Biliary Sepsis

Question 1

Investigations in biliary sepsis

Answer 1

• Blood cultures – prior to the administration of any antimicrobial agent
• Urine culture
• Urea & Electrolytes
• Liver function tests
• Amylase
• CRP
• Full blood count & platelets
• Repeat lactate
• Chest X-ray

Question 2

Ascending cholangitis /biliar sepsis definition

Answer 2

is an infection of the bile duct (cholangitis), usually caused by bacteria ascending from its junction with the duodenum

Question 3

Acute cholecytstitis definition

Answer 3

‘Gallbladder infections usually result from gallstone formation and impaction in the cystic duct, with impaired biliary drainage leading to:

• infection
• oedema
• compressive effects on the local blood supply which may lead to gangrene of the gallbladder.

Question 4

Gall bladder infection may cause

Answer 4

• bloodstream infection
• cholangitis
• liver abscess formation’

Question 5

Inital bilary sepsis treatment

Answer 5

• Intravenous fluids commenced as dehydrated
• Urinary catheter
• Oxygen by mask to maintain sats at >95%
• Discussion should take place with respect to the likely diagnosis of biliary sepsis/acute cholangitis

Question 6

Microbiology of biliary sepsis

Answer 6

Cover in biliary sepsis should include the enteric flora - particularly Gram negative bacilli such as E.coli, Klebsiella spp. and Enterobacter spp.

Gram positive bacteria such as Enterococci and anaerobes such as Bacteroides spp. and the Clostridia.

Question 7

Abx cover in biliary sepsis

Answer 7

• Gentamicin + amoxicillin + metronidazole (note issues with aminoglycosides and renal toxicity esp. in elderly)
• Gentamicin + co –amoxyclav (also issues with C. difficile and co-amoxyclav)
• Piperacillin-tazobactam + gentamicin (broader Gram negative cover; covers anaerobes and most enterococci)
• Ceftriaxone/cefotaxime + metronidazole (note issues with C. difficile and cephalosporins; plus lack of enterococcal cover)
• Ciprofloxacin + metronidazole (note issues with C. difficile and quinolones ; plus lack of enterococcal cover)
• Carbapenem (meropenem/imipenem) where history of infections with more resistant organisms e.g. ESBL producing coliforms – especially in those with recurrent biliary sepsis, prior biliary tract surgical procedures and with biliary – intestinal anastomoses
• It should be noted however that therapy should not only be ‘supportive’ with appropriate antimicrobial therapy but MUST include investigation to identify possible obstruction of the biliary tree with subsequent decompression/drainage if required.