Antimicrobial recommendations for acute biliary infections

Severity	Community-acquired biliary infections			Health-care-associated biliary infections*
Severity	Grade I	Grade II	Grade III*	Health-care-associated biliary infections*
Antimicrobial agents	Cholangitis and cholecystitis	Cholangitis and cholecystitis	Cholangitis and cholecystitis	Health-care-associated cholangitis and cholecystitis
Penicillin-based therapy	Ampicillin/sulbactam^¶ is not recommended if >20% resistance rate	Piperacillin/tazobactam	Piperacillin/tazobactam	Piperacillin/tazobactam
Cephalosporin-based therapy	Cefazolin,^Δ or cefotiam,^Δ or cefuroxime,^Δ or ceftriaxone, or cefotaxime ± metronidazole^◊	Ceftriaxone, or cefotaxime, or cefepime, or cefozopran, or ceftazidime ± metronidazole^◊	Cefepime, or ceftazidime, or cefozopran ± metronidazole^◊	Cefepime, or ceftazidime, or cefozopran ± metronidazole^◊
Cephalosporin-based therapy	Cefmetazole,^Δ cefoxitin,^Δ flomoxef,^Δ cefoperazone/sulbactam	Cefoperazone/sulbactam	Cefepime, or ceftazidime, or cefozopran ± metronidazole^◊	Cefepime, or ceftazidime, or cefozopran ± metronidazole^◊
Carbapenem-based therapy	Ertapenem	Ertapenem	Imipenem/cilastatin, meropenem, doripenem, ertapenem	Imipenem/cilastatin, meropenem, doripenem, ertapenem
Monobactam-based therapy	–	–	Aztreonam ± metronidazole^◊	Aztreonam ± metronidazole^◊
Fluoroquinolone-based therapy^§	Ciprofloxacin, levofloxacin, pazufloxacin ± metronidazole^◊	Ciprofloxacin, levofloxacin, pazufloxacin ± metronidazole^◊	–	–
Fluoroquinolone-based therapy^§	Moxifloxacin	Moxifloxacin	–	–

* Vancomycin is recommended to cover Enterococcus spp for grade III community-acquired acute cholangitis and cholecystitis and health-care-associated acute biliary infections. Linezolid or daptomycin is recommended if vancomycin-resistant Enterococcus (VRE) is known to be colonizing the patient, if previous treatment included vancomycin, and/or if the organism is common in the community.

¶ Ampicillin/sulbactam has little activity left against Escherichia coli. It has been removed from the North American guidelines^[1,2].

Δ Local antimicrobial susceptibility patterns (antibiogram) should be considered for use.

◊ Antianaerobic therapy, including use of metronidazole, tinidazole, or clindamycin, is warranted if a biliary-enteric anastomosis is present. The carbapenems, piperacillin/tazobactam, ampicillin/sulbactam, cefmetazole, cefoxitin, flomoxef, and cefoperazone/sulbactam have sufficient antianaerobic activity for this situation.

§ Fluoroquinolone use is recommended if the susceptibility of cultured isolates is known or for patients with beta-lactam allergies. Many extended-spectrum beta-lactamase (ESBL)-producing gram-negative isolates are fluoroquinolone resistant.

References:

Mazuski JE, Tessier JM, May AK, et al. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect (Larchmt) 2017; 18:1.
Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: Guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis 2010; 50:133.

From: Gomi H, Solomkin JS, Schlossberg D, et al. Tokyo Guidelines 2018: Antimicrobial therapy for acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Sci 2018; 25(1):3-16. https://onlinelibrary.wiley.com/doi/abs/10.1002/jhbp.518. Copyright © 2018 Japanese Society of Hepato-Biliary-Pancreatic Surgery. Reproduced with permission of John Wiley & Sons Inc. This image has been provided by or is owned by Wiley. Further permission is needed before it can be downloaded to PowerPoint, printed, shared or emailed. Please contact Wiley's permissions department either via email: [email protected] or use the RightsLink service by clicking on the 'Request Permission' link accompanying this article on Wiley Online Library (http://onlinelibrary.wiley.com).

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Antimicrobial recommendations for acute biliary infections