›Preferred for moderate severity community-acquired
›Meropenem IV (severe or prior antibiotic exposure)
›1 g IV every 8 hours
›Prior biliary stent, prior ERCP, or resistance risk
›Imipenem-cilastatin IV (alternative)
›500 mg IV every 6 hours
›Renal dosing required
›Add vancomycin or linezolid if Enterococcus suspected
›Vancomycin IV 15-20 mg/kg every 8-12 hours
›AUC-guided monitoring preferred
›Target AUC 400-600 mg x hour/l
›Linezolid IV 600 mg every 12 hours
›Alternative if vancomycin intolerant
›Platelet monitoring with prolonged use
›Avoid aminoglycosides in cholestasis
›Increased nephrotoxicity risk
›Alternative gram-negative coverage preferred
›Duration targets
›Uncomplicated with adequate biliary drainage
›3-5 days after source control
›TG18 and COBRA trial guidance
›Inadequate drainage or abscess
›Extended course 7-14 days
›Imaging-guided response assessment
›Healthcare-associated or resistant organisms
›Longer duration per culture results
›Infectious disease consultation
Biliary drainage (definitive treatment)
›ERCP (treatment of choice)
›Timing by severity
›Grade II: within 24-48 hours (ASGE guideline recommendation)
›Grade III: urgent within 24 hours after stabilization
›Grade I: within 72 hours or next available
›Mortality benefit
›0.5% vs 21% in propensity-matched study for urgent ERCP
›ASGE guideline supports early drainage
›Procedure components
›Sphincterotomy with stone extraction preferred over stent alone
›Bile culture collected at time of drainage
›Biliary stent placement if complete stone removal not feasible
›Percutaneous transhepatic biliary drainage (PTBD)
›Indications
›ERCP failed or not feasible
›Surgically altered anatomy (Roux-en-Y, Whipple)
›Malignant hilar obstruction
›Associated with higher morbidity than ERCP
›Bleeding and bile leak risks
›External drain management
›EUS-guided biliary drainage
›Emerging alternative for failed ERCP
›Comparable outcomes in selected centers
›Requires advanced endoscopy expertise
›Surgical biliary drainage
›Last resort with highest morbidity and mortality
›When endoscopic and percutaneous approaches fail
›T-tube drainage or choledochojejunostomy
Analgesia and supportive care
›Pain management
›Acetaminophen 1 g IV or PO every 6 hours
›First-line analgesic
›Dose reduce in liver failure
›Opioids as needed for severe pain
›Morphine 2-4 mg IV every 4 hours PRN
›Titrate to pain control
›NSAIDs with caution
›Renal and GI risks in sepsis
›Avoid if AKI or coagulopathy
›NPO status
›Anticipate ERCP or procedural intervention
›NPO after midnight or minimum 4-6 hours
›IV maintenance fluids while NPO
›Vitamin K
›Coagulopathy from cholestasis-related vitamin K malabsorption
›Vitamin K 10 mg IV or subcutaneous daily x 3 doses
›Monitor INR response
Definitive surgical management
›Cholecystectomy planning
›If choledocholithiasis is the etiology
›Same admission or within 2-4 weeks post-discharge
›Laparoscopic cholecystectomy preferred
›Timing considerations
›After resolution of acute cholangitis
›Biliary anatomy confirmed on imaging