TG13 antimicrobial therapy for acute cholangitis and cholecystitis

Journal of Hepato-Biliary-Pancreatic Sciences, Jan 2013

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 of resistance in the latter. Selection of agents for community-acquired infections is also recommended on the basis of severity (grades I–III). Free full-text articles and a mobile application of TG13 are available via http://​www.​jshbps.​jp/​en/​guideline/​tg13.​html.

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TG13 antimicrobial therapy for acute cholangitis and cholecystitis

Harumi Gomi 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Joseph S. Solomkin 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Tadahiro Takada 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Steven M. Strasberg 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Henry A. Pitt 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Masahiro Yoshida 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Ryota Higuchi 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 John A. Windsor 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Christos Dervenis 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Kui-Hin Liau 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Myung-Hwan Kim 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 0 T. Takada F. Miura Department of Surgery, Teikyo University School of Medicine , Tokyo, Japan 1 J. A. Windsor Department of Surgery, The University of Auckland , Auckland, New Zealand 2 J. S. Solomkin Department of Surgery, University of Cincinnati College of Medicine , Cincinnati, OH, USA 3 R. Higuchi Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University , Tokyo, Japan 4 K.-H. Liau Hepatobiliary and Pancreatic Surgery, Nexus Surgical Associates, Mount Elizabeth Hospital , Singapore, Singapore 5 H. Gomi (&) Center for Clinical Infectious Diseases, Jichi Medical University , 3311-1, Yakushiji, Shimotsuke, Tochigi 329-0431, Japan 6 C. Dervenis First Department of Surgery, Agia Olga Hospital , Athens, Greece 7 Y. Kimura Department of Surgical Oncology and Gastroenterological Surgery, Sapporo Medical University School of Medicine , Sapporo, Japan 8 M. Yokoe General Internal Medicine, Nagoya Daini Red Cross Hospital , Nagoya, Japan 9 S. Kiriyama Department of Gastroenterology, Ogaki Municipal Hospital , Ogaki, Japan 10 T. Mayumi Department of Emergency and Critical Care Medicine, Ichinomiya Municipal Hospital , Ichinomiya, Japan 11 M.-H. Kim Department of Internal Medicine, Asan Medical Center, University of Ulsan , Seoul, Korea 12 M. Yoshida Clinical Research Center Kaken Hospital, International University of Health and Welfare , Ichikawa, Japan 13 H. A. Pitt Department of Surgery, Indiana University School of Medicine , Indianapolis, IN, USA 14 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 - 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 the gallbladd (...truncated)


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Harumi Gomi, Joseph S. Solomkin, Tadahiro Takada, Steven M. Strasberg, Henry A. Pitt, Masahiro Yoshida, Shinya Kusachi, Toshihiko Mayumi, Fumihiko Miura, Seiki Kiriyama, Masamichi Yokoe, Yasutoshi Kimura, Ryota Higuchi, John A. Windsor, Christos Dervenis, Kui-Hin Liau, Myung-Hwan Kim. TG13 antimicrobial therapy for acute cholangitis and cholecystitis, Journal of Hepato-Biliary-Pancreatic Sciences, 2013, pp. 60-70, Volume 20, Issue 1, DOI: 10.1007/s00534-012-0572-0