Biliary aspirate culture: a necessity or a liability?

We read with great interest the article by Gromski et al. [1]. The authors studied the microbiological profile of biliary aspirates obtained during endoscopy. However, a few points need clarification.

In the study, the bile was aspirated for culture at the discretion of the endoscopist. The severity of cholangitis might play a role in the decision to aspirate the bile, with milder cholangitis with lower bacterial load being missed. Was an analysis comparing the severity of cholangitis and positivity of culture from bile and blood and its correlation with multidrug-resistant organisms performed?

The study showed that presence of biliary stent or biliary sphincterotomy significantly increased the positivity of cultures. Prior study has shown that longer duration of stent indwelling and smaller stent size significantly increased the risk of cholangitis [2]. The comparison of stent indwell time, size of stent, and type of stent with the positivity of cultures would be helpful. The Gromski et al. study showed 98 % and 96 % positive cultures with biliary stent and sphincterotomy, respectively, with significantly higher numbers of resistant organisms. Would these findings imply a life-long risk of cholangitis with resistant organisms? Could these findings be attributed to increases in the prevalence of resistant organisms in the community?

A previous study described biliary candidiasis to be present in 44 % of cases but the majority of these were in immunocompromised patients [3]. Gromski et al. described 28 % of patients with Candida spp. in their bile cultures. Could these be attributed to contaminants or were the patients immunocompromised as in the previous study? Did any of the patients require treatment with antifungal agents?

The authors suggest that their data may be used to generate an algorithm for the reprocessing of reusable endoscopes and the selection of single-use scopes in selected patients. We feel that a study investigating bile aspirated for culture from all ERCPs, and not just those with acute cholangitis, would allow us to draw better conclusions on this decision.

Publication History

Article published online:
27 July 2022

• References

• 1 Gromski MA, Gutta A, Lehman GA. et al. Microbiology of bile aspirates obtained at ERCP in patients with suspected acute cholangitis. Endoscopy 2022; DOI: 10.1055/a-1790-1314.
• 2 Vaishnavi C, Samanta J, Kochhar R. Characterization of biofilms in biliary stents and potential factors involved in occlusion. World J Gastroenterol 2018; 24: 112-123
• 3 Lenz P, Conrad B, Kucharzik T. et al. Prevalence, associations, and trends of biliary-tract candidiasis: a prospective observational study. Gastrointest Endosc 2009; 70: 480-487