and do not have surgical decompression.
• In severely ill patients, treatment is immediate biliary decompression. The method depends on the degree of illness. In the past, drainage was performed surgically. Today, options of percutaneous or endoscopic drainage exist in addition to medical management with antibiotics. Endoscopic drainage has been shown to decrease mortality rates from 30% to 10%.
• Medical therapy can be complementary to surgical or endoscopic treatments. In less ill patients, medical treatment may be all that is necessary.
• Maintain medical therapy and consider elective surgery with patients who show improvement. Patients who are being medically managed and do not improve or who deteriorate should rapidly be referred to undergo either ERCP, sphincterotomy, or percutaneous drainage.
• The mainstay of therapy is drainage. ERCP is the best method to accomplish biliary drainage.
• A novel technique that is being used in Asia in the surgical management of acute cholangitis is endoscopic nasobiliary drainage.⁷

Consultations

• Immediately consult a surgeon and a gastroenterologist.
• While most patients respond to antibiotics and conservative care, a subset requires emergent procedures (eg, ERCP, percutaneous drainage). In deciding to drain, consult with a gastroenterologist and a surgeon.
• Increased mortality is observed in patients with hypotension, acute renal failure, liver abscess, cirrhosis, high malignant strictures, female gender, and advanced age. Therefore, consider decompression earlier for these patients. Patients with malignant obstruction usually do not respond to antibiotics (59% compared to 85%).
• Unstable septic patients require clinical judgment to determine if they will survive until medical therapy has a chance to work or if they require emergency decompression with its associated high mortality rate.

Medication

The goal of antimicrobial therapy is to resolve the infection. Debate exists as to whether the most effective antibiotics must have high biliary concentrations. When high intrabiliary pressures exist due to biliary obstruction, whether any antibiotic is excreted effectively into the bile is doubtful, thus making biliary levels irrelevant. The choice of antibiotics should be guided by local sensitivity patterns.

It is critical that antibiotics are administered early in the management of cholangitis. In the ED, empiric antibiotic therapy should cover against gram-negative aerobic enteric organisms (eg, E coli, Klebsiella species, Enterobacter species), gram-positive organisms (eg, Enterococcus and Streptococcus species), and anaerobes (eg, Bacteroides fragilis, Clostridium perfringens). There is an increase of up to 85% in infectious complications when biliary cultures are not susceptible to the empiric antibiotics. Therefore, traditional therapy with ampicillin and an aminoglycoside is now a less ideal regimen secondary to weakened activity of ampicillin against both aerobic and anaerobic gram-negative bacilli, and is concern for nephrotoxicity of aminoglycosides.

Many newer combinations have been shown to be effective as either a single agent or combination therapy. Combinations include extended-spectrum cephalosporin, metronidazole, and ampicillin. Single-agent regimens include piperacillin and tazobactam; mezlocillin; imipenem; meropenem; ticarcillin and clavulanate; or ampicillin and sulbactam, which can also be combined with metronidazole.

In patients with few comorbidities and who are well-appearing, using a single agent such as cefoxitin (second-generation cephalosporin) may be appropriate. However, cefoxitin’s anaerobic coverage is poor. Newer-generation fluoroquinolones (eg, moxifloxacin) also have broad gram-positive and gram-negative coverage and better anaerobic activity, but they are poorly effective against Pseudomonas species. In patients with multiple comorbidities or who are ill-appearing, broad-spectrum antimicrobials with pseudomonal and enterococcal coverage is recommended. Once blood cultures results are available, the antibiotic regimen can be narrowed based on the culture results.

The following dosages are general recommendations. Please check current sources prior to administration.

Antibiotics

Ampicillin (Omnipen, Marcillin)

Interferes with bacterial cell wall synthesis during active multiplication, causing bactericidal activity against susceptible organisms. Must be used in combination.

Metronidazole (Flagyl)

Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Usually used in combination with other antimicrobial agents.

Gentamicin (Gentacidin, Garamycin)

Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes.
Not DOC. Consider if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms.
Dosing regimens are numerous; adjust dose based on CrCl and changes in volume of distribution. May be given IV/IM.
Follow each regimen by at least a trough level drawn on the third or fourth dose (0.5 h before dosing); may draw a peak level 0.5 h after 30-min infusion.

Cefoxitin (Mefoxin)

A second-generation cephalosporin that has broad gram-negative coverage, while retaining efficacy against gram-positive organisms. It also has activity against anaerobes.
However, it lacks pseudomonal and enterococcal coverage.

Piperacillin/tazobactam (Zosyn)

Antipseudomonal penicillin plus beta-lactamase inhibitor. Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active multiplication. Used in combination therapy.

Cefotaxime (Claforan)

Third-generation cephalosporin that has broad gram-negative spectrum, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms.
Arrests bacterial cell wall synthesis and inhibits bacterial growth by binding to one or more of the penicillin-binding proteins.
Can be used in combination with metronidazole or clindamycin.

Clindamycin (Cleocin)

Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Mezlocillin (Mezlin)

During growth phase, interferes with bacterial cell wall synthesis, causing death in susceptible microorganisms. Has antipseudomonal activity. Use in combination therapies.

Imipenem and cilastatin (Primaxin)

A carbapenem; may be used alone or in combination. Used for treatment of multiple-organism infections for which other agents do not have wide-spectrum coverage or are contraindicated due to potential for toxicity.

Meropenem (Merrem)

A carbapenem; may be used alone or in combination. Broad-spectrum carbapenem antibiotic that inhibits cell-wall synthesis and has bactericidal activity. Effective against most gram-positive and gram-negative bacteria.
Has slightly increased activity against gram-negative organisms and slightly decreased activity against staphylococci and streptococci compared to imipenem.

Ticarcillin and clavulanate potassium (Timentin)

Inhibits biosynthesis of cell wall mucopeptide and is effective during stage of active growth.
Antipseudomonal penicillin plus a beta-lactamase inhibitor that provides coverage against most gram-positive and gram-negative organisms and most anaerobes.

Ampicillin and sulbactam sodium (Unasyn)

Combination antimicrobial agent that uses a beta-lactamase inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens.

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