Risk-Adapted Empiric Therapy for Acute Cholangitis: Beyond the Broad- Versus Narrow-Spectrum Dichotomy

Acute cholangitis requires both timely source control and appropriate empiric antimicrobial therapy. Although unnecessarily broad antimicrobial coverage should be avoided from an antimicrobial stewardship perspective, the choice of empiric therapy should not be reduced to a simple comparison between broad- and narrow-spectrum regimens. Patients with biliary stents, repeated biliary interventions, recurrent cholangitis, healthcare exposure, proton pump inhibitor use, prior resistant-organism isolation, or prior antimicrobial exposure may have an increased risk of antimicrobial-resistant pathogens. In such patients, broad-spectrum empiric therapy may be selected not as routine overtreatment, but as risk-adapted treatment to avoid inadequate initial coverage. Observational studies evaluating empiric antimicrobial spectrum should therefore account for patient-level resistant-pathogen risk, microbiological findings, source-control details, and de-escalation practices. A risk-adapted approach may better balance antimicrobial stewardship with patient safety in acute cholangitis.