ANTIBIOTICS IN BILIARY STONE

Ignatius Riwanto
Dept. of Surgery, Digestive Division
Diponegoro Medical Faculty, Dr
Kariadi Hospital

SDW IV, Semarang October 14-17th 2015

 DEFENCE SYSTEM IN THE BILIARY
TRACT AGAINST BACTERIAL INFECTION
Normal condition : bile is sterile
Bactibilia: the presence of bacteria in the
bile
Sphinchter of Oddi: prevent bacteria reflux
from duodenum
Kupffer cell and the tight junctions
between hepatocytes help prevent bacteria
and toxic metabolits from entering the
hepatobilliary system
Continuous flushing and bacteriostatic
effect the bile salts
Secretory Ig.A and mucous prevent
microbial colonization

Digestive Diseases and Sciences, 1992;37(5) :695-696

 BREAK THE DEFENCE OF BILIARY
SYSTEM
Sphincterotomy of Sphincter
Oddi, stenting, and bilio-
digestive shunt bacterial
reflux
Biliary obstruction increase
biliary pressure influence the
Kupffer Cell function, tight
junction, bile flow, production
on sIg.A increase incidence
of septicemia and endotoxemia
Digestive Diseases and Sciences, 1992;37(5) :695-696
GR I: PREOP
ENDOSCOPIC
DECOMPRESSION
Gr II: WITHOUT
ENDOSCOPIC
DECOMPRTESSION
 Micro-organisms in the bile-duct
obstruction
Biliary infection was found in 57 (31 %) of I8I patients
undergoing biliary surgery.
The presence of bacteria in the bile was significantly (P<0.01)
more common in:
patients requiring emergency operation (16/I7; 94%) vs
patients undergoing elective operations (4I / I 64; 25%).
among those requiring elective operation:
jaundiced patients (I4/25; 56%) than in the non-jaundiced
group (27/139; 19%), particularly when the jaundice was due
to stones (10/I4; 71%) rather than- to malignant disease
obstructing the bile ducts (4/11; 36%).
BACTERIA AND STONE FORMATION
 Bacterial DNA in mixed cholesterol
gallstones
Bacterial 16S rRNA and uidA DNA sequences in E.
coli were detected in all brown pigment, common bile
duct, and mixed cholesterol gallstones [n = 14 (100%)
].
One (14%) of seven pure cholesterol gallstones
yielded a PCR product.
Most (88%) mixed cholesterol gallstones yielded PCR
amplification products from their central, as well as
their outer, portions.
Sequenced products possessed 8898% identity to
16S rRNA genes of E. coli and Pseudomonas species.

American Journal of Gastroenterology (1999) 94, 35023506;

 Pathogenesis of pigment gallstone in
Western societies
370 western pigment stone (black & brown)
73% bacteria positive
Composition:
Calcium Bilirubinate in all pigment stone
Calcium Palmitate of in all infected
Calcium Carbonate 75% on sterile stone
Infected pigment stone: 95% produce slime and 67%
produce -glucoronidase
Conclusion: Bacteria has a major role in pigment (black
and brown) stone formation in western population.

J. GASTROINTEST SURG 2002;6:891-904

WHEN SHOULD WE GIVE ANTIBIOTICS
(PROPHYLACTIC OR THERAPEUTIC ) IN
SURGERY OF BILIARY STONE?

SHOULD TYPE OF STONE BE

CONSIDERED IN GIVING ANTIBIOTICS?
PROPHYLACTIC ANTIBIOTICS IN LOW RISK
PATIENTS UNDERGOING LAPAROSCOPY
CHOLECYETECTOMY USEFUL?
 A selective antibiotic prophylaxis policy for
laparoscopic cholecystectomy is effective in
minimising infective complications
100 Pts Laparoscopy Cholecystectomy
Gr I: 35 Pts with risk factor for bactibilia got
prophylactic antibiotic (Cephalosporine Gen II &
Metronidazole)
Gr II: 65 Pts without risk factors/ low risk no
antibiotics
3 of Gr I (8,57%) Superficial SSI
1 of Gr II (1,5%) Superficial SSI
Conclusion: prophylactic antibiotics for LC pts
with low risk is not useful
HIGH RISK FOR BACTIBILIA THAT NEED
ANTIBIOTICS PROPHYLACTIC

AGE OVER 70 YEARS OF OLD

JAUNDICE
PATIENTS REQUIRING EMERGENCY OPERATION
RECENT RIGORS
CHOLEDOCHOLITHIASIS
HAVING HAD PREVIOUS BILIARY OPERATIONS
 RISK FACTORS FOR BACTIBILIA

ACUTE CHOLECYSTITIS
COMMON DUCT STONE TYPE/
COMPOSITION
EMERGENCY SURGERY OF STONE IS NOT
INTRA-OPERATIVE FINDING RISK FACTOR

AGE >70 YEARS

RECENT ACUTE CHOLECYSTITIS
RECENT OBSTRUCTIVE JAUNDICE
RECENT ACUTE PANCREATITIS
WHAT KIND BACTERIA FOUND
IN BILE OF BILIARY STONE
DISEASE PATIENTS?
 Mohnarin Report 2006-2007:Bacterial Distribution
and Resistance in Biliary Tract Infections

1441 bacterial strains:

952 Gram-negative strains(66.1%),
Escherichia coli(31.0%),
Klebsiella pneumoniae (8.4%) and
Pseudomonas aeruginosa(7.8%)
489 Gram-positive strains(33.9%),
Enterococcus faecalis(11.6%),
E.faecium(9.5%) and
Staphylococcus(7.4 %).
Chinese Journal of Nosocomiology 2008-09
 Bacteriology and antimicrobial susceptibility in biliary tract
disease: an audit of 10-year's experience
The Kaohsiung Journal of Medical Sciences [2002, 18(5):221-228]

Jan 1991 to Aug 2000, 1394 patients positive bile culture is 36%:
GBS 25%, CBDS 66%, IHDS 67% and biliary malignancy 9%
For gallstone diseases:
Gram negative bacteria (74%),
Escherichia coli (36%) and Klebsiella (15%)
Gram positive (15%) bacteria
Enterococcus (6%), Staphylcoccus (3%), Streptococcus (2%).
Anaerobes (6%)
Bacteroides (5%) and Clostridium (3%)
Positive culture:
GB stones with acute cholecystits 47%, without inflammation 17%,
hepatolithiasis with acute cholangitis 75% without cholangitis 51%
 WHAT KIND OF ANTIBIOTICS
SHOULD WE GIVE TO PATIENTS
UNDERGO BILIARY TRACT
SURGERY?
GRADING CHOLECYSTITIS ACUTE (TOKYO
GIDELINES)
 Bacteriological analysis of bile in
acute cholecystitis according to the Tokyo guidelines
(abstract)J Hepatobiliary Pancreat Sci. 2012 Jul;19(4):476-86

163 AC patients
Parameters Mild AC Moderate AC p
Age (mean) 60 67 < 0.05
Body temp. 37.2 37.6 < 0.05
WBC 13,033 15,177 < 0.05
CRP (mg/dl) 8.9 16.9 <0.05
Bactibilia (%) 45.3 67.0 0.0107
bacterial strains, NS
prevalence of NS
antimicrobial
resistance

CONCLUSION: Adequate broad-spectrum antimicrobial therapy should be administered

perioperatively even for Mild patients classified according to the current Tokyo guidelines
MANAGEMEN OF ACUTE CHOLECYSTITIS
GRADING OF CHOLANGITIS (TOKYO GUIDELINES)
MANAGEMEN OF CHOLANGITIS
 ANTIBIOTIC CHOOSING

NO DATA REGARDING LOCAL PATTERN

INTERNATIONAL GUIDELINES
IDSA
Guidelines:
TOKYO GUIDELINES 2012
Cummunity accuired biliary infection
 CONCLUSION
Only Gall stone with high risk of bactibilia, antibiotics
should be given.
High risk of bactibilia including: Acute cholecystitis /
cholangitis, common duct stone, emergency surgery, intra-
operative finding, age >70 years, recent acute
cholecystitis, recent obstructive jaundice, recent acute
pancreatitis
Duration of antibiotic for grade I acute cholecystitis or
without infection but high risk for bactibilia is for 24 hours,
while the others is for 4-7 days.
Local pattern of sensitivity should become first choice,
while Tokyo guidelines can be the other reference in
choosing antibiotics