Empirical antibiotic therapy for acute cholangitis
For the treatment of patients with acute cholangitis who have sepsis or septic shock, see Sepsis and septic shock from a biliary or gastrointestinal tract source. For definitions of sepsis and septic shock, see Identifying sepsis or septic shock.
The empirical regimens in this topic may not be appropriate for patients with risk factors for infection with multidrug-resistant Enterobacterales. These patients may also develop infection with other resistant pathogens (eg vancomycin-resistant enterococci) and Candida species. Seek expert advice to guide antimicrobial choice.
Adjustments to empirical therapy may be required for patients undergoing surgery.
The rationale for antibiotic choice for intra-abdominal infections, including acute cholangitis, is described here.
For empirical therapy of acute cholangitis in adults and children without sepsis or septic shock, as a 2-drug regimen, use:
1gentamicin intravenously; see Principles of aminoglycoside use for prescribing considerations and subsequent dosing. See Modification and duration of therapy for acute cholangitis gentamicin gentamicin gentamicin
adult: see Gentamicin initial dose calculator for adults for initial dose
child younger than 18 years: 7 mg/kg up to 560 mg for initial dose12
OR
1tobramycin intravenously; see Principles of aminoglycoside use for prescribing considerations and subsequent dosing. See Modification and duration of therapy for acute cholangitis tobramycin tobramycin tobramycin
adult: see Tobramycin initial dose calculator for adults for initial dose
child younger than 18 years: 7 mg/kg up to 560 mg for initial dose12
PLUS with either of the above drugs, either of the following
1amoxicillin 2 g (child: 50 mg/kg up to 2 g) intravenously, 6-hourly. For dosage adjustment in adults with kidney impairment, see amoxicillin dosage adjustment. See Modification and duration of therapy for acute cholangitis amoxicillin amoxicillin amoxicillin
OR
1ampicillin 2 g (child: 50 mg/kg up to 2 g) intravenously, 6-hourly. For dosage adjustment in adults with kidney impairment, see ampicillin dosage adjustment. See Modification and duration of therapy for acute cholangitis. ampicillin ampicillin ampicillin
For patients with chronic biliary obstruction, add to the above regimens:
metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) intravenously, 12-hourly. See Modification and duration of therapy for acute cholangitis. metronidazole metronidazole metronidazole
To avoid the need to switch between intravenous antibiotics at 72 hours, a non-aminoglycoside–containing regimen may be used if it is suspected that intravenous therapy will continue for at least 72 hours. If the likely duration of intravenous therapy is not known, start with the aminoglycoside-containing regimen; do not delay antibiotic administration to make this determination. Non-aminoglycoside–containing regimens are also used if gentamicin or tobramycin is contraindicated. For empirical therapy of acute cholangitis in adults and children without sepsis or septic shock, use:
1ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 2 g) intravenously, daily. See Modification and duration of therapy for acute cholangitis ceftriaxone ceftriaxone ceftriaxone
OR
1cefotaxime 2 g (child: 50 mg/kg up to 2 g) intravenously, 8-hourly. For dosage adjustment in adults with kidney impairment, see cefotaxime dosage adjustment. See Modification and duration of therapy for acute cholangitis cefotaxime cefotaxime cefotaxime
OR
1piperacillin+tazobactam 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) intravenously, 8-hourly; see Modification and duration of therapy for acute cholangitis. For dosage adjustment in adults with kidney impairment, see piperacillin+tazobactam dosage adjustment. See Modification and duration of therapy for acute cholangitis. piperacillin + tazobactam piperacillin+tazobactam piperacillin+tazobactam
For patients with chronic biliary obstruction in whom ceftriaxone or cefotaxime is used, add:
metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) intravenously, 12-hourly. See Modification and duration of therapy for acute cholangitis. metronidazole metronidazole metronidazole
Metronidazole is not required for patients with chronic biliary obstruction if piperacillin+tazobactam is used.
For patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, use ceftriaxone or cefotaxime as above.
For patients who have had a severe immediate3 hypersensitivity reaction to a penicillin, ceftriaxone or cefotaxime (at the dosages above) can be considered if a beta-lactam antibiotic is strongly preferred (for considerations, see Severe immediate hypersensitivity: Implications of cross-reactivity between penicillins and cephalosporins).
For patients who have had a severe immediate3 hypersensitivity reaction to a penicillin in whom ceftriaxone or cefotaxime is not used, or for patients who have had a severe delayed4 hypersensitivity reaction to a penicillin, seek expert advice.