Short-Course Antibiotic Treatment Is Not Inferior to a Long-Course One in Acute Cholangitis: A Systematic Review

Abstract

Aims Our aim was to summarize the available literature on the effect of short- versus long-course antibiotic therapy on acute cholangitis. Methods A systematic review was performed according to the PRISMA Statement. We searched three databases for papers discussing the length of ABT in acute cholangitis. Long and short therapy groups were defined based on the most recent guideline available at the time of publication of the articles. Primary outcomes were the rate of recurrent cholangitis and mortality; secondary outcomes included length of hospitalization and the duration of fever after ERCP. Data were extracted on these outcomes and on general characteristics. A narrative synthesis was then provided based on collected data. Results Out of 692 articles produced by our search, four met our inclusion and exclusion criteria. These contained 205 acute cholangitis patients, with 137 and 68 patients receiving short and long antibiotic therapy, respectively. No significant difference was observed in any of the studies on the outcomes of mortality and duration of fever after ERCP between the two groups. One out of four studies found the rate of recurrent cholangitis to be significantly lower in the short antibiotic therapy group (0.0% vs. 13.3%, p = 0.036). Length of hospitalization was only compared in the same retrospective article, where it was found to be significantly shorter in the short-term antibiotic therapy group (with a median of 14 vs. 17.5 days, p < 0.001). Conclusions Our review suggests short-course antibiotic therapy is non-inferior to long-course treatment; however, several limitations underline the need for well-designed randomized trials. Electronic supplementary material The online version of this article (10.1007/s10620-018-5327-6) contains supplementary material, which is available to authorized users.

Antimicrobial therapy of 3 days or less is sufficient after successful ERCP for acute cholangitis

“…The combination of biliary drainage by endoscopic retrograde cholangio‐pancreatography (ERCP) and antimicrobial therapy is the cornerstone of treatment of acute cholangitis 2 3 . However, the optimal duration of antimicrobial therapy is unclear, because there is limited research conducted on this matter 4–9 . Consensus‐based recommendations on antimicrobial treatment duration in current (inter)national guidelines therefore vary from 3 days or less up to 10 days 10–13 .…”

“…2,3 However, the optimal duration of antimicrobial therapy is unclear, because there is limited research conducted on this matter. [4][5][6][7][8][9] Consensus-based recommendations on antimicrobial treatment duration in current (inter) national guidelines therefore vary from 3 days or less up to 10 days. [10][11][12][13] Unnecessary prolonged antimicrobial therapy increases risk of mortality and side-effects, such as diarrhoea and colitis due to Clostridioides difficile infection.…”

Validation of Tokyo Guidelines 2007 and Tokyo Guidelines 2013/2018 Criteria for Acute Cholangitis and Predictors of In-Hospital Mortality

“…However, validation of the TG07 remains poor outside Japan [7, 8]. The Charcot triad is traditionally considered diagnostic for AC; however, it has a low sensitivity [13, 14]. In addition to the Charcot triad, TG07 diagnostic criteria include a history of biliary disease, and it has an increased diagnostic sensitivity for the diagnosis of AC [4, 15].…”

Duration of antibiotic therapy for common infections

“…The authors concluded that provided there was source control, a shorter course of less than a week did not result in higher mortality, duration of fever or higher rates of recurrence. (60) Guidelines from the Surgical Infection Society (SIS) (2017) and the IDSA (2010) advocate < 7 days of therapy for patients with source control. (57,61) Tokyo Guidelines for management of acute cholangitis recommend drainage or source control as the mainstay of therapy followed by 4-7 days of appropriate targeted antimicrobial therapy.…”