Useful Data on Cholangitis Following Kasai Portoenterostomy

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).

Key points:

  • 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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