Presentation on theme: "Antimicrobial Therapy TOKYO GUIDELINES – Tokyo International Consensus Meeting – April 1-2, 2006 Keio Plaza Hotel, Tokyo, Japan Japan, Singapore,"— Presentation transcript:
Antimicrobial Therapy TOKYO GUIDELINES – Tokyo International Consensus Meeting – April 1-2, 2006 Keio Plaza Hotel, Tokyo, Japan Japan, Singapore, Korea, HongKong, China, Taiwan, Argentina, Germany, South Africa, Italy, France, USA, Indonesia, Australia, Thailand, Malaysia, New Zealand, Philippines (S.C. Hilvano: Department of Surgery, College of Medical & Philippine General Hospital)
Antimicrobial Therapy INDICATION – Antimicrobial agents should be administered to all patients diagnosed as having acute cholangitis (recommendation A); the Antimicrobial agents should be administered as soon as the diagnosis of acute cholangitis is suspected or established.
Antimicrobial Therapy Most important FACTORS FOR CONSIDERATION: 1.Antimicrobial activity against causative bacteria 2.Severity of cholangitis 3.Presence/absence of renal and hepatic disease 4.Past history of antimicrobial administration to the patient 5.Local susceptibility patterns (antibiogram) of the suspected causative organisms 6.Biliary penetration of the antimicrobial agents.
Antimicrobial Therapy SELECTION – Antimicrobial drugs should be selected according to the severity assessment (recommendation A). – Empirically administered antimicrobial agents should be changed for more appropriate agents according to the identiﬁed causative microorganisms and their sensitivity to antimicrobials (recommendation A).
DOSAGE – According to local rules and regulations – Drug dosage adjustment should be done in patients with decreased renal function. The Sanford guide to antimicrobial therapy and Goodman and Gilman’s the pharmacological basis of therapeutics should be consulted (recommendation A).
Antimicrobial Therapy DURATION – For patients with moderate (grade II) or severe (grade III) acute cholangitis, antimicrobial agents should be administered for a minimum duration of 5–7 days. More prolonged therapy could be required, depending on the presence of bacteremia and the patient’s clinical response, judged by fever, white blood cell count, and C-reactive protein, when available (recommendation A). – For patients with mild (grade I) acute cholangitis, the duration of antimicrobial therapy could be shorter (2 or 3 days) (recommendation A).
Antimicrobial Therapy BILIARY PENETRATION – Biliary penetration should be considered in the selection of antimicrobial agents in acute cholangitis (recommendation A).
Principles of Management Septic ShockAscending Cholangitis 10 Close monitoring (vital signs, I/O) Hemodynamic support with IV fluids and vasopressors Identify underlying cause for sepsis ABC assessment IV Fluid resuscitation with crystalloids (e.g. plain NSS) Parenteral antibiotics Biliary decompression (severe cases) Extracorporeal shockwave lithotripsy (ESWL) for choleliths
PROGNOSIS more serious than cholecystitis, potentially life-threatening prognosis depends on cause (best to worst) - stones, benign strictures, sclerosing cholangitis, cancer
Looking Ahead – Ascending Cholangitis PrognosisComplications Depends on the following: – Early recognition and treatment of cholangitis – Response to therapy – Underlying medical conditions of the patient Mortality rate: 5-10%, (higher in patients who require emergency decompression or surgery) Good response to antibiotics = good prognosis Liver failure, hepatic abscess, microabscess Acute renal failure Bacteremia, sepsis (gram- negative)
Looking Ahead – Septic Shock PrognosisComplications Depends on the following: – Severity of illness – Co-morbidities – Age Response to antibiotics Acute respiratory distress syndrome (ARDS) Renal dysfunction Disseminated intravascular coagulation (DIC) Mesenteric ischemia Myocardial ischemia and dysfunction
EXTRA SLIDES MIMI’S NOTES
MANAGEMENT Medications: antibiotics active against enteric organisms treatment guidelines from The Medical Letter for intra-abdominal infections reasonable first choices – piperacillin-tazobactam (Zosyn) piperacillin-tazobactam – ticarcillin-clavulanate (Timentin) ticarcillin-clavulanate – ampicillin-sulbactam (Unasyn) ampicillin-sulbactam – carbapenem - ertapenem, imipenem/cilastatin, or meropenem Reference - Clin Infect Dis 2003 Oct 15;37(8):997 previous options no longer recommended cefoxitin (Mefoxin) no longer reliable for Bacillus fragiliscefoxitin – cefotetan (Cefotan) withdrawn from market cefotetan some clinicians prefer piperacillin-tazobactam or ampicillin-sulfactam, with or without aminoglycoside, for bacteremia from biliary tractpiperacillin-tazobactam options if allergic to beta-lactams – fluoroquinolone (ciprofloxacin, levofloxacin or moxifloxacin) plus metronidazole – tigecycline in severely ill patients – cover Pseudomonas with piperacillin-tazobactam, imipenem, meropenem, ceftazidime, cefepime, aztreonam or ciprofloxacinpiperacillin-tazobactamceftazidimecefepime – add metronidazole for B. fragilis coverage – aminoglycoside can be added Reference - Treat Guidel Med Lett 2007 May;5(57):33 TOCTreat Guidel Med Lett 2007 May;5(57):33TOC
tigecyclinetigecycline (Tygacil) tigecycline (Tygacil) FDA approved for IV treatment of complicated intra-abdominal infections and complicated skin and skin structure infections in adults tigecycline – broad spectrum of activity including methicillin-resistant Staphylococcus aureus (MRSA) – may be used as empiric monotherapy for complicated appendicitis, infected burns, intra-abdominal abscesses, deep soft tissue infections, and infected ulcers – Reference - Infection Control Today 2005 Jun 16Infection Control Today 2005 Jun 16 tigecycline not very effective against Pseudomonas (Prescriber's Letter 2005 Jul;12(7):38) tigecycline tigecycline should be used judiciously to reduce resistance, could be useful for resistant organisms but not Pseudomonas (The Medical Letter 2005 Sep 12;47(1217):73) tigecyclineThe Medical Letter 2005
COMPLICATIONS Complications: bacterial cholangitis led to sclerosing cholangitis in case report (BMC Gastroenterology 2002 Jun 3;2:14)BMC Gastroenterology 2002 Jun 3;2:14 Associated conditions: bile stasis renal dysfunction and failure common with toxic cholangitis (1)1
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2008 content/a8v37tr / content/a8v37tr / Review Paper Microbiology and Management of Abdominal Infections Itzhak Brook Digestive Diseases and Sciences Digestive Diseases and Sciences Volume 53, Number 10, Volume 53, Number tent/348u1125q02g1h08/ tent/348u1125q02g1h08/ Diagnostic criteria and severity assessment of acute cholangitis: Tokyo Guidelines Keita Wada, Tadahiro Takada, Yoshifumi Kawarada, Yuji Nimura, Fumihiko Miura, Masahiro Yoshida, Toshihiko Mayumi, Steven Strasberg, Henry A. Pitt and Thomas R. Gadacz, et al. Keita WadaTadahiro Takada Yoshifumi KawaradaYuji Nimura Fumihiko MiuraMasahiro YoshidaToshihiko Mayumi Steven StrasbergHenry A. PittThomas R. Gadacz Journal of Hepato-Biliary- Pancreatic Surgery Journal of Hepato-Biliary- Pancreatic Surgery Volume 14, Number 1, Volume 14, Number 1