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Evaluation of Biliary Bacterial Resistance in Patients with Frequent Biliary Instrumentation, One Size Does Not Fit All

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Abstract

Background

Bacteremia due to cholangitis can occur as a complication of biliary instrumentation. Biliary sepsis can result from frequent endoscopic retrograde cholangiopancreatography (ERCP).

Methods

We hypothesized that routine use of antibiotics in patients who require frequent ERCPs leads to cholangitis resistant to empiric antibiotics used to treat biliary sepsis. We retrospectively reviewed patients with frequent biliary instrumentation and blood stream infection due to cholangitis. Conventional empiric antibiotics were defined as broad-spectrum antibacterial agents predominantly used for community-acquired infections and surgical prophylaxis. Broad-spectrum antibacterial agents used for hospital-onset/multidrug-resistant infections were defined as broad-spectrum MDR antibiotics.

Results

Seventy-eight patients had bacteremia secondary to cholangitis from biliary obstruction. Over 50% of bacteria were not sensitive to conventional empiric antibiotics for biliary sepsis. Thirty-seven patients did not receive post-procedural antibiotics and forty-one patients did. Of the ones who did, 58% later had a bloodstream infection with bacteria resistant to the antibiotic used for prophylaxis, and 26 patients (63%) required a broad-spectrum MDR antibiotic for treatment. The number of ERCPs was not associated with resistance to prophylactic antibiotics (p 0.7103) or needing broad-spectrum MDR antibiotics for treatment of cholangitis-associated bacteremia (p 0.1868). Routine use of antibiotic prophylaxis after ERCP was associated with trend toward need for broad-spectrum MDR antibiotics for cholangitis-associated bacteremia, Chi-square 3.7, 0 0.0540.

Conclusion

Bacterial resistance to conventional empiric antibiotics is an emerging problem. Blood cultures are needed to guide therapy.

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Abbreviations

ERCP:

Endoscopic retrograde cholangiopancreatography

CPT:

Current Procedural Terminology

CDC:

Centers for Disease Control’s (CDC)

MDR:

Multidrug resistant

IQR:

Interquartile range

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Authors and Affiliations

  1. Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Iowa Hospitals and Clinics, 4544 JCP, 200 Hawkins Drive, Iowa City, IA, 52242, USA

    Maen Masadeh, Frederick Johlin & William Silverman

  2. Department of Internal Medicine, Creighton University, 18717 Nicholas Street, Elkhorn, NE, 68022, USA

    Subhash Chandra

  3. Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Hospitals and Clinics, SW 34-G GH, 200 Hawkins Drive, Iowa City, IA, 52242, USA

    Daniel Livorsi

  4. Department of Internal Medicine, University of Iowa Hospitals and Clinics, 4553 JCP, 200 Hawkins Drive, Iowa City, IA, 52242, USA

    William Silverman

Authors
  1. Maen Masadeh
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  2. Subhash Chandra
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  3. Daniel Livorsi
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  4. Frederick Johlin
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  5. William Silverman
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Correspondence to William Silverman.

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Masadeh, M., Chandra, S., Livorsi, D. et al. Evaluation of Biliary Bacterial Resistance in Patients with Frequent Biliary Instrumentation, One Size Does Not Fit All. Dig Dis Sci 63, 3474–3479 (2018). https://doi.org/10.1007/s10620-018-5263-5

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  • DOI: https://doi.org/10.1007/s10620-018-5263-5

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