A recent retrospective study (SH Baek et al. JPGN 2020; 70: 171-77) provide useful information on cholangitis following a Kasai portoenterostomy in patients (n=160) with biliary atresia (BA).
- 126 of 160 (79%) had at least one episode of cholangitis during the study period (2006-2015). Median followup was 49 months in those who had cholangitis compared to 33 months for those who did not develop cholangitis.
- Age at time of Kasai: 63 days in those with cholangitis and 55 days in those without (P=0.42)
- 76% of patients had recurrent cholangitis
- Yield from blood culture was 9%. In those with culture-proven cholangitis, Enterococcus faecium was most common pathogen (28%), followed by E. coli (15%), Enterobacter cloacae (11%), and Klebsiella pneumoniae (9%)
- In their institution, there was a fairly-low susceptibility of gram-negative bacteria to cefotaxime (8/21, 38%). Almost all gram-negative isolates were susceptible to meropenem.
- In their institution, there was fairly-low susceptibility of gram-positive organisms to ampicillin (8/19, 42%) and 100% susceptibility to vancomycin.
- The authors noted that their empiric choice for treatment had been cefotaxime but this has now been reviewed; and a newer regimen, “a frequent alternative,” is the use of vancomycin along with an aminoglycoside.
It is worth noting that Up-to-Date has several recommended regimens for acute cholangitis (in adults). For lower-risk infections, the authors recommend either a single agent like piperacillin-tazobactam or dual therapy with specific cephalosporins (eg. cefotaxime, ceftriaxone) and metronidazole. For higher-risk infections, the Up-to-Date recommendations include meropenem or piperacillin-tazobactam as single agents or one of two cephalosporins (cefepime or ceftazidime) along with metronidazole.
My take: Cholangitis is common after biliary atresia. Familiarity with changing susceptibility, particularly local patterns, will help optimize outcomes.
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