IBCC Episode 44 - Community Acquired Biliary Sepsis
Jul 11, 2019
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This episode covers the importance of accurate diagnosis and imaging for community-acquired biliary sepsis and cholecystitis, discusses bacterial pathogens and antibiotic coverage, emphasizes the use of Piptaso and de-escalation in treatment, and explores the risks and considerations of performing ERCP for patients with biliary sepsis.
Cholecystitis tends to be self-contained within the gallbladder, causing less fulminant sepsis compared to ascending cholangitis.
Antibiotic choice should cover gram-negative bacteria, with piperacillin-tazobactam being a commonly recommended option.
Deep dives
Community-acquired biliary tract infections
Community-acquired biliary tract infections, specifically cholecystitis and ascending cholangitis, are discussed in this podcast. The two conditions share similarities in presentation and treatment. Cholecystitis tends to be self-contained within the gallbladder, causing less fulminant sepsis compared to ascending cholangitis. Ascending cholangitis, in contrast, involves bacteria tracking back into the liver and causing rapid deterioration. Common symptoms include right upper quadrant pain, fever, and nausea. Gram-negative bacteria, especially E. coli, are frequently involved, while gram-positive bacteria and anaerobes may also play a role. Antibiotic choice should cover these organisms, with piperacillin-tazobactam being a commonly recommended option. Source control is crucial, with ERCP and percutaneous transhepatic cholangiography (PTC) being procedures used to address biliary obstruction. Acute cholecystitis management may involve percutaneous cholecystostomy or delayed cholecystectomy, depending on the patient's condition and need for source control.
Lab tests and imaging
Lab tests, including blood cultures, lactate, and liver function tests, aid in the diagnosis of biliary tract infections. Ultrasonography is the initial imaging modality of choice, followed by CT if needed for further evaluation. This approach helps identify gallbladder inflammation, obstruction, and complications such as gangrenous or emphysematous cholecystitis. The use of a HIDA scan, while less common, can provide valuable information about biliary flow.
Antibiotics and patient management
Appropriate antibiotic therapy is crucial in the management of community-acquired biliary tract infections. Piperacillin-tazobactam and meropenem are effective in covering gram-negative and some gram-positive bacteria. Vancomycin is generally not needed, and patients with penicillin allergies can often receive piperacillin-tazobactam safely. De-escalation of antibiotics is recommended once source control is achieved. The duration of antibiotics ranges from 4 to 14 days, depending on the severity and nature of the infection. In cases of simultaneous cholecystitis and ascending cholangitis, prompt source control through ERCP or PTC is essential.
Pitfalls and considerations
Pitfalls to avoid include overlooking ascending cholangitis in patients presenting with nonspecific symptoms, failure to choose appropriate antibiotics targeting the most common pathogens, and delays in performing necessary procedures for source control. It is important to be aware of the limitations of different imaging modalities and the need for repeat imaging in certain situations. Overall, an individualized approach is necessary, weighing the risks and benefits of various interventions and adjusting management based on the patient's clinical course.
