Biliary sepsis. Reviewing treatment options.

Bactobilia is a frequent accompaniment of obstruction in the biliary tract, organisms present being normal intestinal aerobes and anaerobes. Bacterial colonisation of the bile may occur asymptomatically, may predispose to infection postoperatively, or may be associated with an attack of acute cholecystitis, occurring secondary to obstruction. The choice of an antimicrobial regimen for biliary infection should take into account the expected antibiotic sensitivities of organisms colonising bile, whether biliary obstruction or bacteraemia is present, and the activity of the antibiotic in bile. Often, high biliary concentrations of an antibiotic cannot be achieved due to obstruction, and in many cases high blood and tissue concentrations are of greater importance. Surgical prophylaxis should be reserved for patients at high risk of bactobilia (e.g. the elderly), when obstruction is present, for immunosuppressed patients, and those with artificial heart valves. A single perioperative dose of a 'first' or 'second generation' cephalosporin, gentamicin, or co-trimoxazole is effective. Antibiotic therapy for acute cholecystitis should be instituted if there is evidence of systemic toxicity, when surgery is to be delayed, or in patients with identified risk factors for bactobilia. Ampicillin or a cephalosporin may be appropriate in less severe disease, while in seriously ill patients, an aminoglycoside or cephalosporin with metronidazole or clindamycin is appropriate. Oral regimens include amoxycillin, an oral cephalosporin, or co-trimoxazole, in combination with metronidazole. In acute cholangitis, systemic therapy similar to that recommended for acute cholecystitis is indicated. Patients with recurrent cholangitis may have relatively antibiotic-resistant bacteria and efforts should be made to obtain a bacteriological diagnosis. Long term suppressant therapy with oral agents such as amoxycillin, cephalexin, or co-trimoxazole may be tried.