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Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis
Open accessAbstract
Antimicrobial therapy is a mainstay of the management for patients with acute cholangitis and/or cholecystitis. The Tokyo Guidelines 2018 ( TG 18) provides recommendations for the appropriate use of antimicrobials for community‐acquired and healthcare‐associated infections. The listed agents are for empirical therapy provided before the infecting isolates are identified. Antimicrobial agents are listed by class‐definitions and TG 18 severity grade I, II , and III subcategorized by clinical settings. In the era of emerging and increasing antimicrobial resistance, monitoring and updating local antibiograms is underscored. Prudent antimicrobial usage and early de‐escalation or termination of antimicrobial therapy are now important parts of decision‐making. What is new in TG 18 is that the duration of antimicrobial therapy for both acute cholangitis and cholecystitis is systematically reviewed. Prophylactic antimicrobial usage for elective endoscopic retrograde cholangiopancreatography is no longer recommended and the section was deleted in TG 18. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47 . Related clinical questions and references are also included.
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“Biliary infections are often polymicrobial and the choice of the antibiotic should be directed by local practice considering bacterial sensitivities and the degree of liver and/or renal impairment.233”
From EASL Clinical Practice Guidelines on sclerosing cholangitis (2022) · cites this paper as [233]
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“but most patients will respond to endoscopic drainage of the obstruction in combination with antibiotics.231,233”
From EASL Clinical Practice Guidelines on sclerosing cholangitis (2022) · cites this paper as [233]
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Tokyo Guidelines 2018: flowchart for the management of acute cholecystitis
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“Addition of vancomycin is recommended in all health care-associated infections in the Tokyo and IDSA guideline (6, 7); this would have mean treating with vancomycin 379 (46.”
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Blood cultures should be collected for acute cholangitis regardless of severity
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Tan, M., Jensen, T. G., Nielsen, S. L., de Muckadell, O. B. S., & Laursen, S. B. (2021) · Scandinavian Journal of Gastroenterology · doi:10.1080/00365521.2021.1902558 · Cited by 16
“The international Tokyo Guidelines 2018 (TG18) equally recommend initial antimicrobial treatment with: penicillinbased, cephalosporin-based or carbapenem-based therapy for the management of AC or acute cholecystitis – suggesting the optimal choice of antimicrobial therapy to be determined by local antimicrobial suscep…”
BackgroundTian, S., Li, K., Tang, H., Peng, Y., Xia, L., Wang, X., Chen, X., & Zhou, F. (2022) · BMC Infectious Diseases · doi:10.1186/s12879-021-06964-1 · Cited by 16
“The 2013 and 2018 Tokyo guidelines state that if a patient develops severe cholangitis, the choice of empiric antibiotics should be anti-Gramnegative bacteria while covering Gram-positive bacteria [6, 7].”
BackgroundResultSelf-citationBaron, T. H., Jorge, I. A., Husnain, A., Benias, P. C., Reames, B. N., Bhanushali, A., Docimo, S., Bloom, M. B., Salem, R., Murphy, P., et al. (2025) · Annals of Surgery · doi:10.1097/sla.0000000000006741 · Cited by 15
Should Procalcitonin Be Included in Acute Cholecystitis Guidelines? A Systematic Review
Yaow, C. Y. L., Chong, R. I. H., Chan, K. S., Chia, C. T. W., & Shelat, V. G. (2023) · Medicina · doi:10.3390/medicina59040805 · Cited by 15
Zhao, C., Liu, S., Bai, X., Song, J.-T., Fan, Q., & Chen, J. (2022) · Evidence-based Complementary and Alternative Medicine · doi:10.1155/2022/9255444 · Cited by 15
“+e following guidelines were referenced as diagnostic criteria of BTIs: (1) Guidelines for the Diagnosis and Treatment of Acute Biliary Tract Infections [13]; (2) Tokyo Guidelines 2018: Antibacterial +erapy for Acute Cholangitis and Cholecystitis [14].”
BackgroundMethodStathopoulos, P., Lerner, P. M., Astheimer, P., Breitling, L. P., Zumblick, M., Pararas, M., Lohoff, M. D., Gress, T. M., & Denzer, U. W. (2024) · Journal of Gastroenterology and Hepatology · doi:10.1111/jgh.16492 · Cited by 14
“1,9 This regimen was initially applied in 63% of cases with cholangitis.”
Updates on Antibiotic Regimens in Acute Cholecystitis
Fico, V., Greca, A. L., Tropeano, G., Grezia, M. D., Chiarello, M. M., Brisinda, G., & Sganga, G. (2024) · Medicina · doi:10.3390/medicina60071040 · Cited by 14
“Although there are not much data on the microbiology of AC, bile culture is strongly recommended in all cases with the exception of grade 1 according to Tokyo guidelines [33] [57].”
BackgroundGallbladder hemorrhage during orally administered edoxaban therapy: a case report
Itagaki, H., & Katuhiko, S. (2019) · Journal of Medical Case Reports · doi:10.1186/s13256-019-2328-9 · Cited by 14
Safety of Percutaneous Cholecystostomy Early Removal: A Retrospective Cohort Study
Martino, M. D., Mesa, D. M., González, J. M. L., Rodríguez, Á. D. L. H., & Martín‐Pérez, E. (2020) · Surgical Laparoscopy Endoscopy & Percutaneous Techniques · doi:10.1097/sle.0000000000000799 · Cited by 13
“AT duration, median (IQR) 13 (8-20) 11 (8-14) 15 (12-23) < 0.”
InfluentialMiutescu, B. P., Vuletici, D., Burciu, C., Bende, F., Rațiu, I., Moga, T. V., Gadour, E., Bratosin, F., Tummala, D., Şandru, V., et al. (2023) · Life · doi:10.3390/life13112205 · Cited by 13
“Upon analysis, it can be concluded that the current study findings align well with the trends documented in other significant studies [5,29,43].”
BackgroundMethodResultRashid, Z., Munir, M. M., Woldesenbet, S., Khalil, M., Katayama, E., Khan, M. M. M., Endo, Y., Altaf, A., Tsai, S., Dillhoff, M. E., et al. (2024) · Journal of Gastrointestinal Surgery · doi:10.1016/j.gassur.2024.05.009 · Cited by 13
Masuda, S., Koizumi, K., Makazu, M., Uojima, H., Kubota, J., Kimura, K. A., Nishino, T., Sumida, C., Ichita, C., Sasaki, A., et al. (2022) · Journal of Clinical Medicine · doi:10.3390/jcm11102697 · Cited by 13
Li, S., Zhu, X., Zhang, L., Huang, C., & Li, D. (2023) · Medicine · doi:10.1097/md.0000000000033562 · Cited by 13
“WHO defines the quality of life as the feelings and experiences of individuals in different cultures and value systems about their goals, expectations, standards, and living conditions, all the things they care about.[9] Therefore, we conducted this study to explore the effect of pain-education nursing with the aid of…”
BackgroundKasparian, K., Christou, C. D., Petidis, K., Doumas, M. N., & Γιουλεμέ, Ό. (2023) · World Journal of Gastroenterology · doi:10.3748/wjg.v29.i19.3027 · Cited by 13
Yoon, J., Kang, S. W., Shim, W.-S., Lee, J. K., Jang, D. K., Gu, N., Kim, S. K., Lee, K., & Chung, E. K. (2019) · Journal of Chromatography B · doi:10.1016/j.jchromb.2019.121959 · Cited by 13
Gorgulho, A., Cunha, F., Branco, E. A., Azevedo, A., ALMEIDA, F. R. D., Duro, R. P., Andrade, P., Rocha-Pereira, N., & Alves, C. L. (2023) · Antibiotics · doi:10.3390/antibiotics12020288 · Cited by 12
Korean Guidelines for Use of Antibiotics for Intra-abdominal Infections in Adults
Yoon, Y. K., Moon, C., Kim, J., Heo, S. T., Lee, M. S., Lee, S., Kwon, K. T., Kim, S., Korean Society for Antimicrobial Therapy, & Korean Society of Infectious Diseases (2022) · Infection and Chemotherapy · doi:10.3947/ic.2022.0156 · Cited by 12
“4 , 5 ) [1, 7, 30, 73].”
InfluentialSelf-citationStrohäker, J., Wiegand, L., Beltzer, C., Königsrainer, A., Ladurner, R., & Meier, A. (2021) · Antibiotics · doi:10.3390/antibiotics10010071 · Cited by 12
Masuda, S., Koizumi, K., Uojima, H., Kimura, K. A., Nishino, T., Tasaki, J., Ichita, C., & Sasaki, A. (2021) · Cureus · doi:10.7759/cureus.18449 · Cited by 12
“However, evidence for appropriate initial empiric antibiotics is insufficient [9].”
BackgroundDelaplain, P. T., Kaafarani, H. M. A., Benedict, L. A., Guidry, C. A., Kim, D. S., Loor, M. M., Machado-Aranda, D., Mele, T. S., Mendoza, A. E., Morris‐Stiff, G. J., et al. (2022) · Surgical Infections · doi:10.1089/sur.2021.323 · Cited by 12
“…given, there were only five in which more than 50% of respondents chose a single antibiotic duration (Tables 2 and 3): Tokyo-3 acute cholecystitis [10] after percutaneous cholecystostomy (4 + 1 days; 53%), index presentation of ventilator-associated pneumonia (VAP; 7 days; 72%), recurrent VAP (7…”
InfluentialA case of recurrent acute cholecystitis caused by Actinomyces odontolyticus, rare actinomycosis
Furuya, K., Ito, K., Sugiyama, K., Fujita, A., Kanemoto, H., & Shimada, T. (2022) · BMC Infectious Diseases · doi:10.1186/s12879-022-07491-3 · Cited by 12
“Once the source of infection is controlled, the recommended treatment duration for acute cholecystitis is generally up to 7 days, even in severe cases [15].”
BackgroundImpact of empiric antibiotic therapy on the clinical outcome of acute calculous cholecystitis
de Miguel-Palacio, M., González-Castillo, A. M., Membrilla-Fernández, E., Pons-Fragero, M.-J., Pelegrina-Manzano, A., Grande, L., Morera-Casaponsa, R., & Sancho-Insenser, J.-J. (2023) · Langenbeck s Archives of Surgery · doi:10.1007/s00423-023-03063-4 · Cited by 11
“Empiric antibiotic treatment (EAT) is central to every therapeutic option [3, 4].”
Management of Acute Cholangitis and Choledocholithiasis
Smith, S. E. (2024) · Surgical Clinics of North America · doi:10.1016/j.suc.2024.03.007 · Cited by 11
Navigating antibiotic therapy in acute cholangitis: Best practices and new insights
Masuda, S., Imamura, Y., Jinushi, R., Kimura, K. A., Ryozawa, S., & Koizumi, K. (2024) · Journal of Hepato-Biliary-Pancreatic Sciences · doi:10.1002/jhbp.12087 · Cited by 11
Management of primary sclerosing cholangitis: Current state-of-the-art
Cançado, G. G. L., & Hirschfield, G. M. (2024) · Hepatology Communications · doi:10.1097/hc9.0000000000000590 · Cited by 12
Imai, S., Kadomura, S., Momo, K., Kashiwagi, H., Sato, Y., Miyai, T., Sugawara, M., & Takekuma, Y. (2020) · Journal of Infection and Chemotherapy · doi:10.1016/j.jiac.2020.07.014 · Cited by 11
Sansotta, N., Luca, E. D., Nicastro, E., Tebaldi, A., Ferrari, A., & D’Antiga, L. (2021) · Antibiotics · doi:10.3390/antibiotics10030282 · Cited by 11
Sokal, A., Chawki, S., Nguyen, Y., Sauvanet, A., Ponsot, P., Maire, F., Fantin, B., & LASTOURS, V. D. (2021) · European Journal of Clinical Microbiology & Infectious Diseases · doi:10.1007/s10096-021-04289-0 · Cited by 11
Yang, Y., Fu, X., Cai, Z., Qiu, Y., & Mao, L. (2021) · Frontiers in Microbiology · doi:10.3389/fmicb.2021.763296 · Cited by 11
“In PBD patients with Ceftriaxone resistance biliary drainage cultures, the prophylactic antibiotics were selected based on the antimicrobial susceptibility (Gomi et al., 2018).”
BackgroundEndoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound-Guided Gallbladder Drainage
Salameh, H. M., & DiMaio, C. J. (2019) · Gastrointestinal Endoscopy Clinics of North America · doi:10.1016/j.giec.2018.12.002 · Cited by 11
Valappil, M. V., Gulati, S., Chhabra, M., Mandal, A. K., Bakshi, S. D., Bhattacharyya, A., & Ghatak, S. (2019) · Postgraduate Medical Journal · doi:10.1136/postgradmedj-2019-136828 · Cited by 11
When to remove the drainage catheter in patients with percutaneous cholecystostomy?
Kayaoğlu, S. A., & Tilki, M. (2021) · Revista da Associação Médica Brasileira · doi:10.1590/1806-9282.20210787 · Cited by 10
Jeong, H. T., Song, J. E., Kim, H. G., & Han, J. (2022) · Gut and Liver · doi:10.5009/gnl210474 · Cited by 10
“The regional epidemiology and patterns of antibiotic resistance are important factors in selecting appropriate empirical antibiotics.(3) And they vary from region to region.”
BackgroundInfluentialDeng, X., Wang, J., Wu, Q., Pan, L., Mou, T., & Du, C. (2022) · Clinica Chimica Acta · doi:10.1016/j.cca.2022.05.022 · Cited by 10
Management of complex acute biliary disease for the general surgeon: A narrative review
Cadili, L., Streith, L., Segedi, M., & Hayashi, A. (2023) · The American Journal of Surgery · doi:10.1016/j.amjsurg.2023.03.020 · Cited by 10
Singh, A., Kaur, M., Swaminathan, C., Subramanian, A. M., Singh, K., & Sajid, M. S. (2023) · Translational Gastroenterology and Hepatology · doi:10.21037/tgh-23-48 · Cited by 10
“The primary limitation of this systematic review was the lack of evidence for the use of pre-operative antibiotics in moderate and severe acute cholecystitis (as per Tokyo guidelines) (6).”
Edergren, Å., Sandblom, G., Agustsson, T., & Jaafar, G. (2022) · British journal of surgery · doi:10.1093/bjs/znac351 · Cited by 10
Metadata
- Authors
- Gomi, H., Solomkin, J. S., Schlossberg, D., Okamoto, K., Takada, T., Strasberg, S. M., Ukai, T., Endo, I., Iwashita, Y., Hibi, T., Pitt, H. A., Matsunaga, N., Takamori, Y., Umezawa, A., Asai, K., Suzuki, K., Han, H., Hwang, T., Mori, Y., Yoon, Y., Huang, W. S., Belli, G., Dervenis, C., Yokoe, M., Kiriyama, S., Itoi, T., Jagannath, P., Garden, O. J., Miura, F., de Santibañes, E., Shikata, S., Noguchi, Y., Wada, K., Honda, G., Supe, A. N., Yoshida, M., Mayumi, T., Gouma, D. J., Deziel, D. J., Liau, K., Chen, M., Liu, K., Su, C., Chan, A. C. W., Yoon, D., Choi, I., Jonas, E., Chen, X., Fan, S. T., Ker, C., Giménez, M. E., Kitano, S., Inomata, M., Mukai, S., Higuchi, R., Hirata, K., Inui, K., Sumiyama, Y., & Yamamoto, M.
- Affiliations
- University of Tsukuba (JP)
- University of Cincinnati (US)
- Temple University (US)
- Kitakyushu City Hospital Organization (JP)
- Teikyo University (JP)
- Washington University in St. Louis (US)
- Department of Family Medicine Mie Prefectural Ichishi Hospital Mie Japan
- Yokohama City University (JP)
- Oita University (JP)
- Keio University (JP)
- Yotsuya Medical Cube (JP)
- Toho University Ohashi Medical Center (JP)
- Fujinomiya City General Hospital (JP)
- Seoul National University (KR)
- Taoyuan Chang Gung Memorial Hospital (TW)
- Kyushu University (JP)
- Chang Bing Show Chwan Memorial Hospital (TW)
- Ospedale Santa Maria di Loreto Nuovo (IT)
- Agia Olga Hospital (GR)
- Japanese Red Cross Nagoya Daini Hospital (JP)
- Ogaki Municipal Hospital (JP)
- Tokyo Medical University Hospital (JP)
- Lilavati Hospital & Research Centre (IN)
- University of Edinburgh (GB)
- Department of Surgery, Hospital Italiano University of Buenos Aires Buenos Aires Argentina
- Mie Prefectural Ichishi Hospital Mie Japan
- Tokyo Metropolitan Komagome Hospital (JP)
- King Edward Memorial Hospital and Seth G.S. Medical College (IN)
- Japan Council for Quality Health Care (JP)
- University of Occupational and Environmental Health Japan (JP)
- Amsterdam UMC Location University of Amsterdam (NL)
- Rush University Medical Center (US)
- National University of Singapore (SG)
- Cheng Hsin General Hospital (TW)
- Hong Kong Sanatorium and Hospital (HK)
- Yonsei University (KR)
- Konyang University Hospital (KR)
- University of Cape Town (ZA)
- Hepatic Surgery Centre Department of Surgery Tongji Hospital Tongji Medical College Huazhong University of Science and Technology Wuhan China
- Yuan's General Hospital (TW)
- Universidad de Buenos Aires (AR)
- Tokyo Women's Medical University (JP)
- JR Sapporo Hospital (JP)
- Fujita Health University (JP)
- Toho University (JP)
- Corresponding author
- Takada, Tadahiro
- ORCID
- Gomi, Harumi
- Solomkin, Joseph S.
- Okamoto, Kohji
- Takada, Tadahiro
- Strasberg, Steven M.
- Ukai, Tomohiko
- Endo, Itaru
- Iwashita, Yukio
- Hibi, Taizo
- Pitt, Henry A.
- Umezawa, Akiko
- Asai, Koji
- Suzuki, Kenji
- Han, Ho‐Seong
- Hwang, Tsann‐Long
- Mori, Yasuhisa
- Yoon, Yoo‐Seok
- Kiriyama, Seiki
- Itoi, Takao
- Jagannath, Palepu
- Garden, O. James
- Shikata, Satoru
- Noguchi, Yoshinori
- Honda, Goro
- Supe, Avinash Nivritti
- Yoshida, Masahiro
- Mayumi, Toshihiko
- Chen, Miin‐Fu
- Yoon, Dong‐Sup
- Choi, In‐Seok
- Jonas, Eduard
- Fan, Sheung Tat
- Ker, Chen‐Guo
- Giménez, Mariano Eduardo
- Inomata, Masafumi
- Mukai, Shuntaro
- Higuchi, Ryota
- Hirata, Koichi
- Yamamoto, Masakazu
- Venue
- Journal of Hepato-Biliary-Pancreatic Sciences
- Publisher
- Wiley
- Published
- 2018-01
- Volume
- 25
- Issue
- 1
- Pages
- 3-16
- ISSN
- 1868-6974 (ISSN-L)
- 1868-6982
- OpenAlex
- W2765864331
- Cited by
- 451
- References
- 76
- Citations by year
- 2026: 58 · 2025: 65 · 2024: 56 · 2023: 52 · 2022: 61 · 2021: 71 · 2020: 41 · 2019: 31 · 2018: 12
- FWCI
- 4.34
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of Hepato-Biliary-Pancreatic Sciences (publishedVersion)
- PubMed (publishedVersion)
- Pure Amsterdam UMC (submittedVersion, other-oa)
- Data Archiving and Networked Services (DANS) (submittedVersion)
- Institutional Repositories DataBase (IRDB) (submittedVersion)
- Funders
- Washington University in St. Louis
- University of Pittsburgh
- University of Cincinnati
- Rush University
- Temple University
- University of Occupational and Environmental Health
- Teikyo University School of Medicine
- Seoul National University Bundang Hospital
- National University of Singapore
- Keio University
- Konyang University
- Seoul National University
- Yonsei University
- Huazhong University of Science and Technology
- Tongji University
- Chang Gung Medical Foundation
- Universidad de Buenos Aires
- University of Tsukuba
- University of Cape Town
- Fujita Health University
- Tokyo Women's Medical University
- College of Medicine, University of Cincinnati
- College of Medicine, Seoul National University
- Tongji Medical College, Huazhong University of Science and Technology
- Topics
- Health Sciences › Medicine › Gastroenterology › Gallbladder and Bile Duct Disorders
- Health Sciences › Medicine › Infectious Diseases › Antibiotic Use and Resistance
- Health Sciences › Medicine › Urology › Urinary Tract Infections Management
- Keywords
- Tokyo Guidelines 2018, acute cholangitis, cholecystitis, antimicrobial therapy, empirical antibiotic therapy, community-acquired infections, nosocomial infections, antimicrobial resistance, antibiogram, antibiotic de-escalation, antibiotic duration, antibiotic prophylaxis, endoscopic retrograde cholangiopancreatography
- MeSH terms
- Clinical Decision-Making, Acute Disease, Anti-Bacterial Agents, Cholangiopancreatography, Endoscopic Retrograde, Cholangitis, Female, Humans, Male, Tokyo, Treatment Outcome, Practice Guidelines as Topic, Community-Acquired Infections, Cholecystitis, Acute
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