Reply to Chaudhari et al.

We would like to thank Chaudhari et al. for their interest in our recently published manuscript regarding the microbiology of biliary aspirates obtained at the time of endoscopic retrograde cholangiopancreatography (ERCP) in patients with suspected acute cholangitis [1]. When acute cholangitis was suspected, the bile aspirates were positive in 91.8 % of cases. Given the high percentage of positive aspirates, we doubt there would be a significant difference of positive bile cultures if a subgroup analysis on severity of cholangitis were performed.

We agree that it has been demonstrated that biofilm formation and occlusion occur more frequently with longer stent indwell times [2] and are also related to the stent diameter [3] [4]. The aim of our study, however, was not related to the occlusion rate or the rate of cholangitis associated with biliary stents.

The clinical significance of fungal organisms found in the bile cultures is not entirely clear, as no fungemia was identified on blood cultures. Immunocompromised status was not available for all patients in the study and therefore subgroup analysis could not be performed. Our routine practice is to treat fungal organisms from a bile culture aspirate only if one of the following is present: 1) fungemia, 2) sepsis that does not respond to initial antibacterial therapy, or 3) sepsis with fungus as the only organism grown on bile culture.

Finally, Chaudhari et al. propose a study to aspirate bile from all ERCPs (with or without suspected cholangitis) to draw better conclusions on whether to use a single-use duodenoscope. This would have different aims from our current study by assessing the biliary microbial composition from all patients undergoing ERCP. The use of bile culture results is one of many factors that may be considered when deciding which type of duodenoscope to use.

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 Kwon CI, Gromski MA, Sherman S. et al. Time sequence evaluation of biliary stent occlusion by dissection analysis of retrieved stents. Dig Dis Sci 2016; 61: 2426-2435
• 3 Speer AG, Cotton PB, MacRae KD. Endoscopic management of malignant biliary obstruction: stents of 10 French gauge are preferable to stents of 8 French gauge. Gastrointest Endosc 1988; 34: 412-417
• 4 Pedersen FM. Endoscopic management of malignant biliary obstruction. Is stent size of 10 French gauge better than 7 French gauge?. Scand J Gastroenterol 1993; 28: 185-189