Primary sclerosing cholangitis
ICD-10 K83.0 · ICD-11 DB96.2

Treatment of Primary Sclerosing Cholangitis in Acute Bacterial Cholangitis

In patients with primary sclerosing cholangitis, episodes of acute bacterial cholangitis — including suppurative forms — require prompt clinical recognition and timely antibiotic management.

Clinical Scenario
Acute bacterial cholangitis is diagnosed when suppurative cholangitis is present on ERCP, or when at least one major criterion is met — body temperature >38 °C, leukocyte count >12/nl, or C-reactive protein >75 mg/L — together with at least two minor criteria: positive bile culture, ALP or total bilirubin elevated above 2× ULN, and no other identifiable focus of infection.
Treatment Approach
Management is built around empiric antibiotic therapy directed at both gram-negative and gram-positive organisms. The specific agents, route of administration, and indications for biliary decompression — including how episode severity determines the full treatment strategy — are detailed in the complete protocol.
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References

DOI: 10.1016/j.jhep.2022.05.011

According to this definition the diagnosis of acute bacterial cholangitis requires either a single criterion (suppurative cholangitis on ERCP), or at least 1 major criterion (body temperature >38 °C, leukocyte count >12/nl or C-reactive protein >75 mg/L), and at least 2 minor criteria (positive bile culture, increase in ALP or total bilirubin above 2x ULN, no other focus of infection).

Acute bacterial cholangitis should be treated with antibiotics and subsequent biliary decompression if an underlying relevant stricture is present.

The initially selected antibiotic should cover gram-negative and -positive bacteria and a common first-line agent for mild episodes is an aminopenicillin/beta-lactamase inhibitor since these agents can be administered orally.

More severe cases are treated with intravenous antibiotics with piperacillin/tazobactam (sufficient anaerobic coverage in itself) or third generation cephalosporins with inclusion of anaerobic coverage.

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