Multidrug-resistant organisms predispose to relapsing cholangitis in liver graft recipients with stenosis of the biliary anastomosis

Objectives Stenosis of the biliary anastomosis predisposes liver graft recipients to bacterial cholangitis. Endoscopic retrograde cholangiography (ERC) is mandatory, most often including plastic stent insertion. Antibiotics are recommended according to individual judgement, but duration of therapy remains unclear. Furthermore, short antibiotic treatment is warranted to reduce occurrence of multidrug-resistant organisms (MDRO) in this vulnerable population.

Methods All patients undergoing ERC after liver transplantation (LT) at our center were screened for cholangitis according to the Tokyo criteria, with severe cases (i.e. Tokyo-3 cholangitis) being excluded. In total, 59 cases (30 patients) with proven cholangitis were included and analyzed in a retrospective manner. Relapsing cholangitis within 28 days was the primary end point, and risk factors were calculated using generalized estimated equations (GEE) regression.

Results Twenty (34%) cases were graded as Tokyo-1 and 39 (66%) as Tokyo-2. Mean (IQR) time from onset of cholangitis to ERCP was 7.2 (3.2-24.7) hours. Median (IQR) duration of antibiotic therapy was 6 (4-8) days. Stenting was performed in 52/59 (88%) instances, with two stents being the number most used (n=27 cases). Carbapenems (n=19, 32%), piperacillin/tazobactam and fluoroquinolones (each n=14, 24%), cephalosporines (n=10, 17%) were classes of initially administered antibiotics, while no antibiotics were administered in two cases (3%). Relapsing cholangitis was observed in 9 (18%) cases, with MDRO colonization (p=0.027, OR=2.31) being the only significant risk factor.

Conclusion Our data show no difference regarding duration of antibiotic treatment in patients with LT and biliary stenosis. Therefore, prospective data are needed to assess the non-inferiority of shortened antibiotic therapy. In any case, MDRO colonization needs to be taken into account when choosing type and length of antibiotic therapy.

Publication History

Article published online:
07 September 2021