The combination of a
penicillin and an
aminoglycoside has been recommended as the initial treatment of choice for patients with
infections of the biliary tract. However, elderly, septic, patients with
jaundice have a high incidence of renal problems. For this reason, amingolycoside treatment of these patients must be reevaluated as newer less nephrotoxic agents become available. We, therefore, performed a prospective, randomized trial of
ampicillin plus
tobramycin,
cefoperazone and
piperacillin in patients with biliary tract
infections. During a 20 month period, 106 patients with
acute cholecystitis (53) or
cholangitis (53), or both, received one of these
antibiotic regimens for a minimum of five days. In patients with
acute cholecystitis,
ampicillin plus
tobramycin,
cefoperazone and
piperacillin had clinical cure rates of 85, 95 and 95 per cent, respectively. In patients with
cholangitis, however, cure rates for the three regimens were 85, 56 (p less than 0.05 versus
ampicillin plus
tobramycin) and 60 per cent (not significant versus
ampicillin plus
tobramycin), respectively. Moreover, 13 per cent of the patients receiving
cefoperazone had an increased prothrombin time and three of 39 patients receiving this
antibiotic had clinical problems with
bleeding. Nephrotoxicity was greatest in patients with
cholangitis receiving
ampicillin plus
tobramycin, 10 per cent, as compared with 3 per cent in those who did not receive an
aminoglycoside. This difference, however, was not statistically significant. It was concluded that
piperacillin should be considered for
antibiotic management of patients with
acute cholecystitis and that further studies are necessary in patients with
cholangitis to determine whether or not newer agents should replace
penicillin and
aminoglycoside combinations.