Severity | Community-acquired biliary infections | Health-care-associated biliary infections* | ||
Grade I | Grade II | Grade III* | ||
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◊ |
Cefmetazole,Δ cefoxitin,Δ flomoxef,Δ cefoperazone/sulbactam | Cefoperazone/sulbactam | |||
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◊ | – | – |
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.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: permissions@wiley.com 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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