Microbial Types and Patterns of Multidrug Resistance in Patients with Acute Cholangitis

Catassi Viola^*
*Correspondence: Catassi Viola, Department of Medicine, West University of Arad, 310414 Arad, Romania, Email:

Keywords

Acute cholangitis • Microbial types • Multidrug resistance • Antibiotics

Introduction

Acute cholangitis is a condition characterized by inflammation of the bile ducts, typically due to bacterial infection. It is most commonly caused by obstruction of the biliary tree, which can lead to bile stasis and subsequent bacterial overgrowth. The pathogens involved in acute cholangitis can vary widely, influencing treatment outcomes and necessitating a tailored approach to antibiotic therapy. Moreover, the increasing prevalence of Multidrug-Resistant Organisms (MDROs) poses a formidable challenge in managing this condition effectively [1].

The microbial spectrum of acute cholangitis includes both aerobic and anaerobic bacteria, with the most frequent isolates being gram-negative enteric bacteria. Escherichia coli is the predominant pathogen, accounting for a substantial proportion of cases worldwide. Other common pathogens include Klebsiella species, Enterococcus species and anaerobes such as Bacteroides fragilis. The distribution of these pathogens can vary depending on geographical location, healthcare settings and underlying biliary pathology. Multidrug Resistance (MDR) among bacteria causing acute cholangitis has become increasingly prevalent, complicating treatment strategies. MDR is defined as resistance to at least one agent in three or more antimicrobial categories. The mechanisms of resistance vary among different bacterial species and can include enzymatic degradation of antibiotics, alterations in membrane permeability and efflux pump systems [2].

Literature Review

Extended-Spectrum Beta-Lactamase (ESBL) Producing Enterobacteriaceae, ESBL-producing strains, particularly Escherichia coli and Klebsiella pneumoniae, are notable for their resistance to most beta-lactam antibiotics, including cephalosporins and penicillins. This poses challenges in selecting empirical antibiotic therapy, as these organisms are frequently implicated in acute cholangitis. Carbapenem-Resistant Enterobacteriaceae (CRE), resistance to carbapenems, often considered the last-line treatment for severe infections, has emerged among Enterobacteriaceae due to the production of carbapenemases. CRE infections are associated with high mortality rates and limited treatment options, necessitating the use of alternative agents such as polymyxins and tigecycline. Vancomycin-Resistant Enterococci (VRE), enterococci, particularly Enterococcus faecium, have demonstrated resistance to vancomycin, an essential antibiotic for treating gram-positive infections. VRE infections are concerning due to limited therapeutic options and the potential for nosocomial transmission [3].

Given the diverse microbial etiology and the rising prevalence of MDR organisms in acute cholangitis, empirical antibiotic therapy should be guided by local epidemiological data and antimicrobial susceptibility patterns. Tailored therapy based on culture and susceptibility results remains paramount to optimize clinical outcomes and reduce the emergence of further resistance. Future research efforts should focus on novel antimicrobial agents, combination therapies and infection control measures to mitigate the spread of MDR organisms in acute cholangitis. Surveillance of antimicrobial resistance patterns and implementation of antimicrobial stewardship programs are essential to preserve the efficacy of existing antibiotics and improve patient outcomes. Acute cholangitis presents a clinical challenge exacerbated by the diversity of microbial pathogens and the emergence of multidrug resistance. A comprehensive understanding of microbial types and resistance patterns is crucial for guiding effective antibiotic therapy and advancing strategies to combat resistance in clinical practice [4].

Discussion

Acute cholangitis is a critical condition characterized by bacterial infection and inflammation of the bile ducts, which often arises from biliary obstruction due to gallstones, strictures, or malignancies. The infection can progress rapidly to sepsis and organ dysfunction if not promptly treated with appropriate antibiotics and biliary decompression. The causative pathogens vary widely and understanding their antimicrobial susceptibility profiles is crucial for optimizing treatment outcomes. Gram-negative enteric bacteria are the most common pathogens isolated in acute cholangitis. Among these, Escherichia coli is predominant, responsible for a significant proportion of infections globally. It typically exhibits susceptibility to third-generation cephalosporins, but the emergence of Extended-Spectrum Beta-Lactamase (ESBL) producing strains complicates treatment choices. Klebsiella pneumoniae, another prominent gram-negative organism, can also produce ESBLs and has been associated with more severe infections and higher mortality rates. Enterococcus species, particularly Enterococcus faecalis and Enterococcus faecium, are gram-positive cocci commonly implicated in acute cholangitis, especially in cases involving biliary instrumentation or prior antibiotic exposure. Enterococci are intrinsically resistant to many antibiotics, including cephalosporins and can acquire resistance to vancomycin, posing challenges for treatment [5].

Resistance to carbapenems among Enterobacteriaceae, known as CRE, has emerged as a critical public health threat. Carbapenemases, such as KPC (Klebsiella Pneumoniae Carbapenemase) and NDM (New Delhi Metallo-Beta-Lactamase), are enzymes that hydrolyze carbapenem antibiotics, leading to treatment failures and limited therapeutic options. Infections caused by CRE are associated with high mortality rates and require judicious use of alternative agents, including polymyxins (colistin) and tigecycline. Although less common in acute cholangitis compared to other infections, Staphylococcus aureus, particularly MRSA strains, can cause severe infections, especially in patients with biliary instrumentation or healthcare-associated risk factors. MRSA poses challenges due to its resistance to beta-lactam antibiotics, including methicillin, necessitating the use of vancomycin or alternative agents for treatment. Effective management of acute cholangitis requires a multidisciplinary approach involving early recognition, biliary decompression and prompt initiation of appropriate antimicrobial therapy based on local epidemiological data and antimicrobial susceptibility patterns. Empirical therapy should cover a broad spectrum of gram-negative and anaerobic bacteria while considering the risk of multidrug-resistant pathogens [6].

Conclusion

Acute cholangitis presents a complex clinical scenario influenced by the diverse spectrum of microbial pathogens and the increasing prevalence of multidrug resistance. A thorough understanding of microbial types and resistance patterns is essential for guiding empirical antibiotic therapy and improving clinical outcomes in patients with this potentially life-threatening condition. Continued research and proactive measures are necessary to combat antimicrobial resistance and ensure effective management of acute cholangitis worldwide.

Acknowledgement

None.

Conflict of Interest

None.

References

1. Li, Suqing, Leonardo Guizzetti, Christopher Ma and Abdel Aziz Shaheen, et al. "Epidemiology and outcomes of choledocholithiasis and cholangitis in the United States: Trends and urban-rural variations." BMC Gastroenterol 23 (2023): 254.

Google Scholar, Crossref, Indexed at

2. Suh, Suk-Won, Yoo Shin Choi, Seong-Ho Choi and Jae Hyuk Do, et al. "Antibiotic selection based on microbiology and resistance profiles of bile from gallbladder of patients with acute cholecystitis." Sci Rep 11 (2021): 2969.

Google Scholar, Crossref, Indexed at

3. Zimmer, Vincent and Frank Lammert. "Acute bacterial cholangitis." Visc Med 31 (2015): 166-172.

Google Scholar, Crossref, Indexed at

4. Klemm, Elizabeth J., Vanessa K. Wong and Gordon Dougan. "Emergence of dominant multidrug-resistant bacterial clades: Lessons from history and whole-genome sequencing." Proc Natl Acad Sci115 (2018): 12872-12877.

Google Scholar, Crossref, Indexed at

5. Namdari, Sepide, Ali Farhadi, Aida Khademalhoseini and Abbas Behzad-Behbahani, et al. "Emergence of highly multidrug‐resistant bacteria isolated from patients with infections admitted to public hospitals in southwest Iran." Interdiscip Perspect Infect Dis 2021 (2021): 5265379.

Google Scholar, Crossref, Indexed at

6. Aurilio, Caterina, Pasquale Sansone, Manlio Barbarisi and Vincenzo Pota, et al. "Mechanisms of action of carbapenem resistance." Antibiot 11 (2022): 421.

Google Scholar, Crossref, Indexed at