Clinical Impact of Broad- Versus Narrow-Spectrum Empiric Therapy in Acute Cholangitis

02 Apr 20264 min read0 viewsJournal Feed

GIST

by Kazuhiro Aoto, Ryo Inose, Yuichi Muraki The clinical benefit of broad-spectrum empiric therapy in patients with acute cholangitis is unclear. We aimed to evaluate the impact of broad-spectrum and narrow-spectrum empiric therapies on patient outcomes using a Japanese claims database.

The study included patients who were diagnosed with acute cholangitis between April 2014 and August 2022, aged 18–99 years, received antibiotics, had blood cultures collected, and underwent biliary drainage. Patients who received empiric therapy with carbapenems, piperacillin/tazobactam, or fourth-generation cephalosporins were included in the broad-spectrum group, whereas others were included in the narrow-spectrum group.

Of the 4,755 eligible patients, 3,377 were categorized into the narrow-spectrum group and 1,378 into the broad-spectrum group. In the multivariate logistic regression analysis, older age, higher Charlson Comorbidity Index, the presence of sepsis, and intensive care unit admission were associated with increased 30-day in-hospital mortality, whereas the receipt of broad-spectrum empiric therapy was not (adjusted odds ratio, 1.37 [95% confidence interval {CI}, 0.84–2.23]).

Clinical Editorial

Clinical Question and Study Scope

The study interrogates whether broad-spectrum empiric therapy yields superior outcomes over narrow-spectrum empiric therapy in adults with acute cholangitis, using a Japanese claims database spanning April 2014 to August 2022.

Design, Population, and Exposure

All other empiric antibiotics constituted the narrow-spectrum group.

Design: Retrospective cohort analysis with multivariate adjustment and propensity-score methods.
Population: Adults aged 18–99 with acute cholangitis who received antibiotics, had blood cultures collected, and underwent biliary drainage; data drawn from a large Japanese claims dataset.
Exposure groups: Broad-spectrum empiric therapy defined by receipt of carbapenems, piperacillin/tazobactam, or fourth-generation cephalosporins.
Sample size: 4,755 eligible patients; 3,377 in the narrow-spectrum group and 1,378 in the broad-spectrum group.

Key Outcomes and Analytic Approach

Primary outcome: 30-day in-hospital mortality.
Analyses: Multivariate logistic regression identifying predictors of mortality, including age, Charlson Comorbidity Index, sepsis, and ICU admission; broad-spectrum therapy examined as a predictor.
Propensity score matching (PSM) conducted to balance baseline differences and reassess the association between broad-spectrum therapy and mortality.

Main Findings

In multivariate analysis, the adjusted odds ratio for broad-spectrum therapy was 1.37 (95% CI 0.84–2.23).

In the PSM analysis, the odds ratio was 1.43 (95% CI 0.82–2.50).

Specifically, intravenous therapy duration differed by a median of 1 day (IQR 6–11 vs 7–13; 95% CI for difference 0.31–1.69 days).

Hospital stay differed by a median of 3 days (IQR 9–20 vs 11–25; 95% CI for difference 1.87–4.13 days).

Mortality associations: Older age, higher Charlson Comorbidity Index, sepsis, and ICU admission were linked to higher odds of 30-day in-hospital death.
Broad-spectrum therapy impact on mortality: Not associated with improved survival.
Secondary outcomes: In the propensity-matched cohort, broad-spectrum therapy was associated with longer intravenous antibiotic courses and longer hospital stays compared with narrow-spectrum therapy.

Context and Limitations

The study leverages a large administrative dataset, which may carry inherent limitations such as coding accuracy, unmeasured confounding, and lack of granular clinical details (e.g., pathogen data, source control timing, specific severity markers beyond sepsis/ICU status).