Original article
Clinical characteristics, aetiology and mortality/recurrence risk factors of acute cholangitis in patients with and without biliary stentCaracterísticas clínicas, etiología y factores de riesgo de mortalidad/recidiva de la colangitis bacteriana aguda en pacientes con y sin stent biliar

https://doi.org/10.1016/j.eimc.2020.07.010Get rights and content

Abstract

Objectives

Acute cholangitis is one of the most frequent complications in patients carrying biliary stents. The aim of our study is to analyze the demographic and clinical characteristics, as well as the microbiological profile and evolution of patients with acute bacteremic cholangitis, comparing them based upon they were or not biliary stent carriers.

Methods

We performed a retrospective analysis of all consecutive patients over 18 years-old with a stent placement in our center between 2008 and 2017 were included. We compared them with our prospective cohort of patients with a diagnosis of acute bacteremic cholangitis. Primary outcome was 30-day mortality. Secondary outcome was clinical cure at day 7, 14-day mortality and 90-day recurrence.

Results

Two hundred and seventy-three patients were analyzed, including 156 in the stent-related (SR) and 117 in the stent not-related (SNR) group, respectively. Stent-related colangitis patients were younger, with more comorbidities and with a greater severity of infection. Escherichia coli and Klebsiella pneumonia were the most frequent isolation. Enterococcus spp. was the third most frequent isolation in SR group but were uncommon in SNR patients; where E. coli was the most prevalent microorganism. Septic shock (HR 3.44, 95% [CI 1.18–8.77]), inadequate empirical treatment (HR 2.65, 95% CI [1.38–.7.98]) and advanced neoplasia (HR 2.41, 95% CI [1.55–6.44]) were independent 30-day mortality risk factors. The 90-day recurrence rate significantly higher in those patients with stent-related cholangitis (29% vs. 13%, p = 0.016) and stent replacement was associated with lower recurrence rate (HR 0.38, 95% CI [0.11–0.77]).

Conclusions

Clinical and microbiological profile, as well as outcome of patients with SR and SNR cholangitis were different. In SR group, recurrence rate was high and stent replacement was associated with a lower risk.

Resumen

Objetivos

La colangitis aguda es una de las complicaciones más frecuentes en los pacientes portadores de stents biliares. El objetivo de nuestro estudio es analizar las características demográficas y clínicas, así como el perfil microbiológico y la evolución de los pacientes con colangitis bacteriana aguda, comparándolos en función de si eran o no portadores de stents biliares.

Métodos

Se realizó un análisis retrospectivo de todos los pacientes consecutivos mayores de 18 años con un stent colocado en nuestro centro entre 2008 y 2017. Los comparamos con nuestra cohorte prospectiva de pacientes con diagnóstico de colangitis bacteriana aguda. El criterio principal de valoración fue la mortalidad a los 30 días. Los criterios secundarios de valoración fueron la curación clínica el día 7, la mortalidad a los 14 días y la recidiva a los 90 días.

Resultados

Se analizaron 273 pacientes, incluyendo 156 en el grupo relacionado con el stent (RS) y 117 en el grupo no relacionado con el stent (NRS). Los pacientes con colangitis RS eran más jóvenes, con más enfermedades concomitantes y con una mayor intensidad de la infección. Las cepas aisladas más frecuentes fueron Escherichia coli y Klebsiella pneumoniae. Enterococcus spp. fue la tercera cepa aislada más frecuente en el grupo RS, pero no fue frecuente en los pacientes NRS, en los que E. coli fue el microorganismo más prevalente. El choque septicémico (HR: 3,44; IC del 95%: 1,18-8,77), el tratamiento empírico inadecuado (HR: 2,65; IC del 95%: 1,38-7,98) y la neoplasia avanzada (HR: 2,41; IC del 95%: 1,55-6,44) fueron factores de riesgo de mortalidad a los 30 días independientes. La tasa de recidiva a los 90 días fue significativamente más elevada en aquellos pacientes con colangitis RS (29 frente al 13%; p = 0,016) y el reemplazo del stent se asoció a una menor tasa de recidiva (HR: 0,38; IC del 95%: 0,11-0,77).

Conclusiones

El perfil clínico y microbiológico, así como el resultado de los pacientes con colangitis RS y NRS, fue diferente. En el grupo RS la tasa de recidiva fue alta y la sustitución del stent se asoció con un menor riesgo.

Introduction

Biliary stents are commonly used as a palliative treatment of obstructive jaundice in patients with unresectable biliary or pancreatic neoplasias. It has also been indicated in patients with non-malignant obstruction of the bile duct or as a previous step to surgery in patients with resectable neoplasias.1 There are different types of biliary stents (plastic vs. metallic, covered vs. uncovered), with different safety profile and risk of complications. Over time and inevitably, these stents are colonized by microorganisms (fungi and bacteria) that promote the occlusion of the device and increase the risk of cholestasis and acute cholangitis.2, 3

Acute bacteremic cholangitis continues to be a frequent cause of morbidity and mortality in these patients. Elderly patients with solid organ tumors are particularly susceptible,4, 5 with a crude mortality rate of around 11–26%.6, 7 Although some authors have pointed out a greater frequency of colonization of biliary stents by Enterococcus sp. and yeast,8, 9 there is very little information regarding the etiology, management, as well as, prognosis of patients with acute cholangitis related to the presence of a biliary stent.10 In the largest published series,11 a multicenter retrospective study conducted in Japan and Taiwan included more than 6,400 patients with acute cholangitis included, only 16% were carriers of a biliary stent and comparative analysis with non-carriers was not performed.

The aims of our study were to analyze the demographic and clinical characteristics, as well as the microbiological profile and evolution of patients with acute bacteremic cholangitis, comparing patients based upon they were or not biliary stent carriers.

Section snippets

Methods

All consecutive patients over 18 years-old with a stent placement in our center between January 1st 2008 and December 31st 2017 were included. Data were collected retrospectively by reviewing medical electronic records. Only patients with acute bacteremic cholangitis (those who met diagnostic criteria of Tokyo Guidelines 201812) were analyzed. Moreover, we also included all patients with a diagnosis of acute bacteremic cholangitis prospectively collected between October 1st 2015 and October

Results

During the study period 273 patients met eligibility criteria (8 patients were excluding due to missing data), including 156 in the stent-related group (SR) and 117 in the stent not-related (SNR) group. The main demographic, clinical, treatment and outcome characteristics of both group of patients are shown in Table 1. Stent-related acute cholangitis affected more commonly to male and younger patients, with more comorbidities and with a greater severity of infection. The type of stent used was

Discussion

In this study, we have performed a comparative analysis of a cohort of patients with and without biliary stent with acute bacteremic cholangitis.

It was observed that the group of patients with biliary stent were younger, but with more comorbidities, a higher prevalence of advanced solid organ tumors and with a greater severity of infection. In previous studies10, 11 comparing the etiology of both groups of patients (SR vs. SNR groups), differences in demographic, clinical characteristics, as

Authors contributions

AS, AAH, MTPR conceived and designed the study. AS, AAH, OL, AO, MS performed the scientific literature search, collected data, interpreted data. AS, AAH and MTPR wrote the report. All the authors approved the final version of the manuscript. As corresponding author AS had full access to all the data in the study and takes responsibility for the decision to submit for publication.

Funding

No external funding was received for the submitted work.

Conflicts of interest

All the authors have completed the ICMJE form for Disclosure of Potential Conflicts of Interest and declare that (1) AS reports personal fees from Pfizer, Angelini and Merck, outside the submitted work. MTPR reports personal fees from Pfizer and Merck, Astellas and Angelini outside the submitted work. The others authors have nothing to disclose; (2) None of the authors have had relationships in the previous two years with companies that might have an interest in the submitted work; (3) None of

Acknowledgments

Partial data of the submitted work was presented at 29th European Congress on Clinical Microbiology and Infectious Diseases (ECCMID 2019) with abstract numbers 1580 and 1585.

References (22)

  • Y.D. Podnos et al.

    Intra-abdominal sepsis in elderly persons

    Clin Infect Dis

    (2002)
  • Cited by (1)

    View full text