TG13 antimicrobial therapy for acute cholangitis and cholecystitis
Harumi Gomi
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Joseph S. Solomkin
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Tadahiro Takada
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Steven M. Strasberg
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Henry A. Pitt
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Masahiro Yoshida
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Ryota Higuchi
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John A. Windsor
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Christos Dervenis
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Kui-Hin Liau
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Myung-Hwan Kim
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T. Takada F. Miura Department of Surgery, Teikyo University School of Medicine
,
Tokyo, Japan
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J. A. Windsor Department of Surgery, The University of Auckland
, Auckland,
New Zealand
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J. S. Solomkin Department of Surgery, University of Cincinnati College of Medicine
, Cincinnati,
OH, USA
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R. Higuchi Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University
,
Tokyo, Japan
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K.-H. Liau Hepatobiliary and Pancreatic Surgery, Nexus Surgical Associates, Mount Elizabeth Hospital
,
Singapore, Singapore
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H. Gomi (&) Center for Clinical Infectious Diseases, Jichi Medical University
, 3311-1, Yakushiji, Shimotsuke, Tochigi 329-0431,
Japan
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C. Dervenis First Department of Surgery, Agia Olga Hospital
,
Athens, Greece
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Y. Kimura Department of Surgical Oncology and Gastroenterological Surgery, Sapporo Medical University School of Medicine
, Sapporo,
Japan
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M. Yokoe General Internal Medicine, Nagoya Daini Red Cross Hospital
, Nagoya,
Japan
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S. Kiriyama Department of Gastroenterology, Ogaki Municipal Hospital
, Ogaki,
Japan
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T. Mayumi Department of Emergency and Critical Care Medicine, Ichinomiya Municipal Hospital
, Ichinomiya,
Japan
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M.-H. Kim Department of Internal Medicine, Asan Medical Center, University of Ulsan
, Seoul,
Korea
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M. Yoshida Clinical Research Center Kaken Hospital, International University of Health and Welfare
, Ichikawa,
Japan
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H. A. Pitt Department of Surgery, Indiana University School of Medicine
,
Indianapolis, IN, USA
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S. M. Strasberg Section of Hepatobiliary and Pancreatic Surgery, Washington University in Saint Louis School of Medicine
, Saint Louis,
MO, USA
Therapy with appropriate antimicrobial agents is an important component in the management of patients with acute cholangitis and/or acute cholecystitis. In the updated Tokyo Guidelines (TG13), we recommend antimicrobial agents that are suitable from a global perspective for management of these infections. These recommendations focus primarily on empirical therapy (presumptive therapy), provided before the infecting isolates are identified. Such therapy depends upon knowledge of both local microbial epidemiology and patient-specific factors that affect selection of appropriate agents. These patient-specific factors include prior contact with the health care system, and we separate community-acquired versus healthcare-associated infections because of the higher risk
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of resistance in the latter. Selection of agents for
community-acquired infections is also recommended on the basis
of severity (grades IIII).
Free full-text articles and a mobile application of TG13 are
available via http://www.jshbps.jp/en/guideline/tg13.html.
Acute cholangitis and cholecystitis are common conditions
that may result in progressively severe infection,
particularly in debilitated hosts. Epidemiology and risk factors for
acute cholangitis and cholecystitis are provided in a
separated section of TG13: Current terminology, etiology, and
epidemiology of acute cholangitis and cholecystitis. The
primary goal of antimicrobial therapy in acute cholangitis
and cholecystitis is to limit both the systemic septic
response and local inflammation, to prevent surgical site
infections in the superficial wound, fascia, or organ space,
and to prevent intrahepatic abscess formation [1].
In acute cholangitis, drainage of the obstructed biliary
tree (termed source control) was recognized as the mainstay
of therapy long before the introduction of antimicrobial
agents [1]. An additional role of antimicrobial therapy,
allowing delay in operation until patients are more
physiologically stable, was initially defined by Boey and Way [2].
They retrospectively reviewed 99 consecutive patients with
acute cholangitis, and reported that 53 % of their patients
who responded well to antimicrobial therapy were therefore
given elective instead of emergency operation [1, 2].
The role of antimicrobial therapy in the broad range of
diseases subsumed under the term acute cholecystitis
also varies with severity and pathology. In early and
nonsevere cases, it is not obvious that bacteria play a
significant role in the pathology encountered. In these patients,
antimicrobial therapy is at best prophylactic, preventing
progression to infection. In other cases, with clinical
findings of a systemic inflammatory response, antimicrobial
therapy is therapeutic, and treatment may be required until
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