Is an Acute Cholecystitis a Local Infection? Antibiotic Therapy Problems

Abstract

Summary. Objective: to improve the results of surgical treatment of destructive forms of acute cholecystitis, taking into account the sensitivity of the isolated microflora to antibiotics.
 Materials and methods. 347 patients with acute cholecystitis (AC) have been operated in the surgical department of Kiev Regional Clinical Hospital in 2016 – 2019. The control group included 275 AC patients operated on in 2013–2015, similar in sex, age, comorbidities, treatment and surgical tactics to each other, but with an empirical choice of antibiotic therapy. Bacteriological studies were performed to 237 patients with destructive forms of acute cholecystitis, where 531 microflora isolates were seeded.
 Results and discussion. The AC treatment group patients (n=347) were arranged according to Tokyo guidelines (2013) into 3 grades. Mild course (grade I, n=38, 11 %), microbiological studies were not conducted. Antibiotic prophylaxis with beta-lactam antibiotics was used. At moderately severe AC (grade II, n = 260, 75 %) escalation antibiotic therapy was carried out. At severe disease (grade III, n = 49, 14 %) de-escalation antibiotic therapy was performed.
 Most often intestinal group microflora was sown. The highest sensitivity of microflora was marked for linezolid - 100 %. Also high sensitivity of microflora was revealed to beta-lactam antibiotics - 83.3 % (penicillins, cephalosporins, monobactams, and carbapenems).
 The highest resistance was marked for unprotected penicillins: penicillin — 67.7 %, ampicillin — 83.3 %, amoxicillin — 100 %, oxacillin — 100 %; among cephalosporins: cefixime — 75.0 %, cefuroxime — 66.7 %; among fluoroquinolones: lomefloxacin and pefloxa-cin — 100 % resistance to seeded aerobic microflora.
 In the control group (n=275) purulent complications were noted in 9.8 % (27 patients), fatal cases — 6, the total mortality rate was 2.18 %, postoperative — 1.45 % (4 patients). In the study group (n = 347), the number of purulent complications was reduced to 4 % (p˂0.01), the total mortality rate was reduced to 0.58 % (p˂0.05).
 Conclusions: 1. Acute obstructive cholecystitis, acute emphysematous (gas) cholecystitis and AC complicated by choledocholithiasis or cholangitis are referred to the local abdominal infectious process. 2. Infection is not a leading factor on first stage for emphysematous, vascular and post-traumatic forms of AC, but it develops in a destructive gall bladder on second stage. 3. For the patients of the first grade by Tokio guideline 2013 we recommend the use of antibiotic prophylaxis. Under moderate grade — escalation antibiotic therapy and under severe grade of the AC — de-escalation antibiotic therapy, followed by the use of selective antibacterial agents should be administered. 4. The highest selective sensitivity of seeded microflora in patients with destructive forms of AC was marked for oxazolidinones (linezolid) — (100 %), as well as for beta-lactam antibiotics (83.3 %). 5. The control group patients had decreased number of suppurations (from 9.8 to 4 %; p<0.01), and decreased mortality rate (from 2.18 to 0.58 %; p<0.05).