Background: The management of acute cholangitis often relies on the efficacy of selected antibiotic therapy, traditionally informed by both blood and bile culture findings. This study explores the hypothesis that antibiotic therapy guided exclusively by blood culture results would be sufficient. This approach could potentially curb the overuse of broad-spectrum antibiotics, such as carbapenems.
Methods: This prospective, multicenter, randomized trial was conducted during Aug 2015 to Sep 2023. Study patients who were diagnosed with acute cholangitis were allocated to two groups. The control group received antibiotic treatment based on the results of both blood and bile cultures, while the experimental group’s treatment was informed solely by blood culture findings. The study primarily aimed to assess the effectiveness of the antibiotic treatment, as reflected in clinical outcomes, including organ failure, mortality, hospital stay duration, and the frequency of re-intervention for biliary drainage.
Results: The study enrolled 441 patients, and finally 204 patients in experimental group, and 205 patients in control group were analyzed. There were no significant differences in organ failure or mortality between the control and experimental group (12.7% vs. 11.3%, p=0.775). the control group led to a higher rate of switching to carbapenem compared to the experimental group (11.2% vs. 3.4%, p=0.005). The control group had a longer average antibiotic therapy duration (12.8 ± 8.1 days vs. 11.3 ± 6.5 days, p=0.043) and hospital stay (14.1 ± 10.8 days vs. 12.0 ± 8.9 days, p=0.039) compa8red to the experimental group.
Conclusion: Blood culture-guided antibiotic therapy in acute cholangitis effectively reduces reliance on broad-spectrum antibiotics, yielding clinical outcomes comparable to traditional methods. When this approach is implemented alongside adequate bile drainage, it may significantly contribute to decreasing the incidence of multidrug-resistant strains. [JHC1] (Clinicaltrials.gov number: NCT02601417)

Changes from the first empirical antibiotic to second or third-line antibiotics were significantly different between the groups at 55 cases (26.8%) and 35 cases (17.2%), respectively, with statistical significance (p=0.025)

Analysis revealed no significant differences between the control and experimental groups regarding lethal adverse events, which included shock, acute kidney injury, altered mental state, acute respiratory distress syndrome, and death

Myeong Hwan LEE

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