{ "schema_version": 1, "kind": "condition", "id": "cholangitis", "name": "Cholangitis", "category": "chronic", "sources": "Cholangitis - StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK558946/ · ICPC-3 (WONCA International Classification of Primary Care, 3rd edition) class DD82.00 - condition scope only, no dose · Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis (J Hepatobiliary Pancreat Sci 2018;25:3-16, tokyo-guidelines-2018-antimicrobial-jhbp518.pdf) · Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, p255)", "review_status": "reviewed", "verified_against": "Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis (J Hepatobiliary Pancreat Sci 2018;25:3-16, tokyo-guidelines-2018-antimicrobial-jhbp518.pdf) · Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, p255)", "verified_date": "2026-08", "treatments": [ { "id": 432, "generic": "Ceftriaxone", "line": 1, "is_adjunct": false, "form": "injection", "strength_mg": 1000.0, "adult_dose": "1 to 2 g intravenously or intramuscularly, once daily or divided into two doses. Maximum 4 g daily, and no more than 2 g daily where renal and hepatic impairment are present together.", "adult_duration": "Continued in hospital: 4 to 7 days once the source of infection has been controlled, and a minimum of 2 weeks if there is bacteraemia with a gram-positive coccus such as Enterococcus or Streptococcus", "dose_source": "Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, p255)", "rationale": "Two documents, each for a different claim. The Tokyo Guidelines 2018 name the agent: for grade I and grade II community-acquired acute cholangitis their cephalosporin-based options are cefazolin, cefotiam, cefuroxime, ceftriaxone or cefotaxime, and they state that antimicrobial therapy should be started before any percutaneous, endoscopic or operative drainage is performed - which is what makes a first dose in the clinic, on the way to hospital, the right move rather than a delay. The Egyptian formulary supplies the amount: it lists community-acquired intra-abdominal infection among ceftriaxone's indications and gives a general adult intravenous or intramuscular dose of 1 to 2 g once or twice daily. Egypt registers eight ceftriaxone injection products.", "cautions": [ "THIS IS FOR ACUTE ASCENDING BACTERIAL CHOLANGITIS, NOT FOR THE AUTOIMMUNE DISEASES OF THE SAME NAME. Primary biliary cholangitis and primary sclerosing cholangitis are long-term hepatology conditions and no antibiotic is given for them.", "THE ANTIBIOTIC DOES NOT REPLACE THE DRAINAGE, AND MUST NOT DELAY IT. The Tokyo Guidelines state that antimicrobial therapy should be started before any percutaneous, endoscopic or operative procedure - which means the first dose goes in on the way to hospital, not instead of going.", "CEFTRIAXONE IS ON THE GUIDELINE'S OWN RESISTANCE LIST. The Tokyo Guidelines carry ceftriaxone and cefotaxime in a table of agents with a high prevalence of resistance among Enterobacteriaceae, reflecting the global spread of extended-spectrum beta-lactamase producers. Where a local antibiogram shows that resistance, the guideline's answer is a carbapenem, piperacillin with tazobactam, or ceftazidime or cefepime combined with metronidazole. What the resistance rate is in any given Egyptian hospital is a local measurement, and no national figure is claimed for it.", "ANAEROBIC COVER IS ADDED IF THERE IS A BILIARY-ENTERIC ANASTOMOSIS - a previous operation joining bile duct to bowel. The Tokyo Guidelines warrant metronidazole, tinidazole or clindamycin in that situation only, and note that carbapenems, piperacillin with tazobactam, ampicillin with sulbactam, cefmetazole, cefoxitin, flomoxef and cefoperazone with sulbactam already have enough anti-anaerobic activity on their own. The Egyptian formulary's metronidazole monograph states no dosing regimen, so no amount is printed here.", "AMPICILLIN WITH SULBACTAM IS NOT AN EMPIRICAL CHOICE unless the local susceptibility is 80% or better - the Tokyo Guidelines withdraw it below that.", "REYNOLDS' PENTAD IS CHARCOT'S TRIAD PLUS HYPOTENSION AND CONFUSION, and is a surgical or gastroenterological emergency. Charcot's triad is fever, jaundice and right upper quadrant pain.", "Do not give in hypersensitivity to ceftriaxone, any component, or another cephalosporin. Do not give with an intravenous calcium-containing solution in a neonate of 28 days or less, and do not give to a jaundiced neonate, particularly a premature one, because ceftriaxone displaces bilirubin from albumin.", "Blood cultures before the first dose where that is possible, because the duration depends on what grows: a gram-positive coccus in the blood turns a 4 to 7 day course into a minimum of 2 weeks." ], "peds_mgkg_low": 50.0, "peds_mgkg_high": 75.0, "peds_max_mg": 1000.0, "peds_basis": "dose", "peds_unit": "mg", "peds_note": "The Egyptian formulary gives 50 to 75 mg/kg as a single daily dose for mild to moderate infection in infants, children and adolescents, with a daily ceiling of 1,000 mg - and because it is given once a day, that ceiling is also the ceiling on the single dose. For severe infection the same monograph gives 100 mg/kg per day divided every 12 to 24 hours to a maximum of 4,000 mg a day, and a premature or term neonate is given 50 mg/kg every 24 hours. Acute cholangitis in a child is rare and is usually a complication of previous biliary surgery; which of those bands applies is a judgement for the admitting team.", "peds_min_weight_kg": null, "peds_max_weight_kg": null, "peds_age_min_months": null, "peds_age_max_months": null, "peds_age_bands": null, "peds_doses": [ { "weight_kg": 10, "low_mg": 500, "high_mg": 750, "capped": false }, { "weight_kg": 20, "low_mg": 1000, "high_mg": 1000, "capped": true }, { "weight_kg": 30, "low_mg": 1000, "high_mg": 1000, "capped": true }, { "weight_kg": 40, "low_mg": 1000, "high_mg": 1000, "capped": true } ], "brands": [ { "trade_name": "ZOXIDEL 1 GM PD. FOR I.M. INJ.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "RAMEDA > DELTA PHARMA", "price_egp": 22.0, "pack_count": null, "unit_price": null, "strength_mg": 1000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "CEFTRIAXONE SODIUM 1 GM I.M.VIAL (KAHIRA)", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "KAHIRA", "price_egp": 29.0, "pack_count": null, "unit_price": null, "strength_mg": 1000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "ZOXIDEL 1 GM PD. FOR I.V. INJ.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "RAMEDA > DELTA PHARMA", "price_egp": 29.0, "pack_count": null, "unit_price": null, "strength_mg": 1000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "WINTRIAXONE 1 GM PD. FOR I.V INJ.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "SANOFI", "price_egp": 48.0, "pack_count": null, "unit_price": null, "strength_mg": 1000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "VOTRIAXONE 1 GM I.M VIAL", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "CHEMIPHARM", "price_egp": 56.0, "pack_count": null, "unit_price": null, "strength_mg": 1000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "OFRAMAX 1 GM I.M. VIAL", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "RAMEDA > SUN PHARMA EGYPT LIMITED", "price_egp": 71.0, "pack_count": null, "unit_price": null, "strength_mg": 1000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "TRIAXONE 1 GM I.M. VIAL", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "TABUK PHARMACEUTICAL MANUFACTURING COMPANY > TABUK PHARMA", "price_egp": 106.0, "pack_count": null, "unit_price": null, "strength_mg": 1000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "TRIAXONE 1 GM I.V VIAL", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "TABUK PHARMACEUTICAL MANUFACTURING COMPANY > TABUK PHARMA", "price_egp": 106.0, "pack_count": null, "unit_price": null, "strength_mg": 1000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null } ], "condition_id": "cholangitis" }, { "id": 433, "generic": "Referral & safety-netting (no drug therapy)", "line": 1, "is_adjunct": false, "form": null, "strength_mg": null, "adult_dose": "Covers acute ascending (bacterial) cholangitis — fever, jaundice, right upper quadrant pain — a biliary emergency needing same-day hospital admission for IV antibiotics and urgent biliary drainage (ERCP), as well as chronic autoimmune cholangitis (primary biliary cholangitis / primary sclerosing cholangitis) managed long-term with ursodeoxycholic acid under hepatology. GP starts empirical oral antibiotics only as a holding measure before urgent transfer for the acute form.", "adult_duration": "Refer, with advice", "dose_source": "No dose - referral pathway, no medicine given in primary care", "rationale": "Covers acute ascending (bacterial) cholangitis — fever, jaundice, right upper quadrant pain — a biliary emergency needing same-day hospital admission for IV antibiotics and urgent biliary drainage (ERCP), as well as chronic autoimmune cholangitis (primary biliary cholangitis / primary sclerosing cholangitis) managed long-term with ursodeoxycholic acid under hepatology. GP starts empirical oral antibiotics only as a holding measure before urgent transfer for the acute form.", "cautions": [ "Reynolds' pentad is Charcot's triad plus hypotension and confusion, and is a surgical or GI emergency.", "The drug rows above are what the treating service gives. They are here so that the referral is an informed one and so the GP can recognise the regimen the patient comes back on - not as permission to start it without the referral.", "Charcot's triad is fever, jaundice, and right upper quadrant pain." ], "peds_mgkg_low": null, "peds_mgkg_high": null, "peds_max_mg": null, "peds_basis": null, "peds_unit": null, "peds_note": "Children follow the same pathway: recognise and refer. No primary-care medicine is implied.", "peds_min_weight_kg": null, "peds_max_weight_kg": null, "peds_age_min_months": null, "peds_age_max_months": null, "peds_age_bands": null, "peds_doses": null, "brands": [], "condition_id": "cholangitis" } ] }