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AcuteCholangitisMedication:Antibiotics

AcuteCholangitisMedication
Author:TimothyMScott,DOChiefEditor:BarryEBrenner,MD,PhD,FACEPmore...
Updated:Nov10,2014

MedicationSummary
Thegoalofantimicrobialtherapyistoresolvetheinfection.Debateexistsastowhetherthemosteffective
antibioticsmusthavehighbiliaryconcentrations.Whenhighintrabiliarypressuresexistduetobiliaryobstruction,
whetheranyantibioticisexcretedeffectivelyintothebileisdoubtful,thusmakingbiliarylevelsirrelevant.Thechoice
ofantibioticsshouldbeguidedbylocalsensitivitypatterns.
Itiscriticalthatantibioticsareadministeredearlyinthemanagementofcholangitis.IntheED,empiricantibiotic
therapyshouldcoveragainstgramnegativeaerobicentericorganisms(eg,Ecoli,Klebsiellaspecies,Enterobacter
species),grampositiveorganisms(eg,EnterococcusandStreptococcusspecies),andanaerobes(eg,Bacteroides
fragilis,Clostridiumperfringens).Thereisanincreaseofupto85%ininfectiouscomplicationswhenbiliarycultures
arenotsusceptibletotheempiricantibiotics.Therefore,traditionaltherapywithampicillinandanaminoglycosideis
nowalessidealregimensecondarytoweakenedactivityofampicillinagainstbothaerobicandanaerobicgram
negativebacilli,andisconcernfornephrotoxicityofaminoglycosides.
Manynewercombinationshavebeenshowntobeeffectiveaseitherasingleagentorcombinationtherapy.
Combinationsincludeextendedspectrumcephalosporin,metronidazole,andampicillin.Singleagentregimens
includepiperacillinandtazobactammezlocillinimipenemmeropenemticarcillinandclavulanateorampicillinand
sulbactam,whichcanalsobecombinedwithmetronidazole.
Inpatientswithfewcomorbiditiesandwhoarewellappearing,usingasingleagentsuchascefoxitin(second
generationcephalosporin)maybeappropriate.However,cefoxitinsanaerobiccoverageispoor.Newergeneration
fluoroquinolones(eg,moxifloxacin)alsohavebroadgrampositiveandgramnegativecoverageandbetteranaerobic
activity,buttheyarepoorlyeffectiveagainstPseudomonasspecies.Inpatientswithmultiplecomorbiditiesorwho
areillappearing,broadspectrumantimicrobialswithpseudomonalandenterococcalcoveragearerecommended.
Oncebloodculturesresultsareavailable,theantibioticregimencanbenarrowedbasedonthecultureresults.
Thefollowingdosagesaregeneralrecommendations.Pleasecheckcurrentsourcespriortoadministration.

Antibiotics
Viewfulldruginformation

Ampicillin(Omnipen,Marcillin)
Interfereswithbacterialcellwallsynthesisduringactivemultiplication,causingbactericidalactivityagainst
susceptibleorganisms.Mustbeusedincombination.
Viewfulldruginformation

Metronidazole(Flagyl)
Imidazoleringbasedantibioticactiveagainstvariousanaerobicbacteriaandprotozoa.Usuallyusedincombination
withotherantimicrobialagents.
Viewfulldruginformation

Gentamicin(Gentacidin,Garamycin)
Aminoglycosideantibioticforgramnegativecoverage.Usedincombinationwithbothanagentagainstgram
positiveorganismsandonethatcoversanaerobes.
NotDOC.Considerifpenicillinsorotherlesstoxicdrugsarecontraindicated,whenclinicallyindicated,andinmixed
infectionscausedbysusceptiblestaphylococciandgramnegativeorganisms.
DosingregimensarenumerousadjustdosebasedonCrClandchangesinvolumeofdistribution.Maybegiven
IV/IM.
Followeachregimenbyatleastatroughleveldrawnonthethirdorfourthdose(0.5hbeforedosing)maydrawa
peaklevel0.5hafter30mininfusion.
Viewfulldruginformation

Cefoxitin(Mefoxin)
Asecondgenerationcephalosporinthathasbroadgramnegativecoverage,whileretainingefficacyagainstgram
positiveorganisms.Italsohasactivityagainstanaerobes.
However,itlackspseudomonalandenterococcalcoverage.
Viewfulldruginformation

Piperacillin/tazobactam(Zosyn)
Antipseudomonalpenicillinplusbetalactamaseinhibitor.Inhibitsbiosynthesisofcellwallmucopeptideandis
effectiveduringstageofactivemultiplication.Usedincombinationtherapy.
Viewfulldruginformation

Cefotaxime(Claforan)
Thirdgenerationcephalosporinthathasbroadgramnegativespectrum,lowerefficacyagainstgrampositive

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AcuteCholangitisMedication:Antibiotics

organisms,andhigherefficacyagainstresistantorganisms.
Arrestsbacterialcellwallsynthesisandinhibitsbacterialgrowthbybindingtooneormoreofthepenicillinbinding
proteins.
Canbeusedincombinationwithmetronidazoleorclindamycin.
Viewfulldruginformation

Clindamycin(Cleocin)
Lincosamidefortreatmentofseriousskinandsofttissuestaphylococcalinfections.Alsoeffectiveagainstaerobic
andanaerobicstreptococci(exceptenterococci).Inhibitsbacterialgrowth,possiblybyblockingdissociationof
peptidyltRNAfromribosomes,causingRNAdependentproteinsynthesistoarrest.

Mezlocillin(Mezlin)
Duringgrowthphase,interfereswithbacterialcellwallsynthesis,causingdeathinsusceptiblemicroorganisms.Has
antipseudomonalactivity.Useincombinationtherapies.
Viewfulldruginformation

Imipenemandcilastatin(Primaxin)
Acarbapenemmaybeusedaloneorincombination.Usedfortreatmentofmultipleorganisminfectionsforwhich
otheragentsdonothavewidespectrumcoverageorarecontraindicatedduetopotentialfortoxicity.
Viewfulldruginformation

Meropenem(Merrem)
Acarbapenemmaybeusedaloneorincombination.Broadspectrumcarbapenemantibioticthatinhibitscellwall
synthesisandhasbactericidalactivity.Effectiveagainstmostgrampositiveandgramnegativebacteria.
Hasslightlyincreasedactivityagainstgramnegativeorganismsandslightlydecreasedactivityagainststaphylococci
andstreptococcicomparedtoimipenem.
Viewfulldruginformation

Ticarcillinandclavulanatepotassium(Timentin)
Inhibitsbiosynthesisofcellwallmucopeptideandiseffectiveduringstageofactivegrowth.
Antipseudomonalpenicillinplusabetalactamaseinhibitorthatprovidescoverageagainstmostgrampositiveand
gramnegativeorganismsandmostanaerobes.
Viewfulldruginformation

Ampicillinandsulbactamsodium(Unasyn)
Combinationantimicrobialagentthatusesabetalactamaseinhibitorwithampicillin.Coversskin,entericflora,and
anaerobes.Notidealfornosocomialpathogens.

ContributorInformationandDisclosures
Author
TimothyMScott,DOChiefResident,DepartmentofEmergencyMedicine,DetroitMedicalCenter,Wayne
StateUniversitySchoolofMedicine
TimothyMScott,DOisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
Physicians,AmericanMedicalAssociation,AmericanOsteopathicAssociation,EmergencyMedicine
Residents&#039Association
Disclosure:Nothingtodisclose.
Coauthor(s)
AdamJRosh,MDAssistantProfessor,ProgramDirector,EmergencyMedicineResidency,Departmentof
EmergencyMedicine,DetroitReceivingHospital,WayneStateUniversitySchoolofMedicine
AdamJRosh,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergencyMedicine,
AmericanCollegeofEmergencyPhysicians,SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:ReceivedsalaryfromMedscapeforemployment.
ChiefEditor
BarryEBrenner,MD,PhD,FACEPProfessorofEmergencyMedicine,ProfessorofInternalMedicine,
ProgramDirectorforEmergencyMedicine,CaseMedicalCenter,UniversityHospitals,CaseWesternReserve
UniversitySchoolofMedicine
BarryEBrenner,MD,PhD,FACEPisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,
AmericanHeartAssociation,AmericanThoracicSociety,ArkansasMedicalSociety,NewYorkAcademyof
Medicine,NewYorkAcademyofSciences,SocietyforAcademicEmergencyMedicine,AmericanAcademyof
EmergencyMedicine,AmericanCollegeofChestPhysicians,AmericanCollegeofEmergencyPhysicians,
AmericanCollegeofPhysicians
Disclosure:Nothingtodisclose.
Acknowledgements
EugeneHardin,MD,FAAEM,FACEPFormerChairandAssociateProfessor,DepartmentofEmergency
Medicine,CharlesDrewUniversityofMedicineandScienceFormerChair,DepartmentofEmergencyMedicine,

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AcuteCholangitisMedication:Antibiotics

MartinLutherKingJr/DrewMedicalCenter
Disclosure:Nothingtodisclose.
JeffreyAManko,MDAssistantProfessorofEmergencyMedicine,Director,EmergencyMedicineResidency
Program,ConsultingStaff,EmergencyMedicineServices,NewYorkUniversity/BellevueMedicalCenter
JeffreyAManko,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
Physicians,CouncilofEmergencyMedicineResidencyDirectors,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
SallySanten,MDProgramDirector,AssistantProfessor,DepartmentofEmergencyMedicine,Vanderbilt
University
SallySanten,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysicians
andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.

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