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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]
In the citing paper
“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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“Based on the duration of antibiotic treatment for severe cholangitis, treatment for 4–7 days with clinical resolution has been suggested [6].”
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“The Gram-positive and Gram-negative bacteria isolated from the 59 bile aspirates were consistent with findings reported in humans [19, 20], small animals [39, 40, 41–44], single cases of a kinkajou (Potos flavus) [45], and a domestic ferret (Mustela putorius) (non-bile farmed) [46], despite the additional infection pa…”
ResultAcute Acalculous Cholecystitis
Wiel, L. C., Spezzacatene, A., Gortani, G., Saccari, A., Taddio, A., & Barbi, E. (2022) · Pediatric Emergency Care · doi:10.1097/pec.0000000000002735 · Cited by 5
Early laparoscopic cholecystectomy for acute cholecystitis: should we operate beyond the first week?
Barka, M., Jarrar, M. S., Sahli, J., Abdessalem, Z. B., Hamila, F., & Youssef, S. (2023) · Langenbeck s Archives of Surgery · doi:10.1007/s00423-023-02816-5 · Cited by 5
Belyaev, A. M., Thwaite, P., Rossaak, J. I., Chen, J., & Smith, B. (2023) · Journal of Surgical Research · doi:10.1016/j.jss.2023.07.047 · Cited by 5
Microbiological etiology and current resistance patterns in acute calculous cholecystitis
de Miguel-Palacio, M., González-Castillo, A. M., Martín-Ramos, M., Membrilla-Fernández, E., Pelegrina-Manzano, A., Pons-Fragero, M.-J., Grande, L., & Sancho-Insenser, J.-J. (2024) · Cirugía Española (English Edition) · doi:10.1016/j.cireng.2024.04.003 · Cited by 5
Çevik, E., Albadawi, H., Zhang, Z., Demirlenk, Y. M., Atar, D., Keum, H., Kim, J., Graf, E. H., Gunduz, S. G., Rehman, S., et al. (2024) · Advanced Materials · doi:10.1002/adma.202402570 · Cited by 5
Chan, K. S., & Shelat, V. G. (2024) · Antibiotics · doi:10.3390/antibiotics13050411 · Cited by 5
“Specific pathologies have been shown to require a protracted course of antibiotics, such as in cholecystitis and cholangitis complicated by bacteraemia [52], or pyogenic liver abscess (PLA).”
BackgroundApproaches to Cholecystitis: Surgical, Endoscopic, and Percutaneous Management
Cherng, N. B., Achebe, I., Winkie, M., Thomann, J., Then, E. O., & Marya, N. B. (2024) · Journal of Intensive Care Medicine · doi:10.1177/08850666241267262 · Cited by 5
“14 Choice of antibiotic is also dependent on the severity of AC.”
Clinical characteristics and outcomes of Staphylococcus aureus bacteremia from a biliary source
Yang, E., Lee, J., Seo, H., Chung, H., Hyun, S. M., Sung, H., Kim, M., Jung, J., Kim, M. J., Kim, S., et al. (2020) · European Journal of Clinical Microbiology & Infectious Diseases · doi:10.1007/s10096-020-03940-6 · Cited by 5
“as the most common gram-positive organism [8].”
Park, S. C., Gillis-Crouch, G. R., Cox, H. L., Donohue, L. E., Morse, R., Vegesana, K. B., & Mathers, A. J. (2021) · Antimicrobial Agents and Chemotherapy · doi:10.1128/aac.01980-20 · Cited by 5
“on severity of illness as the indication for the empirical use of agents with broader spectra (14, 15).”
BackgroundХатьков, И. Е., Avanesyan, R. G., Akhaladze, G. G., Бебуришвили, А. Г., Bulanov, А. Y., Быков, М. И., Винницкая, Е. В., Виршке, Э. Р., Gabriel, S. A., Гранов, Д. А., et al. (2021) · Terapevticheskii arkhiv · doi:10.26442/00403660.2021.02.200619 · Cited by 5
Li, L., Cheng, L., Sa, R., Qiu, X., & Chen, L. (2022) · Critical Reviews in Oncology/Hematology · doi:10.1016/j.critrevonc.2022.103624 · Cited by 5
Hadano, Y., & Hijikata, T. (2023) · IDCases · doi:10.1016/j.idcr.2023.e01695 · Cited by 5
Acute cholecystitis: Severity assessment and management
Vagholkar, K. (2020) · International Journal of Surgery Science · doi:10.33545/surgery.2020.v4.i2e.433 · Cited by 5
Liu, J., Hu, Y., Lin, K., Lin, K., Lin, H., Chen, R., Li, S., Wang, J., & Zeng, Y. (2020) · Saudi Journal of Gastroenterology · doi:10.4103/sjg.sjg_128_20 · Cited by 6
Hanabata, Y., Yamanaka, K., Shinkura, A., Kurimoto, M., Aoki, H., Harada, K., Kayano, M., Tashima, M., & Tamura, J. (2021) · Journal of Hepato-Biliary-Pancreatic Sciences · doi:10.1002/jhbp.1069 · Cited by 5
Teng, T. Z. J., & Shelat, V. G. (2021) · Surgical Infections · doi:10.1089/sur.2021.209 · Cited by 5
“Enterococcus species make up to 30% of the causative pathogens causing biliary sepsis [1].”
Aetiology, diagnosis and management for ischaemic cholecystitis: current perspectives
Favela, J., Argo, M. B., & Huerta, S. (2023) · eGastroenterology · doi:10.1136/egastro-2023-100004 · Cited by 4
“16 30 31 There are currently two primary drainage procedures employed for patients diagnosed with ischaemic cholecystitis and deemed to be poor surgical candidates: percutaneous transhepatic gallbladder drainage (PTGD) and endoscopic drainage, which can be done via a transpapillary or transmural…”
Kuhara, Y., Kitagawa, H., Kaiki, Y., Omori, K., Shigemoto, N., Akita, T., Uemura, K., Fukuma, S., Takahashi, S., & Ohge, H. (2025) · Journal of Hepato-Biliary-Pancreatic Sciences · doi:10.1002/jhbp.12193 · Cited by 4
Forster, K., Klein, F., Simon, N., Chhatwal, P., Ziesing, S., Heidrich, B., & Solbach, P. (2023) · European Journal of Gastroenterology & Hepatology · doi:10.1097/meg.0000000000002633 · Cited by 4
Risk factors for cefmetazole-non-susceptible bacteremia in acute cholangitis
Onishi, K., Morioka, H., Imaizumi, T., Tsuchimoto, D., Nishio, M., & Komiyama, T. (2023) · Journal of Infection and Chemotherapy · doi:10.1016/j.jiac.2023.11.015 · Cited by 4
Masuda, S., Imamura, Y., Jinushi, R., Kubota, J., Kimura, K. A., Makazu, M., Sato, R., Kako, M., Kobayashi, M., Uojima, H., et al. (2024) · JGH Open · doi:10.1002/jgh3.13047 · Cited by 4
Nomogram for assistant diagnosing acute suppurative cholangitis: a case-control study
He, Y., Wang, H., Zhao, Y.-H., Lv, G.-T., Tao, P., Fu, K., & Liu, Z. (2024) · BMC Gastroenterology · doi:10.1186/s12876-024-03379-5 · Cited by 4
“The positivity rate for bile cultures was 64.4%, consistent with findings from other studies [25].”
ResultInfluentialAlipour, S., Harzandi, N., Sadeghi, A., Rabbani, A., & Houri, H. (2024) · Microbial Pathogenesis · doi:10.1016/j.micpath.2024.107026 · Cited by 4
Yoon, J., Kwack, W. G., Shim, W.-S., Lee, J. K., Jang, D. K., Gu, N., Cho, J., Lee, K., & Chung, E. K. (2020) · Biomedical Chromatography · doi:10.1002/bmc.4957 · Cited by 4
Role of cholangitis in predicting survival in patients with carcinoma of the ampulla of vater
D’Silva, M., Han, H., & Yoon, Y. (2020) · Surgical Oncology · doi:10.1016/j.suronc.2020.08.003 · Cited by 4
Self-citationClinical characteristics and management of acute cholecystitis after cardiovascular surgery
Yasukawa, K., Shimizu, A., Kubota, K., Notake, T., Sugenoya, S., Hosoda, K., Hayashi, H., Kobayashi, R., & Soejima, Y. (2020) · Journal of Hepato-Biliary-Pancreatic Sciences · doi:10.1002/jhbp.872 · Cited by 4
“448 Postoperative hospital staya (days) 18 (6-38) 10 (4-29) .”
Acute cholecystitis caused by gallbladder metastasis from non-small cell lung cancer: a case report
Imaoka, K., Satoh, D., Oshita, K., Yano, T., Kubota, T., Ishida, M., Choda, Y., Yoshimitsu, M., Nakano, K., Harano, M., et al. (2021) · Clinical Journal of Gastroenterology · doi:10.1007/s12328-020-01293-3 · Cited by 4
Kang, E. K., Suh, S., Lee, S. E., Choi, Y. S., Choi, S.-H., Lee, B., Choi, Y., & Jeong, J. (2021) · Surgical Infections · doi:10.1089/sur.2020.358 · Cited by 4
“First, it limits local inflammation and systemic septic response [5] and second, it prevents not only procedure-related surgical site infections from a superficial wound into the organ space, but also intra-hepatic abscess formation [6].”
InfluentialThe Importance of Early Management of Severe Biliary Infection: Current Concepts
Zaragüeta, M. A., Nve, E., Casanova, D., Garro, P., & Badía, J. M. (2021) · International Surgery · doi:10.9738/intsurg-d-20-00046.1 · Cited by 4
Chan, K. S., & Shelat, V. G. (2022) · World Journal of Surgery · doi:10.1007/s00268-022-06559-0 · Cited by 4
An Unusual Case of Acute Cholecystitis Caused by Lactobacillus paracasei
Kim, H. U., Choo, B., Pyakuryal, A., & Shah, M. (2023) · Cureus · doi:10.7759/cureus.40334 · Cited by 4
“Metronidazole is normally used to cover community-acquired biliary infections for anaerobic coverage [4].”
BackgroundResultThe effects of photoactivated ciprofloxacin and bile acids on biofilms on bile duct catheters
Eberhardt, N., González-Santamarina, B., Enghardt, M.-L., Rohland, O., Hussain, I., Tannert, A., Thieme, L., Rubio, I., Rödel, J., Löffler, B., et al. (2024) · International Journal of Antimicrobial Agents · doi:10.1016/j.ijantimicag.2024.107086 · Cited by 4
Ou, Y., Li, J., Liang, C., Hu, C., Yao, M., Huang, Y., Cai, X., & Yan, Y. (2024) · Surgical Endoscopy · doi:10.1007/s00464-024-10737-7 · Cited by 4
“In this study, Gram-negative bacteria was the main bilitis infection bacteria, and various antibiotics, including fluoro-quinolones (e.g., ciprofloxacin [CIP]), carbapenems (e.g., meropenem [MEM]), and tigecycline (TGC), have been contemplated [36].”
Masuda, S., Imamura, Y., Ichita, C., Jinushi, R., Kubota, J., Kimura, K. A., Makazu, M., Sato, R., Kako, M., Kobayashi, M., et al. (2024) · Scientific Reports · doi:10.1038/s41598-024-68999-z · Cited by 4
“Furthermore, while focusing on the current standard treatment duration of ≤ 7 days for the main analysis, we decided to analyze the subgroup with a shortened treat-ment duration of ≤ 3 days, the effectiveness of which is currently being studied 10–15 .”
BackgroundLiu, J., Hu, Q. L., Lamaina, M., Hornor, M. A., Davis, K. A., Reinke, C. E., Peden, C. J., Ko, C. Y., Wick, E. C., & Maggard-Gibbons, M. A. (2019) · Journal of the American College of Surgeons · doi:10.1016/j.jamcollsurg.2019.11.014 · Cited by 4
Tracy, B. M., Paterson, C. W., Torres, D. M., Young, K., Saxe, J. M., Kinstedt, D. P., Zielinski, M. D., Camazine, M. N., Yeh, D. D., Gelbard, R. B., et al. (2021) · The Journal of Trauma: Injury, Infection, and Critical Care · doi:10.1097/ta.0000000000003203 · Cited by 4
“In light of bacterial resistance, medical cost, and because minimal infected tissue remains after a cholecystectomy, the expert panel advised limiting antimicrobial therapy to before and at the time of surgery—citing no benefit to treatment beyond 24 hours of surgery.(12) These new 2018 Tokyo Guidelines also commented…”
BackgroundInfluentialSugiura, R., Naruse, H., Yamamoto, Y., Hatanaka, K., Kinoshita, K., Abiko, S., Miyamoto, S., Suzuki, K., Higashino, M., Kohya, R., et al. (2021) · Revista Española de Enfermedades Digestivas · doi:10.17235/reed.2021.7995/2021 · Cited by 4
Self-citationSchmitz, D., Eigner, U., Schmidt-Wieland, T., Weber, P., Magdeburg, R., Kienle, P., & Rudi, J. (2020) · Case Reports in Gastroenterology · doi:10.1159/000508851 · Cited by 4
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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