さまよう薬剤師のブログ

学位を持っても、センスのない、感染制御専門薬剤師のブログ.  I have Ph.D. but less sense ID pharmacist.

胆嚢炎

消化器の先生からご相談

MRSAのCRBSI患者に胆嚢炎があり
巨体であり、画像で判断しかできず。
なお、CRBSIに対してはVCMを使用中
抗菌薬治療選択をdiscussion

胆嚢炎の重症感は、緊迫していないと、消化器の先生は判断
血液培養からは、Klebsiella oxytoca

VCM投与中なので、TAZ/PIPCは、微妙

緊迫でないため、カルバペネムは避けて提案


Up To Date より復習

はじめに
Acute cholecystitis refers to a syndrome of right upper quadrant pain, fever, and leukocytosis associated with gallbladder inflammation, which is usually related to gallstone disease. Once a patient develops acute cholecystitis, definitive therapy aimed at eliminating the gallstones is recommended. Without definitive therapy, the likelihood of recurrent symptoms or complications is high. 

支持療法
Patients diagnosed with acute cholecystitis should be admitted to the hospital. Initial supportive care includes intravenous fluid therapy, correction of electrolyte disorders, and control of pain. Adequate pain control can usually be achieved with nonsteroidal antiinflammatory drugs (NSAIDs) or opioids. Patients should be kept fasting and those who are vomiting may need placement of a nasogastric tube.

抗菌薬
Acute cholecystitis is primarily an inflammatory process, but secondary infection of the gallbladder can occur as a result of cystic duct obstruction and bile stasis. Many clinicians routinely administer antimicrobial therapy to all patients diagnosed with acute cholecystitis, which are continued until the gallbladder is removed or the cholecystitis clinically resolves. If sepsis is suspected (laboratory or clinical findings), or radiographic findings are indicative of gallbladder ischemia or necrosis, we suggest empiric antibiotic therapy (Grade 2C). Antibiotic options and doses are provided in the table. For patients with uncomplicated cholecystitis, we discontinue antibiotics the day after the cholecystectomy.

The most frequent isolates from the gallbladder or common bile duct were Escherichia coli (41 percent), Enterococcus (12 percent), Klebsiella (11 percent), and Enterobacter (9 percent). 

First choice
  • Monotherapy with a beta-lactam/beta-lactamase inhibitor:
  • Ampicillin-sulbactam¶ 3 g IV every six hours
  • Piperacillin-tazobactamΔ 3.375 or 4.5 g IV every six hours
  • Ticarcillin-clavulanate 3.1 g IV every four hours
  • Combination third generation cephalosporin PLUS metronidazole:
  • Ceftriaxone plus 1 g IV every 24 hours or 2 g IV every 12 hours for CNS infections
  • Metronidazole 500 mg IV every eight hours
Alternative empiric regimens
  • Combination fluoroquinolone◊ PLUS metronidazole:
  • Ciprofloxacin or 400 mg IV every 12 hours
  • Levofloxacin plus 500 or 750 mg IV once daily
  • Metronidazole 500 mg IV every eight hours
  • Monotherapy with a carbapenem§:
  • Imipenem-cilastatin 500 mg IV every six hours
  • Meropenem 1 g IV every eight hours
  • Doripenem 500 mg IV every eight hours
  • Ertapenem¥ 1 g IV once daily

タイミング
The choice and timing of intervention for acute cholecystitis (cholecystectomy, gallbladder drainage) depends upon the severity of symptoms and the patient's overall risk of surgery. Drainage options include percutaneous or open cholecystostomy and endoscopic sphincterotomy.

  • Emergent intervention is indicated for patients with:
-Progressive symptoms and signs such as high fever, hemodynamic instability, or intractable pain in spite of adequate pain medication.
-Suspicion of gallbladder gangrene or gallbladder perforation

  • For patients without emergent indications for definitive therapy who are low risk for surgery, we recommend cholecystectomy during the initial hospitalization (Grade 1A). Cholecystectomy performed early rather than later in the hospitalization may be associated with reduced perioperative morbidity and mortality. Low-risk patients generally undergo laparoscopic cholecystectomy. Compared with open cholecystectomy, laparoscopic cholecystectomy reduces postoperative pain and significantly shortens the length of hospital stay and convalescence. 

  • For patients without emergent indications for definitive therapy, and in whom the risk of cholecystectomy outweighs the potential benefits, gallbladder drainage (percutaneous cholecystostomy, endoscopic sphincterotomy, open cholecystostomy) is indicated if symptoms do not improve with supportive care. Once cholecystitis resolves, the patient’s risk for surgery should be reassessed. Patients who have become reasonable candidates for surgery should undergo elective cholecystectomy. Patients who stabilize with a cholecystostomy tube but continue to be at high-risk for surgery can be considered for percutaneous gallstone extraction with or without mechanical lithotripsy. 

Mortality associated with a single episode of acute cholecystitis depends upon the patient's health and surgical risk. Overall mortality is approximately 3 percent, but is less than 1 percent in young, otherwise healthy patients, and approaches 10 percent in high-risk patients, or in those with complications.