Bile Cultures Research Articles

Positive Intraoperative Bile Culture and Antibiotic Resistance Increase the Risk of Pancreatic Fistula in Patients After Pancreatoduodenectomy

Background/Objectives: A positive intraoperative bile culture (bacterobilia) is considered to be a risk factor for increased morbidity after pancreatoduodenectomy. The aim of our study was to describe the frequency of bacterobilia with a special emphasis on antibiotic resistance and to analyze the association of these findings with postoperative complications, in particular with postoperative pancreatic fistula. Methods: From a prospective database, patients with available intraoperative bile cultures (n = 95) were selected and analyzed. Microbiological test results reported the type of bacteria as well as sensitivity and resistance patterns. Associations between culture results, antibiotic resistance, and postoperative outcomes were assessed. Results: Among 95 patients that were included in this trial, 71 (74.7%) had a positive bile culture. A total of 29.6% (21/71) of patients with positive bile cultures developed POPF grade B/C compared to 8.3% (2/24) of patients with negative bile cultures (p = 0.052). The difference in CR-POPF became statistically significant when at least one of the isolated microorganisms was resistant to ampicillin/sulbactam, the perioperative antibiotic administered for prophylaxis. CR-POPF was diagnosed in 38.5% (15/39) of patients with antibiotic resistance vs. 14.3% (8/56) of patients without resistant microorganisms (p = 0.007). We also identified the isolation of Enterococcus spp. (p = 0.006), resistant Enterobacter (p = 0.031), or resistant Escherichia coli (p = 0.027) as risk factors for pancreatic fistula. Conclusions: The isolation of antibiotic-resistant strains in a positive bile culture is a major risk factor for the development of pancreatic fistula after pancreatoduodenectomy. The most relevant bacteria in our study were Enterococcus spp., Enterobacter cloacae, and Escherichia coli. Thus, broad-spectrum antimicrobial prophylaxis with efficacy against these microorganisms and with low resistance rates should be routinely administered perioperatively.

Patterns, Predictors, and Outcomes of Bacterial Growth and Infectious Complications after Pancreatic Resection.

Infectious complications after pancreatic resections are common, but perioperative factors linked to postoperative bacterial growth are not well-studied. This retrospective study analyzed bacterial cultures from patients undergoing pancreatic resection (November 2008 to October 2022), assessing predictors for positive cultures and characterizing bacteria. Complications and outcomes of patients with positive cultures were also examined. Among 620 patients, bile samples were collected in 95 (95/620; 15.3%), with 60 (60/95; 63.1%) testing positive, 58 of them underwent pancreaticoduodenectomy. Of these, in 50 (50/58; 86.2%) the culture yielded polymicrobial growth but specific types of bacteria were not identified. Multivariate analysis identified preoperative bile duct stenting as a significant predictor of positive bile cultures (OR: 3.54; 95% CI: 1.95-6.42; p < 0.001), and positive cultures were linked to higher reoperation rates (OR: 2.40; 95% CI:1.18-4.90; p < 0.001. Positive drain cultures within 30 days from surgery were associated with higher rates of clinically significant pancreatic fistula (OR: 2.24; 95% CI: 1.00-5.11; p = 0.05), and reoperations) OR: 4.37; 95% CI: 1.62-11.79; p = 0.03). Patients with pancreatic adenocarcinoma and positive bile cultures had shorter disease-free survival with a median of 13 months (95% CI: 8-17) versus 18 months (95% CI: 8-29; p = 0.04). Bile sampling is recommended in all pancreaticoduodenectomies. Managing polymicrobial growth with broad and prolonged antibiotics may reduce postoperative infections.

HPB SO62 - Association of positive bile cultures and the incidence of pancreatic fistulas post pancreaticoduodenectomy[PD

Abstract Background Postoperative pancreatic fistula (POPF) remains a significant complication post pancreaticoduodenectomy (PD). Recent publications show no increased incidence of POPF due to positive bile cultures. A literature search on PubMed did not show any review on the relevance of specific cultures and their exact incidence of POPF. POPF is defined as Drain Amylase greater than three times its serum level on or after postoperative day 3. A relatively benign clinical course is grade A, moderately unwell patients requiring medical/minimal intervention (grade B), and critically ill patients with sepsis, requiring invasive intervention (grade C). Grade B + C is defined as CR-POPF. Method A retrospective single-centre analysis of all patients with pancreaticoduodenectomy between 2017 and 2021 was reviewed. The clinical data that were reviewed were age, gender, length of stay[LOS], tumour staging, mortality rates, Pancreatic duct[PD], Pre-op stenting, the documented incidence of POPF/CR-POPF, Intra-Operative Bile Cultures[IOBC] and antibiotic sensitivity. The primary outcome was POPF. Secondary outcomes were 90-day mortality, LOS, return to theatre, Postoperative haemorrhage (POPH), and organ-specific relevance of POPF. All data was analysed using SPSS IBM version 29. P&amp;lt; 0.05 was taken as clinically significant. Results 100 patients were included in the study. The mean age was 68.8 (SD-9.5). The M: F ratio was 54:46. The mean postoperative length of hospital stay was 19.38 days. 48 patients (48%) were diagnosed with a POPF, among which, 22 patients (47.8%) developed a CR-POPF. 57 patients had a positive IOBC. The incidence of POPF in patients with Positive IOBC was 43/57(75.43%) and that was 5/43(11.62%) of the patients with Negative IOBC (P &amp;lt; .0001).10% of patients had postoperative haemorrhage (POPH). 9% had 90-day mortality. All 9% of patients who had a return to theatre had POPF. Conclusion Univariate analysis and logistic regression demonstrated that a positive IOBC had a higher associated incidence of POPF who underwent PD, with Klebsiella being the most common and statistically significant[P&amp;lt;.005]. The most common antibiotic found to be sensitive was Gentamicin, which is 25 per cent and, in combination with Co-amoxiclav, was found to be sensitive in 21.8% of cases. However, this is a single-centre retrospective study with variable operative techniques for different patient groups. Further studies would be warranted before correlating any results to all populations of patients developing POPF post pancreaticoduodenectomy.

HPB O01 - Colonization of bile with gammaproteobacteria reduces survival after surgery for pancreatic cancer in patients receiving gemcitabine-based adjuvant chemotherapy

Abstract Background Evidence suggests that the biliary microbiome influences the progression of pancreatic ductal adenocarcinoma (PDAC) in patients undergoing adjuvant chemotherapy. Specifically, Gammaproteobacteria (GPB) has been shown to have the potential to develop mutations which can metabolise gemcitabine into an inactive form. This study hypothesised that GPB influences survival in patients with PDAC undergoing adjuvant gemcitabine-based chemotherapy following surgery. Method This was a retrospective study of patients undergoing pancreatoduodenectomy from 2010 to 2020. Associations between patient and tumour characteristics, survival data, and results of intraoperative bile cultures (GPB+ or GPB-) were investigated. Analysis of patients matched by chemotherapy regimen and numbers of cycles of adjuvant therapy was also performed. Survival was analysed using Kaplan–Meier curves and Cox regression analysis. Results Analysis of 359 patients revealed that adjuvant gemcitabine-based therapy improved overall survival (OS). Patients who receive gemcitabine-based chemotherapy with a GPB+ biliary culture had a shorter OS compared to those who were GPB-, and a median survival of 17.9 vs 26.1 months, P=0.006. After matching for key chemotherapy variables, survival was greater in the GPB- group 26.8 vs 19.8, P=0.016. This association was not seen among patients who received no adjuvant therapy or non-gemcitabine based therapy. Conclusion Patients receiving gemcitabine-based chemotherapy after surgery are likely to have reduction in OS if they have a biliary culture positive for GPB.

HPB SO02 - Cutting surgical site infection rates in perihilar cholangiocarcinoma with informed changes to perioperative antibiotic prophylaxis: A quality improvement project in a UK hepatopancreatobiliary tertiary centre

Abstract Background Perihilar cholangiocarcinoma (pCCA) is the most common cancer of biliary epithelia. While potentially curative, surgical resection is associated with high morbidity and mortality. Surgical site infections (SSIs) are common and pernicious. Preoperative biliary instrumentation is universal: to confirm histological diagnosis and deploy stents to relieve jaundice. Patients receive multiple antibiotic courses as periprocedural prophylaxis and to treat cholangitis. They are at high risk of harbouring bacteria not quelled by perioperative prophylactic antibiotics given for other general surgical procedures. Studying the biliary microbiome, this quality improvement project sought to reduce SSIs through informed changes to local guidelines on perioperative antibiotic prophylaxis. Method Health records of all patients undergoing resection for pCCA in a UK hepatopancreatobiliary centre from February 2009 to January 2024 were analysed retrospectively (n=118). For all patients, we routinely sent intraoperative bile swabs for culture and sensitivity. Informed by these microbiology results, multidisciplinary discussion led to changes to local guidelines in March 2019. Formerly, cefuroxime and metronidazole were given on anaesthetic induction, with subsequent antibiotic choice and duration according to surgeon preference. New guidance stipulated teicoplanin and piperacillin/tazobactam be given on induction and for 72 hours postoperatively. We studied the impact of these changes on SSIs within 30 days. Results 75 patients received cefuroxime and metronidazole; 43 patients were given teicoplanin and piperacillin/tazobactam after the policy change. Proportions of patients who developed any SSI substantially fell following the guideline change (55% v 28%; p=0.0049), primarily owing to reductions in intraperitoneal collections (39% v 21%; p=0.047). Rates of deep (8% v 2%; p=0.21) and superficial incisional infections (8% v 5%; p=0.49) were not significantly affected. Associated secondary outcomes were drops in post-hepatectomy liver failure (17% v 5%; p=0.047), and 90-day mortality (16% v 5%; p=0.067), albeit the latter was not statistically significant. Conclusion Invasive investigative work-up, disease complications and exposure to multiple courses of antibiotics prior to resection of pCCA subject patients’ biliary systems to colonisation with antimicrobial-resistant bacteria. We urge centres that undertake these operations to introduce intraoperative bile cultures as a part of routine practice to inform local guidance on perioperative antimicrobial prophylaxis. We demonstrated effective antibiotics in the perioperative period can have enormous benefits to patient outcomes.

Biliary tract infections caused by Enterococcus gallinarum and Escherichia coli: a rare case report.

Enterococcus gallinarum (E. gallinarum), an opportunistic pathogen with intrinsic resistance to vancomycin, has rarely been reported as a predominant pathogen responsible for biliary tract infections. Here, we report a case of biliary tract infections caused by E. gallinarum and Escherichia coli (E. coli) in a 57-year-old Chinese woman with symptoms of upper abdomen pain for 10days. The patient initially received empiric treatment with cefmetazole but failed to improve. Subsequently, bile cultures identified E. gallinarum and E. coli, and cefmetazole was switched to linezolid and meropenem based on drug susceptibility testing. After 10days of antibiotic therapy, the patient successfully recovered and was discharged from the hospital. The findings of this case remind us that E. gallinarum may be the causative factor of biliary tract infections, and timely identification of the causative organism and appropriate antibiotic treatment is important for optimal patient recovery.

Domestic ferrets (Mustela putorius furo) with cholecystitis commonly show hyperbilirubinemia and common bile duct dilation, gallbladder sludge, and gallbladder wall thickening on ultrasound.

To report clinical signs, biological anomalies, treatment, and outcome in domestic ferrets with cholecystitis, describe the ultrasonographic features of cholecystitis, and compare the ultrasonographic appearance of the hepatobiliary system between diseased and healthy ferrets. 11 ferrets with confirmed cholecystitis and abdominal ultrasonography were retrospectively included. Ten healthy ferrets were prospectively recruited to undergo hepatobiliary abdominal ultrasonography. Comparisons of explanatory variables (group, age, body weight, and sex) were performed. The most common clinical signs were nonspecific, and icterus was observed in 1/4 of diseased ferrets. Compared with healthy individuals, diseased ferrets showed a larger common bile duct (CBD; ≥ 2.8 mm), a thicker CBD wall (≥ 0.7 mm), a thicker gallbladder (GB) wall, more frequent echoic GB luminal content, visible intrahepatic bile ducts, and a greater GB volume. Bile culture was positive in 9/11 mostly for Escherichia coli (8/9). Bile cytology indicated septic purulent cholecystitis in 7/7 ferrets. Survival time after antibiotic treatment ranged from 6 to 104 weeks, with a median of 36 weeks. Ferrets with cholecystitis presented with nonspecific clinical signs and frequently showed hyperbilirubinemia. Ultrasonography findings such as enlarged CBD, thickened CBD wall, thicker GB wall, GB sludge, visible intrahepatic bile ducts, and enlarged GB may suggest cholecystitis. Escherichia coli was commonly isolated from bile. The medium-term mortality rate was high despite targeted antibiotherapy. This is the first study describing the clinical signs, biological anomalies, ultrasonographic findings, and outcomes after treatment in a series of domestic ferrets with cholecystitis.

Predictive factors associated with Bile culture positivity And phenotypiCal antIbiogram resistance patterns in patients taken to LaparOscopic cholecystectomy (BACILO): protocol for a prospective observational cohort study and development of a prognostic prediction model.

Bile fluid is aseptic under normal conditions; however, in the presence of cholecystitis, its susceptibility to bacterial colonisation varies, with reported rates of 20%-70% of cases. This process is referred to as bactibilia and/or bacteriobilia and can be considered a secondary complication of biliary stasis and cholecystitis in general. In the management of acute cholecystitis, the antibiotic regimen should be prescribed based on the presumed pathogens involved, taking into consideration the risk factors for resistance patterns according to demographics and local exposure. The aim of this study is to determine the predictive factors for bile culture positivity and antibiotic resistance in patients who underwent laparoscopic cholecystectomy in the Méderi Hospital Network. We hope to develop a predictive model that allows us to better guide antibiotic therapy. This is a prospective observational cohort study with prognostic prediction model. Patients who will undergo laparoscopic cholecystectomy and have bile cultures taken in the Méderi Hospital Network during the study period will be included. The dependent variables will be positive bile culture and antibiotic resistance, and the predictive variables will be age, presence of diabetes, diagnosis of choledocholithiasis, diagnosis of cholecystitis and severity of cholecystitis according to the Tokyo criteria. The minimum sample size has been calculated at 703 patients. Follow-up will continue until a control appointment 15 days after the procedure. The primary outcomes are bile culture positivity and phenotypical antibiogram resistance. For each outcome, a multivariate logistic regression will be performed using frequentist and Bayesian prediction techniques. This study was approved by the Méderi network research department committee (CIMED) and by Universidad del Rosario's Research Ethics Committee (CEI-UR; DVO005 2555-CV1837). Written informed consent is required for participation. The results will be disseminated through the submission of an academic article to a high-impact scientific journal, presentations at academic conferences, and sharing with our institution's faculty to inform antimicrobial therapy management based on local epidemiological data. NCT06314399.

Epidemiological, clinical and microbiological characteristics of patients with biliary tract diseases with positive bile culture in a tertiary hospital

PurposeThe prevalence of biliary tract diseases, which are common gastrointestinal disorders, is steadily rising. If it progresses to sepsis or septic shock, it can endanger the patient's life. Therefore, it is crucial to promptly diagnose bacterial infection in individuals suffering from biliary diseases and comprehend the risk factors associated with infection. The objective of this study was to examine the types of bacteria present in the bile of patients with biliary tract diseases, assess any alterations in their susceptibility to antimicrobial agents, and identify the risk factors contributing to the development of infection in these patients.Patients and methodsFrom June 2019 to November 2022, 317 patients of biliary tract diseases with positive bile culture were included in this hospital-based descriptive analysis. The hospital's computerized medical records were used to collect data on demographic information (including gender, age, and occupation), laboratory, and clinical findings, physical examination results, comorbidities, basic diseases, treatment history, complications, and in-hospital outcomes. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) principles.ResultsOf the 317 patients with positive biliary tract diseases, 247 had benign diseases and 70 had malignant diseases. Patients with benign disease experienced a higher prevalence of statistically significant symptoms such as abdominal pain (81.4% vs. 57.1%, P = 0.000), nausea (31.2% vs. 14.3%, P = 0.005), vomiting (30.0% vs. 12.9%, P = 0.004), and chills (10.9% vs. 2.9%, P = 0.039), while jaundice (12.6% vs. 37.1%, P = 0.000) was more common in patients with malignant disease. At the species level, Escherichia coli (105; 40.5%), Klebsiella pneumoniae (41; 15.8%), and Pseudomonas aeruginosa (30; 11.6%) were the most commonly found Gram-negative bacterial strains in biliary tract infection. Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa were most susceptible to tigecycline, ertapenem and ceftazidime/avibactam, respectively.ConclusionGram-negative bacteria are the most commonly isolated biliary bacteria. Clinical doctors should pay attention to patients with malignant diseases with low hemoglobin, high total bilirubin and high alkaline phosphatase. Carbapenems, tigecycline, and minocycline are the recommended antibiotics for Enterobacteriaceae. In recent years, the proportion of enterococcus has gradually increased, and clinical attention should be paid to enterococcus infection. Linezolid and vancomycin were recommended for the treatment of Enterococci infections. Overall, this work can provide reference for clinical diagnosis, treatment and effective interventions.

Clinical and biochemical factors for bacteria in bile among patients with acute cholangitis.

Acute cholangitis is a clinical syndrome caused by a bacterial infection in the biliary system. The bacteria could exist in the bile before bile drainage despite empirical antibiotic treatment. Patients with acute cholangitis admitted to a tertiary hospital in Southeastern China from August 2011 to September 2021 were involved when bile cultures were performed. Patient information before bile cultures and during hospitalization was extracted from the clinical record database. The risk factors related to bacteria in bile were assessed by univariable and multivairable logistic regression analysis, respectively. A total of 533 patients (66.05%) had bacterial growth in bile. Alanine aminotransferase concentration [odds ratio (OR) = 0.998, P < 0.001], absolute monocyte count (OR = 0.335, P = 0.001), and duration of antibiotic use (OR = 0.933, P = 0.026) were negatively correlated with bacteria in bile. In contrast, C-reactive protein (OR = 1.006, P = 0.003), thrombin time (OR = 1.213, P = 0.033), prothrombin time (OR = 1.210, P = 0.011), and age (OR = 1.025, P < 0.001) were positively correlated with bacteria in bile. Based on an area under the receiver operating characteristic curve of 0.737 (95% CI, 0.697-0.776, P < 0.001), combining these seven variables could efficiently predict the presence of bacteria in bile among patients with acute cholangitis. The combination of clinical indicators before bile drainage could predict the risk of bacteria in bile for patients with acute cholangitis.

Outcomes in COVID-19 Patients with Acute Cholangitis: A Single-Center Retrospective Analysis.

Background and Objectives: This study aimed to assess the impact of coronavirus disease 2019 (COVID-19) on patients with acute cholangitis (AC) by comparing outcomes, complications, and hospital stays in a tertiary Gastroenterology department. Materials and Methods: This retrospective observational cohort study was conducted in a tertiary gastroenterology department, collecting data from all AC and AC + COVID-19 patients between April 2020 and February 2022. Data included clinical and demographic information, COVID-19-specific details, acute cholangitis presentation, medical records, laboratory results, and interventions. AC was diagnosed using Tokyo Guidelines 2018 (TG18) criteria, with all patients undergoing bile culture sampling. Results: The study included 241 patients, 30 in the COVID group and 211 in the non-COVID group. The COVID group's mean age was significantly higher (74.3 vs. 67.3 years, p < 0.009). Abdominal pain was more common in the COVID group (90% vs. 70.6%, p < 0.025). Length of hospital stay was longer for COVID patients (13.5 vs. 7.9 days, p < 0.001). COVID patients had higher incidences of malignant causes of AC, with pancreatic cancer being the most common (30%). Pseudomonas spp. was significantly more prevalent in COVID patients (16.7% vs. 5.7%, p = 0.028). Conclusions: Our study results show that COVID-19 affected the duration of hospitalization for patients with AC. Furthermore, this study presents observations regarding the impact of COVID-19 on AC, revealing differences in microbial profiles.

The Risk Factors of Early Biliary Infection After 125I Particles Stent Implantation in Patients with Malignant Biliary Obstruction

Background: Early biliary infection (EBI) is a significant and prevalent complication following percutaneous transhepatic biliary stenting, especially in cases involving the use of 125I particle stents for malignant biliary obstruction (MBO). Objectives: This study aims to uncover potential risk factors contributing to EBI post-implantation in this patient group. Patients and Methods: In this retrospective study, a total of 231 patients who underwent 125I particle stent implantation between January 2014 and December 2020 were included. Screening based on inclusion/exclusion criteria identified a total of 178 patients (115 males and 63 females, aged 32 - 83 years). Early biliary infection occurrence was monitored within the first 30 days following the stent implantation, when infectious complications are most prevalent. We analyzed baseline characteristics and perioperative parameters of patients, comparing those who developed EBI with those who did not. Multivariate logistic regression was employed to identify significant risk factors for EBI. Results: Out of the 178 patients, 35 (19.7%) developed EBI within 30 days post-implantation. Every EBI case was accompanied by a positive bile culture. Notably, patients with EBI more frequently had diabetes [odds ratio (OR), 3.329; 95% confidence interval (CI), 1.129 - 9.819; regression coefficient (B) = 1.203; P = 0.029], gallstones in the gallbladder or bile ducts (OR, 3.459; 95% CI, 1.060 - 11.283; B = 1.241; P = 0.040), higher level of biliary obstruction (OR, 3.008; 95% CI, 1.243 - 7.280; B = 1.101; P = 0.015), intraoperative biliary bleeding (OR, 5.416; 95% CI, 1.569 - 18.696; B = 1.689; P = 0.008), and postoperative intrahepatic pneumobilia (OR, 2.655; 95% CI, 1.108 - 6.362; B = 0.976; P = 0.029) compared to those without EBI. These factors were positively correlated with EBI development post-implantation. Conversely, the duration from percutaneous transhepatic biliary drainage (PTBD) to 125I stent implantation was longer in patients without EBI (OR, 0.966; 95% CI, 0.940 - 0.992; B = - 0.035; P = 0.012), suggesting a negative association with EBI occurrence. Conclusion: This study identifies diabetes, gallstones in the gallbladder or bile ducts, high-level obstruction, intraoperative biliary bleeding, and postoperative intrahepatic pneumobilia as significant risk factors for EBI. Additionally, a longer interval from PTBD to 125I stent implantation emerges as a protective factor against EBI in patients with MBO undergoing 125I particle stent implantation. These risk factors can offer guidance to minimize post-125I particle stent implantation biliary infection, thereby shortening hospitalization for affected patients.

The Clinical Impact of Different Types of Preoperative Biliary Intervention on Postoperative Biliary Tract Infection of Patients Undergoing Pancreaticoduodenectomy.

Background: For patients with obstructive jaundice and who are indicated for pancreaticoduodenectomy (PD) or biliary intervention, either endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic cholangiography and drainage (PTCD) may be indicated preoperatively. However, the possibility of procedure-related postoperative biliary tract infection (BTI) should be a concern. We tried to evaluate the impact of ERCP and PTCD on postoperative BTI. Methods: Patients diagnosed from June 2013 to March 2022 with periampullary lesions and with PD indicated were enrolled in this cohort. Patients without intraoperative bile culture and non-neoplastic lesions were excluded. Clinical information, including demographic and laboratory data, pathologic diagnosis, results of microbiologic tests, and relevant infectious outcomes, was extracted from medical records for analysis. Results: One-hundred-and-sixty-four patients from the cohort (164/689) underwent preoperative biliary intervention, either ERCP (n = 125) or PTCD (n = 39). The positive yield of intraoperative biliary culture was significantly higher in patients who underwent ERCP than in PTCD (90.4% vs. 41.0%, p < 0.001). Although there was no significance, a trend of higher postoperative BTI (13.8% vs. 2.7%) and BTI-related septic shock (5 vs. 0, 4.0% vs. 0%) in the ERCP group was noticed. While the risk factors for postoperative BTI have not been confirmed, a trend suggesting a higher incidence of BTI associated with ERCP procedures was observed, with a borderline p-value (p = 0.05, regarding ERCP biopsy). Conclusions: ERCP in patients undergoing PD increases the positive yield of intraoperative biliary culture. PTCD may be the favorable option if preoperative biliary intervention is indicated.

The Frequency, Patterns and Management of Bacterial Cholangitis in Living-Donor Liver Transplant Recipients with Biliary Complications: A Single Center Study

Abstract Background Biliary complications are still frequent after liver transplantation especially living donor liver transplantation (LDLT). Bacterial cholangitis is a potentially life-threatening complication. Management is based on antimicrobial therapy and surgical drainage. Bile cultures can play a role in determining the causative agent and optimizing antibiotic therapy. Aim We aimed to assess the incidence of bacterial cholangitis among recipients of LDLL, identify the most common bacteria and their antibiotic susceptibility, and evaluate the role of bile culture and endoscopic retrograde cholangiopancreatography (ERCP) in the management of potential biliary infection. Methods This study was conducted at Ain Shams Center for Organ Transplantation between February 2019 and April 2022. The study included 39 LDLT recipients who developed post-transplant cholangitis on top of biliary complications. Liver function tests, imaging, ERCP, and blood and bile culture and sensitivity were performed in all patients. Results The incidence of biliary complications was 38.2%. Imaging and ERCP findings were consistent regarding the diagnosis of anastomotic stricture. Stones were detected by ERCP in 12 patients when magnetic resonance cholangiopancreatography detected them in only one patient. The most common organism isolated from both bile and blood cultures was E. coli. Antibiotics that matched bile and blood cultures were linezolid, ceftazidime/avibactam, imipenem + cilastatin, and amoxicillin/clavulanic acid. Three bile cultures showed multidrug resistance for combination therapy. Conclusion Anastomotic strictures and cholangitis are common complications of LDLT. E coli is the most common organism detected in bile and blood cultures. Therefore, antibiotic selection based on concurrent blood and bile culture interpretation can help optimize therapy.

Updates on Antibiotic Regimens in Acute Cholecystitis.

Acute cholecystitis is one of the most common surgical diseases, which may progress from mild to severe cases. When combined with bacteremia, the mortality rate of acute cholecystitis reaches up to 10-20%. The standard of care in patients with acute cholecystitis is early laparoscopic cholecystectomy. Percutaneous cholecystostomy or endoscopic procedures are alternative treatments in selective cases. Nevertheless, antibiotic therapy plays a key role in preventing surgical complications and limiting the systemic inflammatory response, especially in patients with moderate to severe cholecystitis. Patients with acute cholecystitis have a bile bacterial colonization rate of 35-60%. The most frequently isolated microorganisms are Escherichia coli, Klebsiella spp., Streptococcus spp., Enterococcus spp., and Clostridium spp. Early empirical antimicrobial therapy along with source control of infection is the cornerstone for a successful treatment. In these cases, the choice of antibiotic must be made considering some factors (e.g., the severity of the clinical manifestations, the onset of the infection if acquired in hospital or in the community, the penetration of the drug into the bile, and any drug resistance). Furthermore, therapy must be modified based on bile cultures in cases of severe cholecystitis. Antibiotic stewardship is the key to the correct management of bile-related infections. It is necessary to be aware of the appropriate therapeutic scheme and its precise duration. The appropriate use of antibiotic agents is crucial and should be integrated into good clinical practice and standards of care.

Ultrasound‐guided percutaneous choledochocentesis in a cat with cholelithiasis, choledocholithiasis and cholangitis due to Klebsiella pneumoniae

AbstractA 13‐year‐old female cat was presented at our Veterinary Teaching Hospital with hyporexia and prostration. The animal underwent cholecystectomy 2 months previously due to partial biliary obstruction resulting from cholecystitis, multiple cholelithiasis, choledocholithiasis, dilation and tortuosity of the bile ducts. Due to the impossibility of puncturing the gall bladder and the persistence of dilation and tortuosity of the extra‐ and intrahepatic ducts identified by ultrasound, a dilated intrabiliary duct was punctured. The objective of the present study was to report the ultrasound‐guided percutaneous choledochocentesis technique, which, to our knowledge, is the first report of its performance in cats. The material was obtained for bile culture and antibiogram, which identified the bacterium Klebsiella pneumoniae, which was multiresistant to most antibiotics and uncommon in the biliary system. The technique was performed uneventfully, and was essential in the present report to assist in the presumptive diagnosis and treatment of cholangitis associated with cholelithiasis and choledocholithiasis.

The role of microbes and parasites in recurrent pyogenic cholangitis.

Recurrent pyogenic cholangitis (RPC) and ascariasis are prevalent in eastern India. Exact pathogenesis of RPC is still a matter of controversy. Hepatobiliary Ascaris infestation has been considered one of the causative factors in Eastern Asia, but conclusive evidence from India is lacking. RPC is associated with multi-drug-resistant (MDR) bacteria, which is a significant source of morbidity and mortality. This study aimed to assess the role of hepatobiliary ascariasis in pathogenesis of RPC and to study microbial profile and their implications in managing RPC patients. Consecutive patients with biliary stones who underwent surgery between March 2020 and December 2021 in a tertiary centre in eastern India were divided into RPC and non-RPC groups. Surgically retrieved samples of bile and biliary stones were sent for bacterial culture and microscopic and histopathological examination to identify the evidence of ascariasis in both groups and to study the microbial profile in RPC group. Eight out of 54 patients (14.8%) in the RPC group had evidence of hepatobiliary ascariasis. None of the patients in non-RPC group showed evidence of ascariasis. Klebsiella was the most common bacterial pathogen on bile culture, and 79% of bacterial isolates were MDR pathogens. Carbapenem group of antibiotics showed the highest sensitivity (66.6%) against bacterial culture growth in RPC patients. This study showed a higher prevalence of hepatobiliary ascariasis in patients with RPC, but a conclusive etiological role is still lacking. RPC is associated with high incidence of MDR bacteria. Carbapenems may be considered the empirical antibiotic of choice in RPC.

Relationship between Intraoperative Bile Culture Outcomes and Subsequent Postoperative Infectious Complications: A Retrospective Cohort Study.

The presence of positive bile culture during intraoperative procedures has been associated with elevated morbidity and mortality rates in hepatobiliopancreatic surgeries, contributing to increased healthcare expenditures. However, the precise impact of bactobilia on the development of postoperative complications remains uncertain due to existing disparities in the published literature. In this retrospective cohort study, we assessed 137 patients who underwent major hepatobiliopancreatic surgery to examine the relationship between intraoperative bile culture outcomes and subsequent postoperative infectious complications. Among patients with bactobilia, a significant 35.1% exhibited systemic or local infectious complications, whereas only 11.1% of those with negative culture results experienced any infectious complications (p = 0.002). Similarly, a notable difference was observed in the incidence of surgical site infections, with 24.3% in the bactobilia group compared to 7.9% in the negative culture group (p = 0.01). A total of 74 monomicrobial cultures with microbiological growth were isolated, predominantly featuring Gram-negative microorganisms, primarily Enterobacteriaceae in 49 cultures. Escherichia coli was identified in 37.8% of positive cultures, while Klebsiella pneumoniae was evident in 21.6%. Gram-positive microorganisms were present in 10 cultures, with Enterococcus emerging as the prevailing species. The logistic regression model identified a positive bile culture as an independent factor significantly associated with infection development (OR: 2.26; 95% confidence interval: 1.23-11; p = 0.02). Considering the limitations of the study, these findings underscore the critical importance of conducting bile cultures during the intraoperative phase to enable vigilant monitoring and prompt management of infectious complications.

Dual-energy CT in acute cholecystitis- features predicting culture-positive bile and outcome

PurposeLow mono-energetic CT has been shown to improve visualization of acute abdominal inflammatory processes. We aimed to determine its utility in patients with acute cholecystitis and potential added value in clinical decision making. MethodsSixty-seven consecutive patients with radiological signs of cholecystitis on contrast-enhanced dual-layer CT imaging were retrospectively identified over a four-year period (2/17–8/21). A ranked Likert scale was created for imaging findings present in acute cholecystitis, including gallbladder mucosal integrity and enhancement and pericholecystic liver parenchymal enhancement. These rankings were correlated with laboratory data, followed by sensitivity, specificity, and odds-ratios calculations. ResultsMucosal integrity and pericholecystic liver enhancement were better seen on low-energetic images by unanimous consensus. Presence of pericholecystic liver enhancement and poorer mucosal wall integrity correlated with positive bile cultures (sensitivity: 93.8 % and 96.9 %, specificity: 37.5 and 50.0 %; odds-ratio: 9.0[1.1–68.1 95 %CI] and 31.0 [2.7–350.7 95 %CI], p = 0.017 and p ≤ 0.001) in patients undergoing cholecystostomy (n = 40/67). Moreover, binary regression modeling showed that the strongest predictor variable for bile culture positivity was the score for pericholecystic liver enhancement (Exp(B) = 0.6, P = 0.022). By contrast, other laboratory markers and other imaging findings (such as GB wall thickness) showed lower sensitivities (76–82 %), specificities (16–21 %) and odds ratios (0.2–4.4) for the prediction of infected bile. ConclusionsPericholecystic liver enhancement and gallbladder wall integrity are better visualized on low-DECT images. These findings also potentially predict bile culture positivity in patients with cholecystitis, which may influence clinical management including the need for intervention.

Efficacy of single-dose versus triple-doses perioperative antimicrobial prophylaxis in patients undergoing laparoscopic cholecystectomy

Introduction: Although debatable, prophylactic antibiotics may be required for patients undergoing cholecystectomy for symptomatic gallstone disease with certain associated risk factors. Our study aimed to perform a non-randomised prospective comparative trial evaluating a single-dose pre-operative antibiotic versus a triple-dose prophylactic post-operative antibiotic in patients with symptomatic uncomplicated cholelithiasis undergoing laparoscopic cholecystectomy. Methodology: This study was a non-randomised prospective comparative study in a single institution. Two hundred patients were enrolled and allocated to two groups. Group A patients were given a single dose of pre-operative prophylactic antibiotic, and Group B patients received a triple dose of prophylactic antibiotic therapy. We also studied the bacteriological profile of bile in all the patients using bile culture and antibiotic sensitivity, and we analysed their association with post-operative surgical site infection (SSI). Results: All the patients were followed up on post-operative days 7 and 30. On post-operative day 7, 2% of patients in Group A and 1% of patients in Group B were found to have SSI, and no statistically significant difference in SSI between the two groups was noted (P = 0.558). On post-operative day 30, no patient was found to have a SSI in either of the two groups. Moreover, post-operative bile culture was obtained in all the cases, and 6% of patients had a positive bile culture. However, none of them developed SSIs on post-operative day 7. Conclusion: A single-dose pre-operative antibiotic is as effective as three perioperative doses in preventing SSI in laparoscopic cholecystectomy for symptomatic, uncomplicated gallstone disease. Our study did not associate port-site SSI with a positive bile culture.