579 - Prophylactic Antibiotics Did Not Decrease Recurrent Cholangitis in Patients with Biliary Atresia After Kasai Portoenterostomy

Background: Biliary atresia (BA) is a rare, progressive, idiopathic, fibro-obliterative disease of the extrahepatic biliary tree seen in children.  The current standard treatment is surgical management with Kasai portoenterostomy (KP).  Bacterial cholangitis is a frequent complication following KP and an important determinant of long-term prognosis.  Use of prophylactic antibiotics is common but not universal and efficacy is controversial.

Methods: A retrospective study was performed that included all patients with BA who underwent KP from November 2002 to July 2019.  Chart review was conducted to collect demographic information and evaluate the use of antibiotic prophylaxis, number of cholangitis episodes, time to liver transplantation (LVT), and survival.

Results: Ninety-one patients with BA underwent KP during the study period.  Seventy-two (79%) received prophylactic antibiotics, and 19 (21%) did not.  The median duration of prophylactic antibiotics was 7 months (interquartile range [IQR] 8.5).  Patients in the no-prophylaxis group had significantly fewer cholangitis episodes (median 0, IQR 1) than in the antibiotic prophylaxis group (median 1, IQR 2), p= 0.0201.  The median time to LVT was 8 months (IQR 8.5) in the antibiotic prophylaxis group, compared to 7 months (IQR 6) in the no-prophylaxis group, p=0.8827.  Of the patients who were on antibiotic prophylaxis, 57 (79.2%) received trimethoprim-sulfamethoxazole (TMP-SMX) alone and 15 (20.8%) received multiple/other antibiotics.  Seven patients (7.7%) had culture-positive cholangitis.  Six of 7 received prophylaxis with TMP-SMX and 5 of 7 grew bacteria that were resistant to TMP-SMX.  No deaths occurred between the postoperative KP period to the time of LVT in both groups.Table 1. Characteristics of Patients in the Prophylaxis and No-prophylaxis Groups.
Table 2. Impact of Prophylactic Antibiotics in the Period Between Kasai Portoenterostomy and Liver Transplantation.
Table 3. Patients with Culture-positive Cholangitis after Kasai Portoenterostomy (n=7).


Conclusion: Antibiotic prophylaxis was frequently used after KP with TMP-SMX being the most common antibiotic used.  Patients in the no-prophylaxis group had significantly fewer cholangitis episodes compared to those receiving antibiotic prophylaxis.  Prophylactic antibiotics did not have an impact on time to LVT.  Our findings suggest that antibiotic prophylaxis is not helpful in decreasing the frequency of cholangitis episodes after KP and may increase the risk for infections with resistant bacteria.  Larger prospective randomized control studies are recommended.