Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis

J Hepatobiliary Pancreat Sci. 2018 Jan;25(1):3-16. doi: 10.1002/jhbp.518. Epub 2018 Jan 9.


Antimicrobial therapy is a mainstay of the management for patients with acute cholangitis and/or cholecystitis. The Tokyo Guidelines 2018 (TG18) provides recommendations for the appropriate use of antimicrobials for community-acquired and healthcare-associated infections. The listed agents are for empirical therapy provided before the infecting isolates are identified. Antimicrobial agents are listed by class-definitions and TG18 severity grade I, II, and III subcategorized by clinical settings. In the era of emerging and increasing antimicrobial resistance, monitoring and updating local antibiograms is underscored. Prudent antimicrobial usage and early de-escalation or termination of antimicrobial therapy are now important parts of decision-making. What is new in TG18 is that the duration of antimicrobial therapy for both acute cholangitis and cholecystitis is systematically reviewed. Prophylactic antimicrobial usage for elective endoscopic retrograde cholangiopancreatography is no longer recommended and the section was deleted in TG18. Free full articles and mobile app of TG18 are available at: Related clinical questions and references are also included.

Keywords: Acute cholangitis; Acute cholecystitis; Antimicrobial therapy; Biliary tract infection; Treatment guidelines.

Publication types

  • Letter
  • Review

MeSH terms

  • Acute Disease
  • Anti-Bacterial Agents / pharmacology
  • Anti-Bacterial Agents / therapeutic use*
  • Cholangiopancreatography, Endoscopic Retrograde / methods*
  • Cholangitis / diagnostic imaging
  • Cholangitis / drug therapy*
  • Cholangitis / microbiology
  • Cholecystitis, Acute / diagnostic imaging
  • Cholecystitis, Acute / drug therapy*
  • Cholecystitis, Acute / microbiology
  • Clinical Decision-Making
  • Community-Acquired Infections / diagnosis
  • Community-Acquired Infections / drug therapy
  • Female
  • Humans
  • Male
  • Practice Guidelines as Topic*
  • Tokyo
  • Treatment Outcome


  • Anti-Bacterial Agents