Elsevier

Journal of Infection

Volume 74, Issue 2, February 2017, Pages 172-178
Journal of Infection

Characteristics, aetiology, antimicrobial resistance and outcomes of bacteraemic cholangitis in patients with solid tumours: A prospective cohort study

https://doi.org/10.1016/j.jinf.2016.10.008Get rights and content

Highlights

  • Bacteraemic cholangitis is frequent in patients with solid tumours.

  • The most frequent causative agents are Enterobacteriaceae and Enterococcus faecium.

  • Multidrug resistance is more frequent in a second episode of cholangitis.

  • Corticosteroids and malignancy-related complications present high mortality rates.

Summary

Objectives

To asses the clinical features, aetiology, antimicrobial resistance and outcomes of bacteraemic cholangitis in patients with solid tumours (ST).

Methods

All consecutive episodes of bacteraemia in hospitalized patients were prospectively analysed (2006–2015).

Results

Of 1852 episodes of bacteraemia, 750 involved patients with ST. Among them, 173 episodes (23%) were due to cholangitis. The most frequent neoplasms were hepato-biliary-pancreatic tumours (68.2%) and gastrointestinal cancer (18.5%); 57.2% of patients had a biliary stent in place. The most frequent causative agents were Escherichia coli (39.3%) followed by Klebsiella pneumoniae (15.1%) and Enterococcus faecium (7.8%). Forty-one episodes (18.7%) were caused by multidrug-resistant (MDR) microorganisms. Patients with a second episode of cholangitis were more likely to have an MDR isolate and to had received inadequate empirical antibiotic therapy. 7-day and 30-day case-fatality rates were 7.6% and 26%, respectively. The only risk factors independently associated with 30-day case-fatality rate were corticosteroids and malignancy-related complications.

Conclusions

Bacteraemic cholangitis is frequent in patients with ST, and is mainly caused by Enterobacteriaceae and E. faecium. The emergence of MDR is of special concern, particularly in patients with a second episode of bacteraemia. Case-fatality rates are high, especially among patients receiving corticosteroids and presenting malignancy-related complications.

Introduction

Bacteraemia is a frequent complication in patients with cancer and is associated with high morbidity and mortality. The source and aetiology of bacteraemia in patients with solid tumours may vary depending on the underlying malignancy.1

Cholangitis is a common source of bacteraemia in cancer patients, occurring mainly in those with hepato-biliary-pancreatic tumours.2 Compared with other bacteraemia sites cholangitis may present some distinctive clinical characteristics, and outcomes of patients with the condition may be closely related to the resolution or drainage of the focus of infection. Cancer patients with cholangitis often present an irreversible obstruction due to tumoral infiltration, and in most cases drainage of infected bile or stent placement or replacement is required.3, 4 Management of patients with cancer and biliary stent obstruction is particularly challenging.

In spite of the clinical relevance of cholangitis in patients with cancer, information regarding this common infection in this specific population is lacking. In recent decades the epidemiology of bacteraemia in cancer patients has changed, with an increase in Gram-negatives as the leading cause, and the rise in antibacterial resistance reported at some institutions, especially among Gram-negatives, is a matter for concern.5, 6, 7, 8, 9 The emergence of antibacterial resistance is particularly worrying in immunocompromised patients with cancer, since administration of adequate empirical antibiotic therapy in patients with bacteraemia has been shown to have a beneficial impact on their outcome.10 So far, the impact of the emergence of multidrug-resistant (MDR) organisms in cancer patients with cholangitis has not been elucidated.

We sought to analyse the clinical features, aetiology, antimicrobial resistance and outcomes of patients with solid tumours and bacteraemic cholangitis in an era of widespread antimicrobial resistance.

Section snippets

Setting, patients, and study design

We conducted a prospective observational study at a 200-bed university referral cancer centre for adults in Barcelona, Spain. We analysed all consecutive episodes of bacteraemic cholangitis occurring in patients with solid tumours from January 2006 to September 2015. Information on baseline characteristics, clinical features, aetiology, empirical antibiotic therapy, and outcome were prospectively collected in a database, as part of the standard infectious disease management at our hospital. We

Study population and patient characteristics

Of 1852 episodes of bacteraemia, 750 (40.5%) involved patients with solid tumours. Among them, 133 patients presented 173 episodes of bacteraemic cholangitis, which was the main cause of bacteraemia (23%) in patients with ST.

Baseline characteristics and clinical manifestations of patients with bacteraemic cholangitis are summarized in Table 1. Most patients were men (61.8%) with a median age of 64 years. The majority of patients had hepato-biliary-pancreatic cancer (68.2%): pancreatic tumour

Discussion

In this prospective study of a large cohort of adults with solid tumours, cholangitis was the leading cause of bacteraemia, mainly in patients with hepato-biliary-pancreatic tumours and those carrying biliary stent. Obstruction of the stent was frequent and often required revision and repermeabilization. Infection by MDR organisms was common, particularly in patients presenting a second episode of cholangitis, in whom inadequate empirical antibiotic therapy was often administered. Mortality in

Conflicts of interest

The authors declare no conflicts of interest.

Author's contribution

All authors were involved in the study concept. CRC, CG, MA, JBG and JC were involved in study design. CRC, CG, JG, JL, MM and CA were involved in data acquisition. CRC, CG and CA were involved in data analysis or interpretation. CRC, CG, JBG and JC drafted and revised the manuscript. All authors reviewed and approved the final version of the manuscript.

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