Treatment of Cholangitis

Immediate Antibiotic Therapy

The American College of Gastroenterology recommends starting antibiotics within 1 hour if septic shock is present, otherwise within 4 hours of suspected cholangitis 1
For mild-to-moderate cholangitis, aminopenicillin/beta-lactamase inhibitor combinations are first-line and can be administered orally, providing adequate coverage against gram-negative bacteria and gram-positive organisms 3, 1
For severe cholangitis, piperacillin/tazobactam is the preferred agent, providing sufficient anaerobic coverage without additional agents 3, 1, 2
Carbapenems should be reserved for unstable patients or those with risk factors for ESBL-producing organisms 1, 2

Patients with severe acute cholangitis and high-grade strictures require urgent biliary decompression as they are at high risk of mortality 5
ERCP with balloon dilatation is the treatment of choice for biliary decompression in moderate-to-severe cholangitis 1
Percutaneous transhepatic biliary drainage is indicated when ERCP fails or is contraindicated 1

Patients with complex intrahepatic cholangiopathy may require prophylactic long-term antibiotics with antibiotic rotation, but this should only be considered under exceptional circumstances due to antibiotic resistance risk 3, 4
Candida in bile is associated with poor prognosis and markedly reduced transplant-free survival, typically occurring in late-stage disease with high-grade stenoses 3, 4

Never delay biliary drainage in moderate-to-severe cholangitis, as this significantly worsens outcomes and increases mortality 2
Do not use antibiotics alone without addressing biliary obstruction in patients with high-grade strictures—this will not sterilize the biliary tract 4, 5
Avoid routine long-term antibiotics for PSC treatment in the absence of recurrent bacterial cholangitis due to resistance concerns 6