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Difficulty: EasyGastroenterology and Hepatology

A 58-year-old man is hospitalized for acute ascending cholangitis. On admission, he presented with fever, jaundice, and right upper quadrant abdominal pain. He was started on empiric intravenous piperacillin-tazobactam, and an endoscopic retrograde cholangiopancreatography (ERCP) was performed, successfully removing a common bile duct stone and establishing biliary drainage. Forty-eight hours later, the patient is afebrile, his vital signs are stable, and his abdominal pain has significantly improved. Both blood and bile cultures grow Escherichia coli. Susceptibility testing indicates the organism is susceptible to ceftriaxone, ciprofloxacin, and piperacillin-tazobactam. Which of the following is the most appropriate next step in antibiotic management?

  1. Switch to intravenous ceftriaxoneAnswer
  2. B
    Continue intravenous piperacillin-tazobactam
  3. C
    Switch to intravenous meropenem
  4. D
    Switch to intravenous cefepime and metronidazole
  5. E
    Add intravenous vancomycin

Answer

Switch to intravenous ceftriaxone
The most appropriate next step is to switch to intravenous ceftriaxone. In the management of acute cholangitis, initial empiric therapy requires broad-spectrum coverage (such as piperacillin-tazobactam) to cover common biliary pathogens, including Gram-negative rods and anaerobes. However, once biliary drainage (source control) is achieved and culture/susceptibility data become available, fundamental antibiotic stewardship principles mandate de-escalation to the narrowest-spectrum, most targeted agent effective against the isolated organism. Because the Escherichia coli isolate is susceptible to ceftriaxone, continuing piperacillin-tazobactam is unnecessarily broad.

Step-by-Step Solution

1
Identify the patient's clinical status and culture results.
The patient is clinically improving after source control (ERCP), and cultures show E. coli susceptible to multiple agents, including ceftriaxone.
Clinical stability and culture data dictate the choice of definitive antibiotic therapy.
2
Apply principles of antibiotic stewardship.
Select the narrowest-spectrum effective agent.
De-escalation from empiric broad-spectrum therapy prevents antimicrobial resistance and reduces the risk of adverse effects.

Key Concept

Antibiotic de-escalation in acute cholangitis following culture and susceptibility results
Estimated Time:1m 0s
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Topics

Gastroenterology and Hepatology

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