Surgery in cholangitis: bacteriology and choice of antibiotic

Owing the frequent occurrence of intrahepatic stones in orientals, cholangitis presents a real problem. Surgery and antimicrobial drug therapy are the main forms of treatment. A retrospective study of choledochotomy, including biliary tract surgery, performed between July 1987 and June 1990, was conducted. Cases with negative common duct exploration during cholecystectomy were excluded. Among 186 cases, 128 (68%) had positive bile growth, which was defined as cholangitis. Sepsis-related complications occurred in 51 patients (27.4%), including 3 surgical deaths, 30 wound infections, and 18 others. The complication rate was higher in the cholangitis group than in the negative group (37.5% vs. 5.2%). However, if peri-operative antibiotics were effective against the cultured bacteria species, the complication rate was 16.9%; if not, the complication rate was 85.3%. For the different-generation cephalosporins used in the peri-operative period, the complication rates were 32.2%, 20.8%, and 27.6% each for 1st, 2nd, and 3rd generation cephalosporins, with no statistically significant differences. In microbiological study, polymicrobial infection was the rule. On average, 2.3 species were grown from each specimen. Enterococcus proved the most important species with a 54% culture rate. E. coli and Pseudomonas were important gram-negative bacilli, with culture rates of 46.1% and 39.1%, respectively. Anaerobic species were cultured in 12.3% of the patients. For good coverage of cholangitis prior to operation, the proper antibiotic should have potency against gram-positive Enterococcus, gram-negative bacilli, especially Pseudomonas and E. coli, and anaerobic species, especially Bacteroides.