Antimicrobial therapy for acute cholecystitis: Tokyo Guidelines
Masahiro Yoshida
10
Tadahiro Takada
10
Yoshifumi Kawarada
9
Atsushi Tanaka
8
Yuji Nimura
15
Harumi Gomi
14
Masahiko Hirota
13
Fumihiko Miura
10
Keita Wada
10
Toshihiko Mayumi
12
Joseph S. Solomkin
17
Steven Strasberg
16
Henry A. Pitt
11
Jacques Belghiti
6
Eduardo de Santibanes
7
Sheung-Tat Fan
4
Miin-Fu Chen
5
Giulio Belli
2
Serafin C. Hilvano
3
Sun-Whe Kim
0
Chen-Guo Ker
1
0
Department of Surgery, Seoul National University College of Medicine
, Seoul,
Korea
1
Division of HPB Surgery, Yuan's General Hospital
, Taoyuan,
Taiwan
2
Department of General and HPB Surgery, Loreto Nuovo Hospital
, Naples,
Italy
3
Department of Surgery, Philippine General Hospital, University of the Philippines
, Manila,
Philippines
4
Department of Surgery, The University of Hong Kong
,
Hong Kong, China
5
Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University
, Taoyuan,
Taiwan
6
Department of Digestive Surgery and Transplantation, Hospital Beaujon
, Clichy,
France
7
Department of Surgery, University of Buenos Aires
,
Buenos Aires, Argentina
8
Department of Medicine, Teikyo University School of Medicine
,
Tokyo, Japan
9
Mie University School of Medicine
, Mie,
Japan
10
Department of Surgery, Teikyo University School of Medicine
, 2-11-1 Kaga, Itabashi-ku,
Tokyo 173-8605, Japan
11
Department of Surgery, Indiana University School of Medicine
,
Indianapolis, USA
12
Department of Emergency Medicine and Critical Care, Nagoya University School of Medicine
, Nagoya,
Japan
13
Department of Gastroenterological Surgery, Kumamoto University Graduate School of Medical Science
, Kumamoto,
Japan
14
Division of Infection Control and Prevention, Jichi Medical University Hospital
, Tochigi,
Japan
15
Division of Surgical Oncology, Department of Surgery, Nagoya University Graduate School of Medicine
, Nagoya,
Japan
16
Department of Surgery, Washington University in St Louis and Barnes-Jewish Hospital
,
St Louis, USA
17
Department of Surgery, Division of Trauma and Critical Care, University of Cincinnati College of Medicine
, Cincinnati,
USA
Acute cholecystitis consists of various morbid conditions, ranging from mild cases that are relieved by the oral administration of antimicrobial drugs or that resolve even without antimicrobials to severe cases complicated by biliary peritonitis. Microbial cultures should be performed by collecting bile at all available opportunities to identify both aerobic and anaerobic organisms. Empirically selected antimicrobials should be administered. Antimicrobial activity against potential causative organisms, the severity of the cholecystitis, the patient's past history of antimicrobial therapy, and local susceptibility patterns (antibiogram) must be taken into consideration in the choice of antimicrobial drugs. In mild cases which closely mimic biliary colic, the administration of nonsteroidal anti-inflammatory drugs (NSAIDs) is recommended to prevent the progression of inflammation (recommendation grade A). When causative organisms are identified, the antimicrobial drug should be changed for a narrower-spectrum antimicrobial agent on the basis of the species and their susceptibility testing results.
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Acute cholecystitis consists of various morbid
conditions, ranging from mild cases that are relieved by
the oral administration of antimicrobial drugs or that
resolve even without antimicrobials to severe cases
complicated by biliary peritonitis, each of which
requires a different treatment strategy. Decisions on
antimicrobial therapy must be based upon knowledge of
the likely infecting microorganisms, the
pharmacokinetics/pharmacodynamics and adverse reactions/effects of
available agents, and the results of local antimicrobial
susceptibility testing (local antibiogram). The severity
of illness and history of exposure to antimicrobials are
also key factors in determining appropriate therapy.
Once presumptive antimicrobial agents are selected and
administered, they should be changed for more
appropriate agents, based on the organisms identified and
their susceptibility testing results. Continuous use of
unnecessarily broader-spectrum agents should be
avoided to prevent the emergence of antimicrobial resistance.
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
strategy, including antimicrobial therapy, for acute
cholecystitis. In an extensive literature search, we were
faced with the fact that there were very few, if any,
randomized controlled trials (RCTs) of antimicrobial
therapy for acute cholecystitis. Therefore, we propose
consensus-based and in vitro activities-based guidelines
for empirical antimicrobial therapy for acute
cholecystitis. The text is organized in a question and
recommendation format.
Q1. What microbiological studies should be performed
in acute cholecystitis?
Bile and blood culture should be performed at all
available opportunities, especia (...truncated)