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Bacteriological analysis of bile in acute cholecystitis according to the Tokyo guidelines

  • Original Article
  • Published:
Journal of Hepato-Biliary-Pancreatic Sciences

Abstract

Background

We performed bacteriological analysis of bile in acute cholecystitis (AC) patients graded in severity according to the Tokyo guidelines.

Methods

We enrolled 163 AC patients in whom bacteriological analysis of bile was performed.

Results

Significant differences in age (60 vs. 67 years), body temperature (BT) (37.2 vs. 37.6°C), white blood cell count (13,033 vs. 15,177/mm3), and serum C-reactive protein (CRP) (8.9 vs. 16.9 mg/dL) were found between the Mild and Moderate severity groups. The prevalence of bactibilia differed significantly between Mild and Moderate patients (45.3 vs. 67.0%, P = 0.0107); however, there were no significant differences in the bacterial strains, prevalence of antimicrobial resistance, or polymicrobial isolation frequency between the 2 groups. Our local antibiogram revealed that several microorganisms showed higher resistance rates; these were also isolated even in Mild cases. Advanced age, high BT, high serum CRP, and presence of marked local infection were identified as being significantly associated with high risk of bactibilia. Receiver operating characteristic curve analysis indicated the optimal cutoff value of age to be 65 years, of BT to be 37.5°C, and of serum CRP to be 13.4 mg/dL.

Conclusion

Adequate broad-spectrum antimicrobial therapy should be administered perioperatively even for Mild patients classified according to the current Tokyo guidelines. These results suggest that more precise severity grades may need to be established, including age and CRP as additional parameters.

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Authors and Affiliations

  1. Department of Surgery, Toho University Ohashi Medical Center, 2-17-6 Ohashi, Meguro-ku, Tokyo, 153-8515, Japan

    Koji Asai, Manabu Watanabe, Shinya Kusachi, Hidenori Tanaka, Hiroshi Matsukiyo, Akihiro Osawa, Tomoaki Saito, Hajime Kodama, Toshiyuki Enomoto, Yoichi Nakamura, Yasushi Okamoto, Yoshihisa Saida & Jiro Nagao

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  1. Koji Asai
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Correspondence to Koji Asai.

Discussion at the plenary session of the 23rd Congress of the Japanese Society of Hepato-Biliary-Pancreatic Surgery, 9 June 2011

Discussion at the plenary session of the 23rd Congress of the Japanese Society of Hepato-Biliary-Pancreatic Surgery, 9 June 2011

Comments by T. Beppu

The present study showed an excessively high frequency of antimicrobial resistance. Were these patients administered preoperative antimicrobial therapy? Or did these patients have other co-morbid diseases, i.e., present as compromised hosts?

Answer by K. Asai

I agree, and therefore conducted further investigations of antimicrobial resistance and the prevalence of polymicrobial infections, including the microbial species in the present cases. The prevalence of polymicrobial infection cases was significantly higher among the elderly and those with elevated CRP values. The incidences of overall postoperative and local infectious complications were also higher. This means that patients with higher risk and severe inflammation often had polymicrobial infections. However, the antimicrobial-resistant cases had delayed operation and preoperative gallbladder drainage significantly more frequently. This shows that delayed operation including preoperative gallbladder drainage to be associated with the incidence of antimicrobial agent resistance.

Comments by H. Kimura

You mentioned that appropriate management is needed to prevent postoperative complications. Your results revealed a high risk factor as regards bactibilia. What is your therapeutic strategy based on the present results?

Answer by K. Asai

From the viewpoint of antimicrobial resistance, we considered delayed operation after preoperative gallbladder drainage to be inappropriate. With the current therapeutic strategy in our hospital, early laparoscopic cholecystectomy without gallbladder drainage is usually performed according to the guidelines.

Comments by M. Kayahara

At the community hospital, there were numerous elderly high-risk AC patients. These patients were considered to have a severe status. Do you have any data on the therapeutic results in the elderly with AC? In addition, what is your therapeutic strategy for patients taking anticoagulants?

Answer by K. Asai

I have already analyzed the data from elderly patients with AC. They had significantly higher incidences of severe inflammation, overall postoperative and local infectious complications, and a significantly higher frequency of bactibilia. In addition, the elderly with AC had a significantly higher frequency of anticoagulant treatments. These patients basically receive conservative management with gallbladder drainage. After inflammatory findings improve, systemic evaluation is conducted. If general anesthesia is judged to be possible, laparoscopic cholecystectomy is selected as an elective operation. The timing of the operation is usually 1 week after admission. In patients whose inflammation fails to improve after drainage, we perform emergency surgery for life-saving purposes. The surgical procedure for such cases varies depending on the conditions of individual patients, but we make it a policy to perform LC if this procedure is applicable.

Comments by S. Egawa

You mentioned the severity discrepancy between the Japanese domestic guidelines and the Tokyo guidelines. You also stated that Severe AC in the Tokyo guidelines is rare. Therefore, do you think that the severity classification in the Tokyo guidelines should be changed?

Answer by K. Asai

I used the Japanese domestic versions for the proceedings, and then the Tokyo guidelines for writing the manuscript. The inflammatory criteria differ between these guidelines. Therefore, Moderate AC in the Tokyo guidelines presents severe inflammation comparable to Severe AC in the domestic guidelines. The presence of marked local inflammation of the gallbladder such as gangrenous cholecystitis was included in Moderate AC in the Tokyo guidelines. We also analyzed inflammatory variables according to both guidelines, and the following inflammatory severities were followed: Mild in the domestic guidelines, Mild in the Tokyo guidelines, Moderate in the domestic guidelines, Moderate in the Tokyo guidelines, and Severe in the domestic guidelines. Regarding Severe AC in the Tokyo guidelines, a past study showed the same results as ours. Severe AC was very rare and was different from acute cholangitis. Therefore, when we compare therapeutic results according to severity grades internationally, inadequate case severity distributions create certain problems. This makes it difficult to assess cases depending on severity grades. It is my hope that the Tokyo guidelines will be revised to incorporate severity classifications similar to those of the domestic guidelines.

Comments by J. Fujimoto

This presentation is an excellent study of bile assessment according to the guidelines. In the future, how will you apply these results to clinical cases? For example, will high-risk patients receive early operation without gallbladder drainage? You described the antimicrobial spectrum in your manuscript. Even Mild AC should be treated with broad-spectrum antimicrobial agents. Which patients will be treated with such broad-spectrum antimicrobial agents?

Answer by K. Asai

We basically performed early laparoscopic cholecystectomy for every case. From the viewpoint of antimicrobial agents, as mentioned in the presentation and in the manuscript, Mild AC in the current Tokyo guidelines includes cases with more severe inflammation. Furthermore, bile culture more frequently revealed the presence and complexity of bactibilia. Therefore, we mentioned that the current antimicrobial recommendation is not adequate against Mild AC according to the Tokyo guidelines. However, we emphasized that inappropriate broad-spectrum antimicrobial agents should not be used, i.e., that appropriate use depends on the results of the bile culture. However, for the first administration, the antimicrobial agents recommended according to severity in the domestic guidelines are preferable.

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Asai, K., Watanabe, M., Kusachi, S. et al. Bacteriological analysis of bile in acute cholecystitis according to the Tokyo guidelines. J Hepatobiliary Pancreat Sci 19, 476–486 (2012). https://doi.org/10.1007/s00534-011-0463-9

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