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Title Antimicrobial Therapy for Acute Cholecystitis: Tokyo Guidelines View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by HKU Scholars Hub Title Antimicrobial therapy for acute cholecystitis: Tokyo Guidelines Yoshida, M; Takada, T; Kawarada, Y; Tanaka, A; Nimura, Y; Gomi, H; Hirota, M; Miura, F; Wada, K; Mayumi, T; Solomkin, JS; Author(s) Strasberg, S; Pitt, HA; Belghiti, J; de Santibanes, E; Fan, ST; Chen, MF; Belli, G; Hilvano, SC; Kim, SW; Ker, CG Journal Of Hepato-Biliary-Pancreatic Surgery, 2007, v. 14 n. 1, p. Citation 83-90 Issued Date 2007 URL http://hdl.handle.net/10722/84203 Rights J Hepatobiliary Pancreat Surg (2007) 14:83–90 DOI 10.1007/s00534-006-1160-y Antimicrobial therapy for acute cholecystitis: Tokyo Guidelines Masahiro Yoshida1, Tadahiro Takada1, Yoshifumi Kawarada2, Atsushi Tanaka3, Yuji Nimura4, Harumi Gomi5, Masahiko Hirota6, Fumihiko Miura1, Keita Wada1, Toshihiko Mayumi7, Joseph S. Solomkin8, Steven Strasberg9, Henry A. Pitt10, Jacques Belghiti11, Eduardo de Santibanes12, Sheung-Tat Fan13, Miin-Fu Chen14, Giulio Belli15, Serafin C. Hilvano16, Sun-Whe Kim17, and Chen-Guo Ker18 1 Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo 173-8605, Japan 2 Mie University School of Medicine, Mie, Japan 3 Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan 4 Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan 5 Division of Infection Control and Prevention, Jichi Medical University Hospital, Tochigi, Japan 6 Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Science, Kumamoto, Japan 7 Department of Emergency Medicine and Critical Care, Nagoya University School of Medicine, Nagoya, Japan 8 Department of Surgery, Division of Trauma and Critical Care, University of Cincinnati College of Medicine, Cincinnati, USA 9 Department of Surgery, Washington University in St Louis and Barnes-Jewish Hospital, St Louis, USA 10 Department of Surgery, Indiana University School of Medicine, Indianapolis, USA 11 Department of Digestive Surgery and Transplantation, Hospital Beaujon, Clichy, France 12 Department of Surgery, University of Buenos Aires, Buenos Aires, Argentina 13 Department of Surgery, The University of Hong Kong, Hong Kong, China 14 Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan 15 Department of General and HPB Surgery, Loreto Nuovo Hospital, Naples, Italy 16 Department of Surgery, Philippine General Hospital, University of the Philippines, Manila, Philippines 17 Department of Surgery, Seoul National University College of Medicine, Seoul, Korea 18 Division of HPB Surgery, Yuan’s General Hospital, Taoyuan, Taiwan Abstract Introduction Acute cholecystitis consists of various morbid conditions, ranging from mild cases that are relieved by the oral admin- Acute cholecystitis consists of various morbid condi- istration of antimicrobial drugs or that resolve even without tions, ranging from mild cases that are relieved by antimicrobials to severe cases complicated by biliary peritoni- the oral administration of antimicrobial drugs or that tis. Microbial cultures should be performed by collecting bile resolve even without antimicrobials to severe cases at all available opportunities to identify both aerobic and complicated by biliary peritonitis, each of which re- anaerobic organisms. Empirically selected antimicrobials quires a different treatment strategy. Decisions on an- should be administered. Antimicrobial activity against poten- timicrobial therapy must be based upon knowledge of tial causative organisms, the severity of the cholecystitis, the the likely infecting microorganisms, the pharmacokinet- patient’s past history of antimicrobial therapy, and local sus- ceptibility patterns (antibiogram) must be taken into consid- ics/pharmacodynamics and adverse reactions/effects of eration in the choice of antimicrobial drugs. In mild cases available agents, and the results of local antimicrobial which closely mimic biliary colic, the administration of nons- susceptibility testing (local antibiogram). The severity teroidal anti-infl ammatory drugs (NSAIDs) is recommended of illness and history of exposure to antimicrobials are to prevent the progression of infl ammation (recommendation also key factors in determining appropriate therapy. grade A). When causative organisms are identifi ed, the anti- Once presumptive antimicrobial agents are selected and microbial drug should be changed for a narrower-spectrum administered, they should be changed for more appro- antimicrobial agent on the basis of the species and their sus- priate agents, based on the organisms identifi ed and ceptibility testing results. their susceptibility testing results. Continuous use of unnecessarily broader-spectrum agents should be avoid- Key words Acute cholecystitis · Anti-infective agents · Guide- ed to prevent the emergence of antimicrobial resistance. lines · Infection · Biliary Furthermore, the duration of therapy should be strictly evaluated periodically to avoid unnecessarily prolonged use of antimicrobial agents. In this article we discuss the medical treatment stra- tegy, including antimicrobial therapy, for acute chole- cystitis. In an extensive literature search, we were faced with the fact that there were very few, if any, Offprint requests to: M. Yoshida randomized controlled trials (RCTs) of antimicrobial Received: May 31, 2006 / Accepted: August 6, 2006 therapy for acute cholecystitis. Therefore, we propose 84 M. Yoshida et al.: Antimicrobial therapy for acute cholecystitis consensus-based and in vitro activities-based guidelines Patients with mild case of disease, with little abdominal for empirical antimicrobial therapy for acute cholecys- pain and mild infl ammatory fi ndings, (closely mimick- titis. The text is organized in a question and recommen- ing biliary colic), may be observed and treated with oral dation format. antimicrobial drugs or even observed without anti- microbials. In these patients, the administration of nonsteroidal anti-infl ammatory drugs (NSAIDs) is Q1. What microbiological studies should be performed recommended, as described below. in acute cholecystitis? When early cholecystectomy is performed, antimicro- bial therapy may be considered prophylactic in that the Bile and blood culture should be performed at all infection itself is surgically removed. available opportunities, especially in severe cases (recommendation B). Q3. Is the administration of NSAIDs to patients The clinical signifi cance of microbial examination in suffering from an attack of biliary colic effective to acute cholecystitis depends on the severity of the dis- prevent the development of acute cholecystitis? ease. Although most mild and moderate cases are cur- able without microbial information, biliary infection is Administration of NSAIDs to patients with an associated with postoperative complications and higher attack of biliary colic is recommended, to prevent mortality rates in patients with severe cases or biliary the onset of acute cholecystitis (recommendation stones. A positive bile culture is correlated with the A). progression of the cholecystitis to a severe form (level 2b–3b).1,2 Therefore, especially in severe cases, gall- NSAIDs such as diclofenac or indomethacin should be bladder bile should be collected at the time of operative, used in the medical treatment for their analgesic effects laparoscopic, or percutaneous intervention for culture and their inhibition of prostaglandin release from the and susceptibility testing. A sample of the gallbladder gallbladder wall. An RCT of NSAID administration wall should be sent separately for culture, and for his- (75 mg diclofenac; intramuscular injection) in patients topathology if needed. Aerobic cultures only should with biliary colic attack showed that the NSAID had the be obtained. Positive rates for bacterial culture in effect of relieving the patients’ pain and preventing the acute cholecystitis and other biliary diseases are listed progression of the disease to acute cholecystitis (level in Table 1 (level 2b–3b).3–8 1b).9 Although it has been reported that NSAIDs ef- The importance of blood culture results is relatively fectively improve gallbladder function in patients with limited in acute cholecystitis and the presence of posi- chronic cholangitis (level 3a),10 there is no report to date tive blood cultures does not alter the agents to be used showing that NSAID administration after the onset of or the duration of treatment. acute cholecystitis alleviates the disease. Q2. How should antimicrobial agents be used in Q4. What are the important factors for consideration patients with acute cholecystitis? in antimicrobial drug selection? Antimicrobial agents should be administered to (1) Antimicrobial activity against causative patients diagnosed with acute cholecystitis, except bacteria for those with mild cases (recommendation A). (2) Severity of acute cholecystitis Table 1. Bacterial culture positive rates in bile (%) in various biliary diseases Choledo- Non-biliary Chole- Acute cholithiasis Hepatolithiasis Bile disease lithiasis cholecystitis (+cholangitis) (+cholangitis) Chang (2002)3 Gallbladder 17.0 47.0 63.0 70.0 Csendes (1996)4, 5 Gallbladder 0 22.2 46.1 Csendes (1994)6 Gallbladder 0 32.0 41.0 58.0 Maluenda (1989)2 Gallbladder 0 43.0 Csendes (1975)7 (Gallbladder wall) 47.0 (Chronic; 33) Kune (1974)8 Gallbladder 0 13.0 54.0 59.0 M. Yoshida et al.: Antimicrobial therapy for acute cholecystitis 85
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