What are the recommended antibiotic regimens for the acute management of cholangitis?

Recommended antibiotic regimens for the acute management of cholangitis:

Although the provided UK guidelines do not explicitly list antibiotic regimens specifically for acute cholangitis, the management principles align with those for acute biliary infections such as cholecystitis and complicated intra-abdominal infections.

Empirical antibiotic therapy should cover Gram-negative and anaerobic bacteria commonly implicated in biliary infections. A typical regimen includes:

• Amoxicillin combined with gentamicin and metronidazole: Amoxicillin 500 mg three times daily (increased to 1 g four times daily if severe infection), gentamicin initially 5 to 7 mg/kg once daily with therapeutic drug monitoring, and metronidazole 500 mg three times daily.
• For penicillin-allergic patients or when amoxicillin is unsuitable, ciprofloxacin 400 mg twice or three times daily combined with metronidazole 500 mg three times daily may be used, but fluoroquinolones should be reserved for when other antibiotics are inappropriate due to risk of serious side effects.

Intravenous antibiotics are recommended initially, especially in complicated cases or if the patient is systemically unwell, with review and possible step-down to oral therapy within 48 hours based on clinical response and imaging.

Definitive management includes early biliary decompression and cholecystectomy as indicated.

These recommendations are consistent with the Tokyo guideline TG13 flowchart for acute cholangitis and cholecystitis management and UK expert reviews.

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