The impact of delayed biliary decompression and antimicrobial therapy in 260 patients with cholangitis-associated septic shock.
CCCF ePoster library. Karvellas C. Nov 1, 2016; 150971; 90 Disclosure(s): None
Dr. Constantine Karvellas
Dr. Constantine Karvellas
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Abstract
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Topic: Retrospective or Prospective Cohort Study

The impact of delayed biliary decompression and antimicrobial therapy in 260 patients with cholangitis-associated septic shock.


Karvellas, Constantine J.1,2 ; Abraldes, Juan G.2; Zepeda-Gomez, Sergio2; Moffat, Dana C.3; Mirzanejad, Yazdan4;Vazquez Grande, Gloria5, 6 ;Koohpayehzadeh Esfahani, Ehsan6; Kumar, Anand5, 7. for the Cooperative Antimicrobial Therapy of Septic Shock (CATSS) Database Research Group

  1. Division of Critical Care Medicine, University of Alberta, Edmonton, AB Canada.
  2. Division of Gastroenterology and Hepatology, University of Alberta, Edmonton, Canada.
  3. Division of Gastroenterology, University of Manitoba, Winnipeg, Canada.
  4. Section of Infectious Diseases, Surrey Memorial Hospital, Surrey, Canada.
  5. Section of Critical Care Medicine, University of Manitoba, Winnipeg, Canada.
  6. Department of Microbiology, University of Manitoba, Winnipeg, Canada.
  7. Section of Infectious Diseases, University of Manitoba, Winnipeg, Canada. 


Abstract:

Background: Cholangitis-associated septic shock carries significant mortality. There is uncertainty regarding the most appropriate time to achieve biliary decompression.
Objective: To determine whether timing of biliary decompression and antimicrobial therapy affect survival in cholangitis patients with septic shock.
Methods: Nested retrospective cohort study of all cholangitis-associated septic shock patients (hypotension requiring vasopressors) from an international, multicenter database (CATTS) between 1996-2011. Time to therapy (antimicrobials, biliary decompression) were defined from the development of shock.
Results: Among 260 patients (mean age 69 years, 57% male), overall mortality was 37%. Compared to non-survivors (n=96), survivors (n=164) had lower mean admission APACHE II (22 vs. 28, p<0.001) and lower median serum lactate on admission (3.4 vs. 4.6, p<0.001). Survivors were more likely to receive appropriate antimicrobial therapy earlier (median 2.6 vs. 6.8 hours from shock, p<0.001). Survivors were also more likely to undergo successful biliary decompression earlier (median 8.8 vs. 22 hours, p<0.001). After adjusting for covariates, APACHEII (Odds ratio ~ OR 1.21 per increment (1.11-1.32), time delay to appropriate antimicrobial therapy (OR 1.15 per hour (1.07-1.25) and delayed biliary decompression > 12 hours (OR 3.40 (1.12-10.31) were all significantly associated with increased mortality (p<0.04 for all; c-statistic 0.896).
Conclusions: Patients with septic shock secondary to acute cholangitis have significant mortality. Delays in endoscopic biliary decompression >12 hours and receipt of appropriate antimicrobial therapy were significantly associated with hospital outcome. Early initiation of antimicrobial therapy and urgent biliary decompression (within 12 hours) could potentially improve outcomes in this high-risk patient population.

Supplementary file legends
 
File 1 (Table): Multivariable Logistic Regression Analysis: Independent associations with in-hospital mortality in acute cholangitis patients presenting with septic shock.

File 2: Predicted hospital mortality rate for acute cholangitis patients with associated septic shock as calculated by logistic regression. In Panel A, the independent variable is delay in antimicrobial therapy (hours). Panel B demonstrates this with APACHE II score is the independent variable. Regression lines for time to biliary decompression less than or greater than 12 hours (worse outcomes) have been selected as representative. Grey bands represent 95% confidence intervals.
 
File 3: Predicted hospital mortality rate acute cholangitis patients with associated septic shock using multivariable logistic regression (patients who received appropriate antimicrobials prior to development of shock or had missing variables were excluded). In this figure, the independent variable is delay in antimicrobial therapy (hours). Different curves represent this relationship adjusted for different APACHEII values. Regression lines for APACHEII scores of 20, 30 and 40 have been selected as representative. Grey bands represent 95% confidence intervals.


References:

1.         Mosler P. Diagnosis and management of acute cholangitis. Curr Gastroenterol Rep 2011;13(2):166-72.
2.         James PD, Kaplan GG, Myers RP, et al. Decreasing mortality from acute biliary diseases that require endoscopic retrograde cholangiopancreatography: a nationwide cohort study. Clin Gastroenterol Hepatol 2014;12(7):1151-1159 e6.
3.         Sugiyama M, Atomi Y. Treatment of acute cholangitis due to choledocholithiasis in elderly and younger patients. Arch Surg 1997;132(10):1129-33.
4.         Lai EC, Mok FP, Tan ES, et al. Endoscopic biliary drainage for severe acute cholangitis. N Engl J Med 1992;326(24):1582-6.
5.         Khashab MA, Tariq A, Tariq U, et al. Delayed and unsuccessful endoscopic retrograde cholangiopancreatography are associated with worse outcomes in patients with acute cholangitis. Clin Gastroenterol Hepatol 2012;10(10):1157-61.
6.         Salek J, Livote E, Sideridis K, Bank S. Analysis of risk factors predictive of early mortality and urgent ERCP in acute cholangitis. J Clin Gastroenterol 2009;43(2):171-5.
7.         Lee CC, Chang IJ, Lai YC, Chen SY, Chen SC. Epidemiology and prognostic determinants of patients with bacteremic cholecystitis or cholangitis. Am J Gastroenterol 2007;102(3):563-9.
8.         Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006;34(6):1589-96.
 



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