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

BackgroundCholangitis-associated septic shock carries significant mortality. There is uncertainty regarding the most appropriate time to achieve biliary decompression. AimTo determine whether the timing of biliary decompression and anti-microbial therapy affect the survival in cholangitis patients with septic shock. MethodsNested retrospective cohort study of all cholangitis-associated septic shock patients (hypotension requiring vasopressors) from an international, multi-centre database between 1996 and 2011. ResultsAmong 260 patients (mean age 69years, 57% male), overall mortality was 37%. Compared to nonsurvivors (n=96), survivors (n=164) had lower mean admission Acute Physiology And Chronic Health Evaluation (APACHE) II (22 vs. 28, P<0.001) and lower median serum lactate on admission (3.4 vs. 4.6mmol/L, P<0.001). Survivors were more likely to receive appropriate anti-microbial therapy earlier (median 2.6 vs. 6.8h from shock, P<0.001). Survivors were also more likely to undergo successful biliary decompression earlier (median 8.8 vs. 22h, P<0.001). After adjusting for co-variates, APACHE II (odds ratio, OR 1.21 per increment (1.11-1.32), time delay to appropriate anti-microbial therapy [OR 1.15 per hour (1.07-1.25)] and delayed biliary decompression >12h [OR 3.40 (1.12-10.31)] were all significantly associated with increased mortality (P<0.04 for all; c-statistic 0.896). ConclusionsPatients with septic shock secondary to acute cholangitis have significant mortality. Endoscopic biliary decompression >12h after the onset of shock and delayed receipt of appropriate anti-microbial therapy were both significantly associated with adverse hospital outcome. This might suggest that early initiation of anti-microbial therapy and urgent biliary decompression (within 12h) could potentially improve outcomes in this high-risk patient population.