Role of antibiotic therapy in mild acute calculus cholecystitis: a prospective randomized controlled trial

Source Control and Antibiotics in Intra-Abdominal Infections

Intra-abdominal infections (IAIs) account for a major cause of morbidity and mortality, representing the second most common sepsis-related death with a hospital mortality of 23-38%. Prompt identification of sepsis source, appropriate resuscitation, and early treatment with the shortest delay possible are the cornerstones of management of IAIs and are associated with a more favorable clinical outcome. The aim of source control is to reduce microbial load by removing the infection source and it is achievable by using a wide range of procedures, such as definitive surgical removal of anatomic infectious foci, percutaneous drainage and toilette of infected collections, decompression, and debridement of infected and necrotic tissue or device removal, providing for the restoration of anatomy and function. Damage control surgery may be an option in selected septic patients. Intra-abdominal infections can be classified as uncomplicated or complicated causing localized or diffuse peritonitis. Early clinical evaluation is mandatory in order to optimize diagnostic testing and establish a therapeutic plan. Prognostic scores could serve as helpful tools in medical settings for evaluating both the seriousness and future outlook of a condition. The patient's conditions and the potential progression of the disease determine when to initiate source control. Patients can be classified into three groups based on disease severity, the origin of infection, and the patient's overall physical health, as well as any existing comorbidities. In recent decades, antibiotic resistance has become a global health threat caused by inappropriate antibiotic regimens, inadequate control measures, and infection prevention. The sepsis prevention and infection control protocols combined with optimizing antibiotic administration are crucial to improve outcome and should be encouraged in surgical departments. Antibiotic and antifungal regimens in patients with IAIs should be based on the resistance epidemiology, clinical conditions, and risk for multidrug resistance (MDR) and Candida spp. infections. Several challenges still exist regarding the effectiveness, timing, and patient stratification, as well as the procedures for source control. Antibiotic choice, optimal dosing, and duration of therapy are essential to achieve the best treatment. Promoting standard of care in the management of IAIs improves clinical outcomes worldwide. Further trials and stronger evidence are required to achieve optimal management with the least morbidity in the clinical care of critically ill patients with intra-abdominal sepsis.

Management of intra-abdominal infections: recommendations by the Italian council for the optimization of antimicrobial use

Intra-abdominal infections (IAIs) are common surgical emergencies and are an important cause of morbidity and mortality in hospital settings, particularly if poorly managed. The cornerstones of effective IAIs management include early diagnosis, adequate source control, appropriate antimicrobial therapy, and early physiologic stabilization using intravenous fluids and vasopressor agents in critically ill patients. Adequate empiric antimicrobial therapy in patients with IAIs is of paramount importance because inappropriate antimicrobial therapy is associated with poor outcomes. Optimizing antimicrobial prescriptions improves treatment effectiveness, increases patients' safety, and minimizes the risk of opportunistic infections (such as Clostridioides difficile) and antimicrobial resistance selection. The growing emergence of multi-drug resistant organisms has caused an impending crisis with alarming implications, especially regarding Gram-negative bacteria. The Multidisciplinary and Intersociety Italian Council for the Optimization of Antimicrobial Use promoted a consensus conference on the antimicrobial management of IAIs, including emergency medicine specialists, radiologists, surgeons, intensivists, infectious disease specialists, clinical pharmacologists, hospital pharmacists, microbiologists and public health specialists. Relevant clinical questions were constructed by the Organizational Committee in order to investigate the topic. The expert panel produced recommendation statements based on the best scientific evidence from PubMed and EMBASE Library and experts' opinions. The statements were planned and graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) hierarchy of evidence. On November 10, 2023, the experts met in Mestre (Italy) to debate the statements. After the approval of the statements, the expert panel met via email and virtual meetings to prepare and revise the definitive document. This document represents the executive summary of the consensus conference and comprises three sections. The first section focuses on the general principles of diagnosis and treatment of IAIs. The second section provides twenty-three evidence-based recommendations for the antimicrobial therapy of IAIs. The third section presents eight clinical diagnostic-therapeutic pathways for the most common IAIs. The document has been endorsed by the Italian Society of Surgery.

Intra-abdominal infections survival guide: a position statement by the Global Alliance For Infections In Surgery

Intra-abdominal infections (IAIs) are an important cause of morbidity and mortality in hospital settings worldwide. The cornerstones of IAI management include rapid, accurate diagnostics; timely, adequate source control; appropriate, short-duration antimicrobial therapy administered according to the principles of pharmacokinetics/pharmacodynamics and antimicrobial stewardship; and hemodynamic and organ functional support with intravenous fluid and adjunctive vasopressor agents for critical illness (sepsis/organ dysfunction or septic shock after correction of hypovolemia). In patients with IAIs, a personalized approach is crucial to optimize outcomes and should be based on multiple aspects that require careful clinical assessment. The anatomic extent of infection, the presumed pathogens involved and risk factors for antimicrobial resistance, the origin and extent of the infection, the patient's clinical condition, and the host's immune status should be assessed continuously to optimize the management of patients with complicated IAIs.

Laparoscopic cholecystectomy in calculous cholecystitis: are antibiotics necessary?

Laparoscopic cholecystectomy in patients with cholecystitis is considered the best, appropriate and safe method of treatment for gallstone disease. However, the role of antibiotic administration before or after cholecystectomy to reduce infectious complications, particularly surgical site infections, or mortality is less clear. Many patients receive empiric antibiotics, but the feasibility of their use has not been proven. Some guidelines suggest the use of antibiotic prophylaxis for all cholecystectomies, although current evidence does not indicate any benefit to this practice in the absence of risk factors. This review examines the results of antibiotic use in laparoscopic cholecystectomy for chronic and acute calculous cholecystitis. Most studies argue against the need to use prophylactic antibiotics during elective surgery in low-risk patients. In cases of mild and moderate acute cholecystitis, the use of antibiotics to prevent postoperative infectious complications has no evidence of effectiveness, although these recommendations are also ambiguous. It is not recommended to use postoperative antibiotics after elective laparoscopic cholecystectomy, as well as for mild or moderate acute cholecystitis. However, additional studies with well-defined patient populations and comparable outcomes are needed to better assess the most appropriate timing and duration of antibiotic use in patients undergoing laparoscopic cholecystectomy. We used MedLine database on the PubMed platform and the Cochrane library to search for literature sources.

A clinician's guide to gallstones and common bile duct (CBD): A study protocol for a systematic review and evidence-based recommendations

Background and Aims

Gallstones are one of the most common and costly diseases of the gastrointestinal tract and occur when a combination of deposits consisting of fat or minerals accumulate in the gallbladder or common bile duct (CBD). This paper provides a comprehensive review of gallstone epidemiology, diagnosis, and management, focusing on current clinical guidelines and evidence-based approaches.

Methods

A systematic literature review gathered information from various sources, including PubMed, Trip, Google Scholar, Clinical Key, and reputable medical association websites. Keywords related to gallstones, CBD stones, cholelithiasis, choledocholithiasis, and guidelines were used to extract relevant recommendations. Expert consultations and consensus meetings localized the recommendations based on the target population and available resources.

Results

The paper discusses demographic factors, dietary habits, and lifestyle influences contributing to gallstone formation. Gallstones are categorized into cholesterol and pigment types, with varying prevalences across regions. Many individuals with gallstones remain asymptomatic, but complications can lead to serious and potentially life-threatening conditions. Diagnosis relies on history, physical examination, laboratory tests, and transabdominal ultrasound. Specific predictive factors help categorize patients into high, moderate, or low probability groups for CBD stones.

Conclusion

Evidence-based recommendations for gallstone diagnosis and management are presented, emphasizing individualized treatment plans. Surgical interventions, nonsurgical treatments like oral litholysis with UDCA, and stenting are discussed. The management of gallstones in pregnant women is also addressed, considering the potential risks and appropriate treatment options during pregnancy.

Comparison of bacterial profile of gallbladder with gallstones from patients undergoing cholecystectomy due to complicated and uncomplicated cholelithiasis: changes in the epidemiological scenario

INTRODUCTION

cholelithiasis is a highly prevalent disease of the digestive system in the world. In Brazil, it is a routine condition, whose studies suggest a prevalence of around 10% of adults. Colonization of bile and gallstone pathogens can occur when there is bacterial stasis and proliferation. This proliferation is facilitated by the adhesion and biofilm formation capacity of some bacteria. There are also lithogenic processes that involve bacterial participation. Studies have shown changes in the microbiota of the gallbladder of patients undergoing cholecystectomy, which may impact empirical treatment with antibiotics.

METHODOLOGY

microbiological analyzes of the sonication fluid of the gallstones and of two samples with bile were performed. Identification and antimicrobial susceptibility testing were performed according to a standard routine.

RESULTS

of the 34 patients, 76.4% were female. The age group was 48 years +/- 16.61. Acute cholecystitis occurred in 50% of cases. Bactobilia was evidenced in 32.1% of the cases. Klebisiella pneumoniae was noted as the most prevalent pathogen in acute cholecystitis; and Enterobacter sp, in cases of uncomplicated cholelithiasis. Greater sensitivity was obtained in the search for microorganisms in the sonication fluid samples of the stones in relation to the bile samples (p=0.0058).

CONCLUSION

there was a higher prevalence of bactobilia in patients with acute cholecystitis compared to those with uncomplicated cholelithiasis. The use of sonication in bacterial investigation proved to be superior to the conventional method and can be considered.

Infection or Inflammation: Are Uncomplicated Acute Appendicitis, Acute Cholecystitis, and Acute Diverticulitis Infectious Diseases?

Background: It is recognized increasingly that common surgical infections of the peritoneal cavity may be treated with antibiotic agents alone, or source control surgery with short-course antimicrobial therapy. By extension, testable hypotheses have emerged that such infections may not actually be infectious diseases, but rather represent inflammation that can be treated successfully with neither surgery nor antibiotic agents. The aim of this review is to examine extant data to determine which of uncomplicated acute appendicitis (uAA), uncomplicated acute calculous cholecystitis (uACC), or uncomplicated mild acute diverticulitis (umAD) might be amenable to management using supportive therapy alone, consistent with the principles of antimicrobial stewardship. Methods: Review of pertinent English-language literature and expert opinion. Results: Only two small trials have examined whether uAA can be managed with observation and supportive therapy alone, one of which is underpowered and was stopped prematurely because of challenging patient recruitment. Data are insufficient to determine the safety and efficacy of non-antibiotic therapy of uAA. Uncomplicated acute calculous cholecystitis is not primarily an infectious disease; infection is a secondary phenomenon. Even when bactibilia is present, there is no high-quality evidence to suggest that mild disease should be treated with antibiotic agents. There is evidence to indicate that antibiotic prophylaxis is indicated for urgent/emergency cholecystectomy for uACC, but not in the post-operative period. Uncomplicated mild acute diverticulitis, generally Hinchey 1a or 1b in current nomenclature, does not benefit from antimicrobial agents based on multiple clinical studies. The implication is that umAD is inflammatory and not an infectious disease. Non-antimicrobial management is reasonable. Conclusions: Among the considered disease entities, the evidence is strongest that umAD is not an infectious disease and can be treated without antibiotic agents, intermediate regarding uACC, and lacking for uAA. A plausible hypothesis is that these inflammatory conditions are related to disruption of the normal microbiome, resulting in dysbiosis, which is defined as an imbalance of the natural microflora, especially of the gut, that is believed to contribute to a range of conditions of ill health. As for restorative pre- or probiotic therapy to reconstitute the microbiome, no recommendation can be made in terms of treatment, but it is not recommended for prevention of primary or recurrent disease.

High rates of recurrence of gallstone associated episodes following acute cholecystitis during long term follow-up: a retrospective comparative study of patients who did not receive surgery

INTRODUCTION

Patients who are admitted with acute cholecystitis (AC) and do not undergo urgent cholecystectomy, are usually referred for interval cholecystectomy. Many do not have surgery for various reasons, and some of those do not suffer from any recurrent symptoms. The primary objective of this study was to assess the rate and nature of recurrent gallstone-related events in this population over a long period, and its association with demographic and clinical parameters. A secondary objective was to assess the reasons for not undergoing surgery.

METHODS

This is a retrospective cohort study, where the study group were adult patients admitted with AC. Patients that have suffered recurrent episodes were compared with those who did not. A control group of patients that had undergone cholecystectomy following an admission with AC was used for comparison. Demographic and clinical parameters were recorded for all patients, and the association with a recurrent episode was analyzed using univariate analysis.

RESULTS

The study population was 197 patients. The group of patients who did not undergo surgery were significantly older (68.7 vs 54.2) and sicker (ASA > 3 50% vs 19%). The rate of recurrent episodes in the study group was 38.5%, and it was not found to be associated with the studied parameters. There was a trend towards higher gallstone disease specific mortality in the study group (5.5% vs 1.45% p = 0.062).

CONCLUSIONS

This is a study of long-term follow-up of patients following an episode of AC we showed that the rate of recurrent episodes is quite high and involves severe inflammatory diseases, such as obstructive jaundice and pancreatitis.

Surgical Infection Society Guidelines for Antibiotic Use in Patients Undergoing Cholecystectomy for Gallbladder Disease

Background: Manifestations of gallbladder disease range from intermittent abdominal pain (symptomatic cholelithiasis) to potentially life-threatening illness (gangrenous cholecystitis). Although surgical intervention to treat acute cholecystitis is well defined, the role of antibiotic administration before or after cholecystectomy to decrease morbidity or mortality is less clear. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee convened to develop guidelines for antibiotic use in patients undergoing cholecystectomy for gallbladder disease to prevent surgical site infection, other infection, hospital length of stay, or mortality. PubMed, Embase, and the Cochrane Database were searched for relevant studies. Evaluation of the published evidence was performed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. Using a process of iterative consensus, all authors voted to accept or reject each recommendation. Results: We recommend against routine use of peri-operative antibiotic agents in low-risk patients undergoing elective laparoscopic cholecystectomy. We recommend use of peri-operative antibiotic agents for patients undergoing laparoscopic cholecystectomy for acute cholecystitis. We recommend against use of post-operative antibiotic agents after elective laparoscopic cholecystectomy for symptomatic cholelithiasis. We recommend against use of post-operative antibiotic agents in patients undergoing laparoscopic cholecystectomy for mild or moderate acute cholecystitis. We recommend a maximum of four days of antibiotic agents, and perhaps a shorter duration in patients undergoing cholecystectomy for severe (Tokyo Guidelines grade III) cholecystitis. Conclusions: This guideline summarizes the current Surgical Infection Society recommendations for antibiotic use in patients undergoing cholecystectomy for gallbladder disease.

Reduction of risk of infection during elective laparoscopic cholecystectomy using prophylactic antibiotics: a systematic review and meta-analysis

BACKGROUND

Whether perioperative administration is required in elective laparoscopic cholecystectomy (LC) in patients with low risk of infection remains controversial.

OBJECTIVE

To investigate whether perioperative use of prophylactic antibiotics during elective LC can reduce the incidence of postoperative infection using a meta-analysis.

METHODS

Pubmed, Cochrane Library, Embase, and reference lists were searched up to October 26, 2020, for randomized controlled trials (RCTs) of the perioperative use of antibiotics during LC. A systematic review with meta-analysis, meta-regression, and GRADE (Grading of Recommendations Assessment, Development and Evaluation) of the evidence was conducted. The Cochrane (RoB 2.0) tool was used to assess the risk of bias.

RESULT

A total of 14 RCTs were ultimately included in the meta-analysis, involving a total of 4360 patients. The incidence of surgical site infections, distant infections, and overall infections was investigated and the relationship with the perioperative use of prophylactic antibiotics during LC analyzed. The results indicated that in low-risk patients undergoing elective LC, prophylactic antibiotics reduce the incidence of surgical site infections (RR 0.66; 95% CI 0.45-0.98), with a moderate GRADE of evidence, distant infections (RR 0.34; 95% CI 0.16-0.73), with a low GRADE of evidence and overall infections (RR 0.57; 95% CI 0.40-0.80), with a moderate GRADE of evidence.

CONCLUSIONS

The present meta-analysis demonstrates that the perioperative use of antibiotics in LC is effective in low-risk patients, possibly reducing the incidence of surgical site infections, distant infections, and overall infections. However, in view of the limitations of the study, it is recommended that studies with a more rigorous design (for downgraded factors) and larger sample size should be conducted in the future so that the conclusions above can be further verified through key result indicators.

Empirical antibiotics for acute cholecystitis-what generation of antibiotics is an appropriate choice? A prospective, randomized controlled study

BACKGROUND

In cases of acute cholecystitis (AC), empirical antibiotics are used to prevent infectious morbidities following cholecystectomy. However, there are still no exact guidelines on which antibiotics to use.

METHODS

We enrolled 300 patients who had been admitted for cholecystectomy because of grade I or II AC. We randomly allocated them to one of two groups empirically: the first group was to be given first-generation cephalosporins (group I, 150 patients) and the second group was to be given second-generation cephalosporins (group II, 150 patients). We analyzed the clinical outcomes and the incidence of postoperative infectious morbidities.

RESULTS

The incidence rate of overall infectious morbidities (18 cases, 12% in group I; 17 cases, 11.3% in group II; P = .859) showed no difference between the two groups. The incidence rate of sepsis (only one case, 0.7% in group II, P = 1.000) or surgical site infection (nine cases, 6% in group I and eight cases, 5.3% in group II, P = 1.000) were also similar in both groups.

CONCLUSIONS

The empirical use of first-generation cephalosporins for mild-to-moderate AC without gallbladder perforation was not inferior to using second-generation cephalosporin for prophylaxis against postoperative infection. Our results could allow for a tailored treatment strategy of empirical antibiotics according to the severity of the cholecystitis.

Early Procalcitonin Assessment in the Emergency Department in Patients with Intra-Abdominal Infection: An Excess or a Need?

Background: Intra-abdominal infection (IAI) is a wide range of intra-abdominal disease. Management involves empirical therapy and source control. Procalcitonin (PCT) has been suggested to assist in defining individual infection status and delivering individualized therapy. The aim of this study was to investigate the effects on patient outcomes of an early procalcitonin (PCT) assessment (in the emergency department [ED]) in patients with IAI. Methods: This was a retrospective, mono-centric study evaluating consecutive patients admitted to the ED from 2015 to 2019 with diagnosis of IAI. According to whether there had been PCT determination in the ED, patients were divided into no ePCT determination (no-ePCT) and early PCT determination in the ED (ePCT). The primary endpoint was the intra-hospital mortality rate. Secondary endpoints were occurrence of major complications and length of hospital stay (LOS). The propensity score match (PSM) was generated using a logistic regression model on the baseline covariates considered to be potentially influencing the decision to determine PCT in the ED and confounding factors identified as significant at a preliminary statistical analysis with respect to in-hospital death. Results: A series of 3,429 patients were included. The ePCT group consisted to 768 (22.4%), whereas the no-ePCT group contained 2,661 patients (77.6%). When the PSM was matched to the two groups, no significant difference was observed. Considering patients with uncomplicated infections, the PCT determination was associated with a higher mortality rate. We found no significant differences regarding outcomes with the exception of LOS, which was slightly longer in the ePCT group. However, we observed a tendency toward a minor difference in the number of complications in the ePCT group, in particular a reduced rate of progression to sepsis. Conclusion: Early PCT determination could be irrelevant in IAIs. The PCT value may be cost-effective and possibly improve the prognosis in cIAIs. Further research is needed to understand the optimal use of PCT, including in combination with other emerging diagnostic tests.

Gallbladder Disorders: A Comprehensive Review

Gallbladder disorders encompass a wide breadth of diseases that vary in severity. We present a comprehensive review of literature for the clinical presentation, pathophysiology, diagnostic evaluation, and management of cholelithiasis-related disease, acute acalculous cholecystitis, functional gallbladder disorder, gallbladder polyps, gallbladder hydrops, porcelain gallbladder, and gallbladder cancer.

Clinical Presentation and Incidence of Anaerobic Bacteria in Surgically Treated Biliary Tract Infections and Cholecystitis

(1) Background: Cholecystitis and cholangitis are among the most common diseases treated by general surgery. Gallstones lead to inflammation and bacterial infection of the biliary tract. Biliary infections can lead to live threatening bacteremia and liver abscesses. The true role of anaerobes remains unclear. (2) Methods: We retrospectively analyzed bacterial cultures from biliary samples obtained from bile ducts and gallbladders at our tertiary care center. Patient characteristics and clinical outcomes were analyzed. (3) Results: In our database of 1719 patients, 365 patients had microbial testing, of which 42 grew anaerobic bacteria. Anaerobes were more frequently cultured in patients with hepatic abscesses and gallbladder perforation. These patients were older and had more comorbidities than the control group. The overall outcomes of all patients were favorable and the resistance rate to commonly used antibiotics remained low. (4) Conclusions: Anaerobes in biliary tract infections appear to be underdiagnosed and more prevalent in the elderly with advanced disease. Due to low antibiotic resistance, the combination of source control and adjunct anti-infective treatment leads to favorable outcomes.

Characteristics and outcome of elderly patients admitted for acute Cholecystitis to medical or surgical wards

BACKGROUND

Elderly patients admitted because of acute cholecystitis are usually not operated during their initial admission and receive conservative treatment. To help formulate a new admission policy regarding elderly patients with acute cholecystitis we compared the demographic and clinical characteristics and outcome of patients > 65 with acute cholecystitis admitted to medical or surgical wards.

METHODS

This retrospective study included all patients > 65 years admitted for acute cholecystitis between January, 2009 and September, 2016. Data were retrieved from the electronic health records.

RESULTS

A total of 187 patients were detected, 54 (29%) in medical departments and 133 (71%) in surgical wards. The mean age (±SD) was 80 ± 7.5 and was higher among those in medical than surgical wards (84 ± 7 versus 79 ± 7, p <  0.05). Patients hospitalized in medical departments had more comorbidity, disability and mental impairment. However, there was no difference in mortality between the two groups, 1 (2%) and 6 (4%) respectively. Independent predictors for hospitalization in medical departments were chronic obstructive pulmonary disease (OR = 9.8, 95% C. I 1.6-59) and the Norton Scale score (NSS)(OR = 0.7, 95% C. I 0.7-0.8). Impaired mental condition was the only predictor for hospitalization > 1 week. The strongest predictor for having cholecystostomy was admission to the surgical department (OR = 14.7, 95% C. I 3.9-56.7). Linear regression showed a negative correlation between NSS and length of hospitalization (LOH; Beta = - 0.5).

CONCLUSION

Elderly patients with acute cholecystitis who require conservative management, especially those with severe functional and mental impairment can be safely hospitalized in medical departments. Outcome was not inferior in terms of mortality and LOH. These results have practical policy implications for the placement of elderly patients with acute cholecystitis in medical rather than surgical departments.

Diagnosis and management of acute cholecystitis: a single-centre audit of guideline adherence and patient outcomes

Background

The Tokyo Guidelines were published in 2007 and updated in 2013 and 2018, with recommendations for the diagnosis and management of acute cholecystitis. We assessed guideline adherence at our academic centre and its impact on patient outcomes.

Methods

This is a retrospective chart review of patients with acute calculous cholecystitis who underwent cholecystectomy at our institution between November 2013 and March 2015. Severity of cholecystitis was graded retrospectively if it had not been documented preoperatively. Compliance with the Tokyo Guidelines' recommendations on antibiotic use and time to operation was recorded. Cholecystitis severity groups were compared statistically, and logistic regression was used to determine predictors of complications.

Results

One hundred and fifty patients were included in the study. Of these, 104 patients were graded as having mild cholecystitis, 45 as having moderate cholecystitis, and 1 as having severe cholecystitis. Severity was not documented preoperatively for any patient. Compliance with antibiotic recommendations was poor (18.0%) and did not differ by cholecystitis severity (p = 0.90). Compliance with the recommendation on time to operation was 86.0%, with no between-group differences (p = 0.63); it improved when an acute care surgery team was involved (91.0% v. 76.0%, p = 0.025). On multivariable analysis, comorbidities (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.19-1.85, p < 0.001) and conversion to laparotomy (OR 13.45, 95% CI 2.16-125.49, p = 0.01) predicted postoperative complications, while severity of cholecystitis, antibiotic compliance and time to operation had no effect.

Conclusion

In this study, compliance with the Tokyo Guidelines was acceptable only for time to operation. Although the poor compliance with recommendations relating to documentation of severity grading and antibiotic use did not have a negative affect on patient outcomes, these recommendations are important because they facilitate appropriate antibiotic use and patient risk stratification.

The SIFIPAC/WSES/SICG/SIMEU guidelines for diagnosis and treatment of acute appendicitis in the elderly (2019 edition)

The epidemiology and the outcomes of acute appendicitis in elderly patients are very different from the younger population. Elderly patients with acute appendicitis showed higher mortality, higher perforation rate, lower diagnostic accuracy, longer delay from symptoms onset and admission, higher postoperative complication rate and higher risk of colonic and appendiceal cancer. The aim of the present work was to investigate age-related factors that could influence a different approach, compared to the 2016 WSES Jerusalem guidelines on general population, in terms of diagnosis and management of elderly patient with acute appendicitis. During the XXIX National Congress of the Italian Society of Surgical Pathophysiology (SIFIPAC) held in Cesena (Italy) in May 2019, in collaboration with the Italian Society of Geriatric Surgery (SICG), the World Society of Emergency Surgery (WSES) and the Italian Society of Emergency Medicine (SIMEU), a panel of experts participated to a Consensus Conference where eight panelists presented a number of statements, which were developed for each of the four topics about diagnosis and management of acute appendicitis in elderly patients, formulated according to the GRADE system. The statements were then voted, eventually modified and finally approved by the participants to the Consensus Conference. The current paper is reporting the definitive guidelines statements on each of the following topics: diagnosis, non-operative management, operative management and antibiotic therapy.

A proposal for a comprehensive approach to infections across the surgical pathway

Despite evidence supporting the effectiveness of best practices in infection prevention and management, many healthcare workers fail to implement them and evidence-based practices tend to be underused in routine practice. Prevention and management of infections across the surgical pathway should always focus on collaboration among all healthcare workers sharing knowledge of best practices. To clarify key issues in the prevention and management of infections across the surgical pathway, a multidisciplinary task force of experts convened in Ancona, Italy, on May 31, 2019, for a national meeting. This document represents the executive summary of the final statements approved by the expert panel.

Drain in laparoscopic cholecystectomy in acute calculous cholecystitis: a randomised controlled study

BACKGROUND

There is paucity of evidence regarding the role of drain in laparoscopic cholecystectomy (LC) in acute calculous cholecystitis (ACC), and surgeons have placed the drains based on their experiences, not on evidence-based guidelines. This study aims to assess the value of drain in LC for ACC in a randomised controlled prospective study.

PATIENTS AND METHODS

All patients with mild and moderate ACC undergoing LC were assessed. Preoperatively, patients with choledocholithiasis, Mirizzi syndrome and biliary stent were excluded. Intraoperatively or postoperatively, patients with complications, partial cholecystectomies and malignancies were excluded. Patients were randomised using computer-generated random numbers into two groups at the end of cholecystectomy before closure. Requirement of radiologically guided (ultrasonography () or CT) percutaneous aspiration/drainage of symptomatic intra-abdominal collection or reoperation; continuation of parenteral antibiotics beyond 24 hours or change in antibiotics empirically or based on peritoneal fluid culture sensitivity; requirement of postoperative USG or CT scan based on postoperative clinical course; wound infection rates; postoperative pain using numeric rating scale at 6 and 24 hours; and the duration of hospital stay in both groups were noted.

RESULTS

Forty-two out of 50 consecutive patients were randomised into two equal groups. Pain score at 6 and 24 hours was less in patients without drain. All other complication rates and duration of stay were similar in both groups.

CONCLUSIONS

Drains should not be placed routinely after LC in ACC as it increases pain and does not help in detecting or decreasing complications.

Endoscopic Retrograde Cholangiopancreatography and Endoscopic Ultrasound-Guided Gallbladder Drainage

"Gallbladder disease is one of the most common gastrointestinal diseases encountered in clinical practice. Surgical removal and percutaneous drainage are both widely available and effective in the management of acute cholecystitis. Several endoscopic approaches exist as an alternative to these interventions. These include transpapillary approaches via endoscopic retrograde cholangiopancreatography (ERCP), transmural drainage and access approaches via endoscopic ultrasound (EUS), and endoscopic surgical approaches using natural orifice transluminal endoscopic surgery (NOTES) techniques. This article reviews the epidemiology and pathophysiology of gallbladder diseases and discusses the various percutaneous, surgical, and endoscopic approaches to managing gallbladder disease."

Extended Postoperative Antibiotics Versus No Postoperative Antibiotics in Patients Undergoing Emergency Cholecystectomy for Acute Calculous Cholecystitis: A Systematic Review and Meta-Analysis

Objectives. To compare the outcomes of extended postoperative antibiotics versus no postoperative antibiotics in patients with acute calculous cholecystitis undergoing emergency cholecystectomy. Methods. We performed a systematic review and conducted a search of electronic information sources to identify all randomized controlled trials comparing outcomes of extended postoperative antibiotics versus no postoperative antibiotics in patients with acute calculous cholecystitis undergoing emergency cholecystectomy. Postoperative infectious complications and surgical site infections were primary outcome measures. The secondary outcome measures included postoperative morbidity, postoperative noninfectious complications, urinary tract infections, pneumonia, length of hospital stay, postoperative mortality, and need for readmission. Random or fixed effects modeling was applied to calculate pooled outcome data. Results. Four randomized controlled trials enrolling 953 patients were identified. The included populations in the extended antibiotic group and no antibiotic group were comparable in terms of baseline characteristics. There was no difference between the 2 groups in terms of postoperative infectious complications (odds ratio [OR] =0.94, P = .79), surgical site infections (OR = 1.13, P = .72), postoperative morbidity (OR = 0.93, P = .70), postoperative noninfectious complications (OR = 0.85, P = .57), urinary tract infections (OR = 0.69, P = .55), pneumonia (OR = 0.33, P = .14), length of hospital stay (mean difference = 0.78, P = .25), postoperative mortality (risk difference = -0.00, P = .65), and need for readmission (OR = 0.87, P = .70). Conclusions. Our results suggest that extended postoperative antibiotic therapy does not improve postoperative infectious or noninfectious outcomes in patients with mild or moderate acute calculous cholecystitis undergoing emergency cholecystectomy. Postoperative antibiotics should not be routinely used and should be preserved only for selected cases.

Percutaneous Cholecystostomy Versus Conservative Treatment for Acute Cholecystitis: a Cohort Study

BACKGROUND

Percutaneous cholecystostomy is frequently used as a treatment option for acute calculous cholecystitis in patients unfit for surgery. There is sparse evidence on the long-term impact of cholecystostomy on gallstone-related morbidity and mortality in patients with acute calculous cholecystitis. This study describes the long-term outcome of acute calculous cholecystitis following percutaneous cholecystostomy compared to conservative treatment.

METHODS

This was a cohort study of patients admitted at our institution from 2006 to 2015 with acute calculous cholecystitis without early or delayed cholecystectomy. Endpoints were gallstone-related readmissions, recurrent cholecystitis, and overall mortality.

RESULTS

The investigation included 201 patients of whom 97 (48.2%) underwent percutaneous cholecystostomy. Patients in the cholecystostomy group had significantly higher age, comorbidity level, and inflammatory response at admission. The median duration of catheter placement in the cholecystostomy group was 6 days. The complication rate of cholecystostomy was 3.1% and the mortality during the index admission was 3.5%. The median follow-up was 1.6 years. The rate of gallstone-related readmissions was 38.6%, and 25.3% had recurrence of cholecystitis. Cox regression analyses revealed no significant differences in gallstone-related readmissions, recurrence of acute calculous cholecystitis, and overall mortality in the two groups.

CONCLUSIONS

Percutaneous cholecystostomy in the treatment of acute calculous cholecystitis was neither associated with long-term benefits nor complications. Based on the high gallstone-related readmission rates of this study population and todays perioperative improvements, we suggest rethinking the indications for non-operative management including percutaneous cholecystostomy in acute calculous cholecystitis.

Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis

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: http://www.jshbps.jp/modules/en/index.php?content_id=47. Related clinical questions and references are also included.

Management of intra-abdominal infections: recommendations by the WSES 2016 consensus conference

This paper reports on the consensus conference on the management of intra-abdominal infections (IAIs) which was held on July 23, 2016, in Dublin, Ireland, as a part of the annual World Society of Emergency Surgery (WSES) meeting. This document covers all aspects of the management of IAIs. The Grading of Recommendations Assessment, Development and Evaluation recommendation is used, and this document represents the executive summary of the consensus conference findings.

Proposal for shorter antibiotic therapies

OBJECTIVES

Reducing antibiotic consumption has now become a major public health priority. Reducing treatment duration is one of the means to achieve this objective. Guidelines on the therapeutic management of the most frequent infections recommend ranges of treatment duration in the ratio of one to two. The Recommendation Group of the French Infectious Diseases Society (SPILF) was asked to collect literature data to then recommend the shortest treatment durations possible for various infections.

METHODS

Analysis of the literature focused on guidelines published in French and English, supported by a systematic search on PubMed. Articles dating from one year before the guidelines publication to August 31, 2015 were searched on the website.

RESULTS

The shortest treatment durations based on the relevant clinical data were suggested for upper and lower respiratory tract infections, central venous catheter-related and uncomplicated primary bacteremia, infective endocarditis, bacterial meningitis, intra-abdominal, urinary tract, upper reproductive tract, bone and joint, skin and soft tissue infections, and febrile neutropenia. Details of analyzed articles were shown in tables.

CONCLUSION

This work stresses the need for new well-conducted studies evaluating treatment durations for some common infections. Following the above-mentioned work focusing on existing literature data, the Recommendation Group of the SPILF suggests specific study proposals.

Randomized clinical trial of extended versus single-dose perioperative antibiotic prophylaxis for acute calculous cholecystitis

Background

Many patients who have surgery for acute cholecystitis receive postoperative antibiotic prophylaxis, with the intent to reduce infectious complications. There is, however, no evidence that extending antibiotics beyond a single perioperative dose is advantageous. This study aimed to determine the effect of extended antibiotic prophylaxis on infectious complications in patients with mild acute cholecystitis undergoing cholecystectomy.

Methods

For this randomized controlled non-inferiority trial, adult patients with mild acute calculous cholecystitis undergoing cholecystectomy at six major teaching hospitals in the Netherlands, between April 2012 and September 2014, were assessed for eligibility. Patients were randomized to either a single preoperative dose of cefazolin (2000 mg), or antibiotic prophylaxis for 3 days after surgery (intravenous cefuroxime 750 mg plus metronidazole 500 mg, three times daily), in addition to the single dose. The primary endpoint was rate of infectious complications within 30 days after operation.

Results

In the intention-to-treat analysis, three of 77 patients (4 per cent) in the extended antibiotic group and three of 73 (4 per cent) in the standard prophylaxis group developed postoperative infectious complications (absolute difference 0·2 (95 per cent c.i. –8·2 to 8·9) per cent). Based on a margin of 5 per cent, non-inferiority of standard prophylaxis compared with extended prophylaxis was not proven. Median length of hospital stay was 3 days in the extended antibiotic group and 1 day in the standard prophylaxis group.

Conclusion

Standard single-dose antibiotic prophylaxis did not lead to an increase in postoperative infectious complications in patients with mild acute cholecystitis undergoing cholecystectomy. Registration number: NTR3089 (www.trialregister.nl).

The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide. The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important. In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs. The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.

Conservative treatment of acute cholecystitis: a systematic review and pooled analysis

BACKGROUND

In medical practice, the tendency to remove an inflamed gallbladder is deeply rooted. Cholecystectomy, however, is associated with relatively high complication rates, and therefore the decision whether or not to perform surgery should be well considered. For some patients, the surgical risk-benefit profile may favour conservative treatment. The objective of this study was to examine the short- and long-term outcome of conservative treatment of patients with acute calculous cholecystitis.

METHODS

A systematic search of MEDLINE, Embase and Cochrane Library databases was performed. Prospective studies reporting on the success rate of conservative treatment (i.e. non-invasive treatment) of acute cholecystitis during index admission were included, as well as prospective and retrospective studies reporting on the recurrence rate of gallstone-related disease during long-term follow-up (i.e. ≥12 months) after initial non-surgical management. Study selection was undertaken independently by two reviewers using predefined criteria. The risk of bias was assessed. The pooled success and mortality rate during index admission and the pooled recurrence rate of gallstone-related disease during long-term follow-up were calculated using a random-effects model.

RESULTS

A total of 1841 patients were included in 10 randomized controlled trials and 14 non-randomized studies. Conservative treatment during index admission was successful in 87 % of patients with acute calculous cholecystitis and in 96 % of patients with mild disease. In the long term, 22 % of the patients developed recurrent gallstone-related disease. Pooled analysis showed a success rate of 86 % (95 % CI 0.8-0.9), a mortality rate of 0.5 % (95 % CI 0.001-0.009) and a recurrence rate of 20 % (95 % CI 0.1-0.3).

DISCUSSION

Conservative treatment of acute calculous cholecystitis during index admission seems feasible and safe, especially in patients with mild disease. During long-term follow-up, less than a quarter of the patients appear to develop recurrent gallstone-related disease, although this outcome is based on limited data.

Safety and efficacy of antibiotic prophylaxis in patients undergoing elective laparoscopic cholecystectomy: A systematic review and meta-analysis

BACKGROUND AND AIM

Owing to persistent controversy regarding the use of routine antibiotic prophylaxis in patients undergoing elective laparoscopic cholecystectomy and the availability of several new randomized controlled trials (RCTs), we conducted an up-to-date meta-analysis to provide the best current evidence. The aim of the article is to evaluate the safety and efficacy of routine antibiotic prophylaxis in low-risk patients undergoing elective laparoscopic cholecystectomy.

METHODS

We conducted a comprehensive literature review of the PubMed, Embase, and Cochrane Library databases for RCTs that compared antibiotic prophylaxis versus placebo or no antibiotics in low-risk patients undergoing elective laparoscopic cholecystectomy.

RESULTS

The meta-analysis included 21 RCTs (5207 patients). Antibiotic prophylaxis reduced the incidence of surgical site infections (risk ratio [RR] 0.61, 95% confidence interval [CI] 0.45 to 0.82, P = 0.001) and global infections (RR 0.55, 95% CI 0.38 to 0.79, P = 0.001) during hospitalization or after discharge, and postoperative length of hospital stay (weighted mean difference -0.16, 95% CI -0.28 to -0.04, P = 0.008). No adverse events were reported. Subgroup analyses demonstrated that two doses of antibiotic and 3-10 doses of antibiotic significantly reduced the incidence of surgical site infections compared with placebo or no antibiotics (two doses: RR 0.16, 95% CI 0.06-0.47; 3-10 doses: RR 0.46, 95% CI 0.27-0.80), while a single dose of antibiotic administration did not.

CONCLUSION

Antibiotic prophylaxis is safe and effective in reducing surgical site infections and global infections during hospitalization or after discharge, and postoperative length of hospital stay in low-risk patients undergoing elective laparoscopic cholecystectomy.

Systematic review of antibiotic treatment for acute calculous cholecystitis

BACKGROUND

Intravenous antibiotics are frequently used in the initial management of acute calculous cholecystitis (ACC), although supportive care alone preceding delayed elective cholecystectomy may be sufficient. This systematic review assessed the success rate of antibiotics in the treatment of ACC.

METHODS

A systematic search of MEDLINE, Embase and Cochrane Library databases was performed. Primary outcomes were the need for emergency intervention and recurrence of ACC after initial non-operative management of ACC. Risk of bias was assessed. Pooled event rates were calculated using a random-effects model.

RESULTS

Twelve randomized trials, four prospective and ten retrospective studies were included. Only one trial including 84 patients compared treatment with antibiotics to that with no antibiotics; there was no significant difference between the two groups in terms of length of hospital stay and morbidity. Some 5830 patients with ACC were included, of whom 2997 had early cholecystectomy, 2791 received initial antibiotic treatment, and 42 were treated conservatively. Risk of bias was high in most studies, and all but three studies had a low level of evidence. For randomized studies, pooled event rates were 15 (95 per cent c.i. 10 to 22) per cent for the need for emergency intervention and 10 (5 to 20) per cent for recurrence of ACC. The pooled event rate for both outcomes combined was 20 (13 to 30) per cent.

CONCLUSION

Antibiotics are not indicated for the conservative management of ACC or in patients scheduled for cholecystectomy.

Laparoscopic approach in gastrointestinal emergencies

This review focuses on the laparoscopic approach to gastrointestinal emergencies and its more recent indications. Laparoscopic surgery has a specific place in elective procedures, but that does not apply in emergency situations. In specific emergencies, there is a huge range of indications and different techniques to apply, and not all of them are equally settle. We consider that the most controversial points in minimally invasive procedures are indications in emergency situations due to technical difficulties. Some pathologies, such as oesophageal emergencies, obstruction due to colon cancer, abdominal hernias or incarcerated postsurgical hernias, are nearly always resolved by conventional surgery, that is, an open approach due to limited intraabdominal cavity space or due to the vulnerability of the bowel. These technical problems have been solved in many diseases, such as for perforated peptic ulcer or acute appendectomy for which a laparoscopic approach has become a well-known and globally supported procedure. On the other hand, endoscopic procedures have acquired further indications, relegating surgical solutions to a second place; this happens in cholangitis or pancreatic abscess drainage. This endoluminal approach avoids the need for laparoscopic development in these diseases. Nevertheless, new instruments and new technologies could extend the laparoscopic approach to a broader array of potentials procedures. There remains, however, a long way to go.

Antimicrobials: a global alliance for optimizing their rational use in intra-abdominal infections (AGORA)

Intra-abdominal infections (IAI) are an important cause of morbidity and are frequently associated with poor prognosis, particularly in high-risk patients. The cornerstones in the management of complicated IAIs are timely effective source control with appropriate antimicrobial therapy. Empiric antimicrobial therapy is important in the management of intra-abdominal infections and must be broad enough to cover all likely organisms because inappropriate initial antimicrobial therapy is associated with poor patient outcomes and the development of bacterial resistance. The overuse of antimicrobials is widely accepted as a major driver of some emerging infections (such as C. difficile), the selection of resistant pathogens in individual patients, and for the continued development of antimicrobial resistance globally. The growing emergence of multi-drug resistant organisms and the limited development of new agents available to counteract them have caused an impending crisis with alarming implications, especially with regards to Gram-negative bacteria. An international task force from 79 different countries has joined this project by sharing a document on the rational use of antimicrobials for patients with IAIs. The project has been termed AGORA (Antimicrobials: A Global Alliance for Optimizing their Rational Use in Intra-Abdominal Infections). The authors hope that AGORA, involving many of the world's leading experts, can actively raise awareness in health workers and can improve prescribing behavior in treating IAIs.

Protocol for extended antibiotic therapy after laparoscopic cholecystectomy for acute calculous cholecystitis (Cholecystectomy Antibiotic Randomised Trial, CHART)

INTRODUCTION

Acute calculous cholecystitis represents one of the most common complications of cholelithiasis. While laparoscopic cholecystectomy is the standard treatment in mild and moderate forms, the need for antibiotic therapy after surgery remains undefined. The aim of the randomised controlled Cholecystectomy Antibiotic Randomised Trial (CHART) is therefore to assess if there are benefits in the use of postoperative antibiotics in patients with mild or moderate acute cholecystitis in whom a laparoscopic cholecystectomy is performed.

METHODS AND ANALYSIS

A single-centre, double-blind, randomised trial. After screening for eligibility and informed consent, 300 patients admitted for acute calculus cholecystitis will be randomised into two groups of treatment, either receiving amoxicillin/clavulanic acid or placebo for 5 consecutive days. Postoperative evaluation will take place during the first 30 days. Postoperative infectious complications are the primary end point. Secondary end points are length of hospital stay, readmissions, need of reintervention (percutaneous or surgical reinterventions) and overall mortality. The results of this trial will provide strong evidence to either support or abandon the use of antibiotics after surgery, impacting directly in the incidence of adverse events associated with the use of antibiotics, the emergence of bacterial resistance and treatment costs.

ETHICS AND DISSEMINATION

This study and informed consent sheets have been approved by the Research Projects Evaluating Committee (CEPI) of Hospital Italiano de Buenos Aires (protocol N° 2111).

RESULTS

The results of the trial will be reported in a peer-reviewed publication.

TRIAL REGISTRATION NUMBER

NCT02057679.

Duration of Antimicrobial Therapy in Treating Complicated Intra-Abdominal Infections: A Comprehensive Review

BACKGROUND

Surgeons managing intra-abdominal infections should always respect the basic principles of antibiotic treatment. An adequate duration of antimicrobial therapy is important to optimize empiric therapy and minimize selective pressures favoring antimicrobial resistance.

METHODS

The optimal duration of antibiotic therapy for intra-abdominal infections (IAIs) has been debated in the last years. A literature research, based on PubMed database and limited to English language publications, was performed without restriction of time or type of manuscript.

RESULTS

In stable patients a short course of antimicrobial therapy (3-5 d) after adequate source control, depending on fever and leukocytosis, may be a reasonable option. In critically ill patients with severe sepsis and septic shock, an individualized approach is always mandatory and patient's inflammatory response should be monitored regularly. Procalcitonin may be helpful for guiding antibiotic treatment in critically ill surgical patients and in predicting treatment response.

CONCLUSIONS

General surgeons managing intra-abdominal infections should always respect the basic principles of antibiotic treatment. Duration of antimicrobial treatment is an important variable to evaluate in treating complicated intra-abdominal infections.

Surgical management of acute cholecystitis

BACKGROUND

Acute cholecystitis occurs in approximately 1% of patients with known gallstones. It presents as a surgical emergency and usually requires hospitalisation for treatment. It is associated with significant morbidity and mortality, particularly in the elderly. Cholecystectomy is advocated for acute cholecystitis; however, the timing of cholecystectomy and the value of the additional treatments have been a matter of debate. This review examines the available evidence regarding the optimal surgical management of patients with acute cholecystitis.

METHODS

A literature search was performed on the MEDLINE, EMBASE and WHO International Clinical Trials Registry Platform, databases for English language publications. The MeSH headings 'cholecystitis', 'acute', 'gallbladder', 'inflammation', 'surgery', 'cholecystectomy', 'laparoscopic', 'robotic', 'telerobotic' and 'computer-assisted' were used.

RESULTS

Data from eight randomised controlled trails and three population-based analyses show that early cholecystectomy for acute cholecystitis performed on the index admission is safe and not associated with increased conversion rates or morbidity in comparison to conservative treatment followed by elective cholecystectomy. Delaying cholecystectomy increases readmissions for gallstone-related events, complications, hospital stay and mortality in the elderly. Early cholecystectomy is also more cost-effective. Randomised trials addressing antibiotic use in acute cholecystitis suggest that antibiotics should be stopped on the day of cholecystectomy. Insufficient trials have been performed to address the optimal analgesia regime post cholecystectomy. Similarly, a lack of trials on intraoperative cholangiography and management of common bile duct stones in patients with acute cholecystitis means that treatment of concomitant bile duct stones should be based on institutional expertise and resource availability. As regards acute cholecystitis in elderly and high-risk patients, case series and retrospective studies would suggest that cholecystectomy is more effective and of lower mortality than percutaneous cholecystostomy. There is not enough evidence to support the routine use of robotic surgery, single-incision laparoscopic cholecystectomy or natural orifice transluminal endoscopic surgery (NOTES) in the treatment of acute cholecystitis.

CONCLUSIONS

Trial evidence would favour a policy of early laparoscopic cholecystectomy following admission with acute cholecystitis. The optimal approach to support early cholecystectomy is suggested but requires evidence from further randomised trials.

Calculated Antibiosis of Acute Cholangitis and Cholecystitis

Background

The aim of this article is to present the most recent suggestions for the therapy of acute cholangitis and cholecystitis based on a review of the current literature.

Methods

We performed a systematic literature search in the Medline, PubMed, and Google Scholar databases using the keywords mentioned above. This article is strongly influenced by the publication of the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07, TG13) in 2007 and 2013. These were the first practical guidelines targeting diagnosis and treatment of acute cholangitis and cholecystitis. These guidelines are based on the best published evidence and a consensus conference of international experts in the field.

Results and Conclusion

Acute cholangitis and acute cholecystitis are common conditions that may result in progressively severe infection and death when not treated appropriately. Beside supportive therapy and antiobstructive measures, therapy with antimicrobial agents is an important component in the management of affected patients. Here, we discuss the use of antimicrobial agents that are suitable for the first-line management of these infections. Empirical therapy depends upon the knowledge of local microbial epidemiology and patient-specific factors affecting the selection of appropriate agents.

Economic impact of redundant antimicrobial therapy in US hospitals

BACKGROUND

Overutilization of antimicrobial therapy places patients at risk for harm and contributes to antimicrobial resistance and escalating healthcare costs. Focusing on redundant or duplicate antimicrobial therapy is 1 recommended strategy to reduce overutilization and its attendant effects on patient safety and hospital costs.

OBJECTIVE

This study explored the incidence and economic impact of potentially redundant antimicrobial therapy.

METHODS

We conducted a retrospective analysis of inpatient administrative data drawn from 505 nonfederal US hospitals. All hospitalized patients discharged between January 1, 2008, and December 31, 2011, were eligible for study inclusion. Potentially redundant antimicrobial therapy was identified from pharmacy records and was defined as patients receiving treatment with overlapping antibiotic spectra for 2 or more consecutive days.

RESULTS

We found evidence of potentially inappropriate, redundant antimicrobial coverage for 23 different antimicrobial combinations in 394 of the 505 (78%) hospitals, representing a total of 32,507 cases. High-frequency redundancies were observed in 3 antianaerobic regimens, accounting for 22,701 (70%) of the cases. Of these, metronidazole and piperacillin-tazobactam accounted for 53% (n = 17,326) of all potentially redundant cases. Days of redundant therapy totaled 148,589, representing greater than $12 million in potentially avoidable healthcare costs.

CONCLUSIONS

Our study suggests that there may be pervasive use of redundant antimicrobial therapy within US hospitals. Appropriate use of antimicrobials may reduce the risk of harm to patients and lower healthcare costs.

Biliary microflora in patients undergoing cholecystectomy

BACKGROUND

The management of acute cholecystitis requires a sound knowledge of the biliary microflora.

METHODS

Bile samples were taken for culture according to a standard routine during all cholecystectomies performed from April 2007 to February 2009 in the Department of Surgery at Enköping Hospital. The use of antibiotics within the 3-mo period before surgery, indication for surgery, prophylactic antibiotics, and post-operative complications were recorded prospectively.

RESULTS

Altogether, 246 procedures were performed during the study period, of which 149 (62%) were done on women. The mean (±SD) age of the study subjects was 49±16 y. Bacterial growth was seen in cultures from 34 (14%) of the subjects. The mean age of subjects with positive cultures was 64 y and that of subjects with negative cultures was 47 y (p<0.001). Positive culture was seen in 16 (31%) of the 51 patients who underwent operations for acute cholecystitis, whereas positive cultures were obtained in 18 of 195 patients without acute cholecystitis (9%) (p<0.001). Resistance to ampicillin was recorded in three of 34 (9%) of the cultures with bacterial growth, to co-trimoxazole in one of the 34 (3%) cultures, to fluoroquinolones in one of the 34 (3%) cultures, and to cephalosporins in one of the 34 (3%) cultures. Resistance to piperacillin-tazobactam was not observed in any of the cultures. In multivariable logistic regression analysis, a positive culture was the only factor significantly associated with risk for post-operative infectious complications (p<0.05).

DISCUSSION

Bacterial growth in the bile is observed more often in patients undergoing surgery for acute cholecystitis. The microflora of the bile is probably important for the outcome of surgery, but further studies are required for assessing the effectiveness of measures for preventing infectious post-operative complications.

How long is antibiotic therapy necessary after urgent cholecystectomy for acute cholecystitis?

OBJECTIVE

The objective of the study was to analyze surgical site infection (SSI) frequency with different duration antibiotic courses to establish the minimum necessary duration.

METHODS

This is an observational study of prospective surveillance of 287 consecutive patients (mean age 67.8 years) operated on for acute cholecystitis of grade II severity in the first 72 h. Postoperative antibiotics had been withdrawn before diagnosis of any infection as an inclusion criterion. Patients were classified into three groups, according to therapy duration: group 1 (0-4 days, n = 45, 15.7 %); group 2 (5-7 days, n = 75, 26.1 %); and group 3 (>7 days, n = 167, 58.2 %). A multivariable analysis of risk infection was performed.

RESULTS

Overall SSI frequency in groups 1, 2, and 3 was 2.2, 10.7, and 9 %, respectively. Risk analysis showed an increase in both crude and adjusted relative risks of overall infection in group 2 (crude relative risk (RR): 4.80 (0.62-37.13); adjusted RR, 2.03 (0.20-20.91)) and in group 3 (crude RR, 4.04 (0.55-29.79); adjusted RR, 2.35 (0.28-20.05)) by comparison with group 1, although without statistical significance. As a result, treatment lasting 4 days or less was not associated with overall surgical site infection incidence higher than longer treatment.

CONCLUSION

Antibiotic treatment over 4 days after early cholecystectomy provides no advantage in decreasing surgical site infection incidence.

[Minimally invasive surgical therapy of acute cholecystitis]

Acute cholecystitis is the most common complication of cholecystolithiasis. It develops in about 10 % of symptomatic patients and gangrenous cholecystitis, gallbladder perforation, gallbladder empyema, or abscesses are typical complications. Cholecystectomy is the most relevant therapy to achieve pain reduction, to prevent the progression of inflammation or local complications and to minimize the risk of recurrence. Surgical therapy can be supported by medical and interventional treatment modalities depending on the severity of the disease. The present review summarizes the surgical aspects in acute cholecystitis with a focus on laparoscopic cholecystectomy which is the gold standard of therapy.

Antibiotic therapy in acute calculous cholecystitis

Acute calculous cholecystitis may progress in a variety of ways from mild cases treatable with (or even without) oral antibiotics to severe cases complicated by bile peritonitis that require emergency surgical or radiological intervention. A sample of bile should always be sent for microbial cultures to identify aerobic and anaerobic bacterial organisms. Empirically selected broad spectrum antibiotic therapy (with a defined duration, dosage and administration route) should be prescribed according to the severity of the cholecystitis, an associated history of recent antibiotic therapy, and local bacterial susceptibility patterns. As soon as causative organisms have been identified, antibiotic therapy should be adjusted to a narrower spectrum antimicrobial agent based on the specific micro-organism(s) and the results of sensitivity testing.