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. 2023 Jul 16;12(14):4711. doi: 10.3390/jcm12144711

Table 6.

Main novelties in the management of biliary infection over the last decade. Modified from Amillo-Zaragüeta et al. [82].

Increasing isolation of Enterococcus spp., Enterococcus faecium, and Pseudomonas in acute cholangitis.
Increased resistance of E. coli and Klebsiella spp. to quinolones.
QuickSOFA (qSOFA) proposed as a new bedside score to identify sepsis (2016) but not recommended as an alternative to SIRS, NEWS, MEWS by the Surviving Sepsis Campaign 2021.
Surviving Sepsis Campaign “Hour-1 bundle” (revised 2021):

  • Measure lactate levels;

  • Blood cultures prior to antibiotic administration;

  • Administer broad-spectrum antibiotics;

  • Rapidly administer 30 mL/kg crystalloids if hypotension or lactate ≥ 4 mmol/L;

  • Administer vasopressors if patient is hypotensive during or after fluid resuscitation to maintain MAP ≥ 65 mm.

Changes in Tokyo Guidelines 2007, 2013, and 2018 (TG07, TG13, TG18)

  • The diagnostic criteria for acute cholecystitis in TG13 have better specificity and higher diagnostic accuracy than the first edition (TG07).

  • The severity classification of acute cholecystitis in TG13 and TG18 is recommended unchanged.

  • The diagnostic criteria for acute cholangitis TG13 are recommended as TG18 criteria.

  • The TG13 acute cholangitis severity classification criteria are recommended as TG18 criteria and may be useful for indicating biliary drainage in grade II patients.

  • MRI/CPMRI recommended for the diagnosis of acute cholangitis in TG18, as they are useful for diagnosing the cause and for assessing inflammation.

Role of endoscopic ultrasound (EUS) in the diagnosis of choledocholithiasis.
Early laparoscopic cholecystectomy is recommended in acute cholecystitis.
Cholecystostomy is recommended in unstable patients with acute cholecystitis.
Early biliary drainage is recommended in acute cholangitis.
New endoscopic techniques combined with EUS are incorporated for drainage of the gallbladder or bile ducts.

SIRS: Systemic Inflammatory Response Syndrome. NEWS: National Early Warning Score. MEWS: Modified Early Warning Score. MRI: Magnetic Resonance Imaging. CPMRI: Magnetic Resonance cholangiopancreatography.