Colecistectomía laparoscópica urgente por colecistitis aguda litiásica en Pediatría / Urgent laparoscopic cholecystectomy as a result of acute calculous cholecystitis in pediatrics

Introducción: Pese al aumento en la prevalencia de colelitiasisdurante las últimas décadas, no se han desarrollado recomendacionessobre el mejor tratamiento de la colecistitis aguda litiásica (CA) enPediatría. Caso clínico: Paciente varón de 4 años y 20 kg de peso sin antecedentes de interés, que acude derivado por sepsis de origen abdominal. Analíticamente destaca leucocitosis con hemoglobina, función hepáticay bilirrubina normales. La ecografía abdominal muestra colelitiasis, hidrops vesicular y proceso inflamatorio compatible con plastrón apendicular. En laparoscopia diagnóstica se observa apéndice macroscópicamentenormal y colecistitis aguda. Ante la situación del paciente se realiza,conjuntamente con Cirugía General, colecistectomía laparoscópica. Elpaciente se recupera sin incidencias tras 5 días de ingreso bajo coberturacon piperacilina-tazobactam. Comentarios: No existen recomendaciones sobre el tratamiento dela CA en niños. En los pacientes sépticos, la colaboración entre cirujanospediátricos y cirujanos generales permite contemplar la colecistectomíaurgente como una opción segura.(AU)

Introduction: In spite of the increase in the prevalence of cholelithiasis in the last decades, no recommendations regarding the best treatmentof acute calculous cholecystitis (AC) in pediatrics have been developed. Clinical case: 4-year-old, 20kg male patient with no significanthistory referred to our institution as a result of abdominal sepsis. Theblood count showed leukocytosis, with normal hemoglobin and bilirubinlevels, and a normal liver function. The abdominal ultrasonography revealed cholelithiasis, gallbladder hydrops, and an inflammatory processcompatible with appendicular plastron. In the diagnostic laparoscopy,the appendix was macroscopically normal, and acute cholecystitis wasobserved. Given the patient’s situation, and in cooperation with theGeneral Surgery Department, laparoscopic cholecystectomy was carriedout. The patient recovered uneventfully on hospitalization day 5 underpiperacillin-tazobactam treatment. Discussion: There are no recommendations regarding AC treatmentin children. In septic patients, cooperation between general and pediatricsurgeons allows urgent cholecystectomy to be considered as a safe option.(AU)

Impact of empiric antibiotic therapy on the clinical outcome of acute calculous cholecystitis.

PURPOSE: Although mortality and morbidity of severe acute calculous cholecystitis (ACC) are still a matter of concern, the impact of inadequate empirical antibiotic therapy has been poorly studied as a risk factor. The objective was to assess the impact of the adequacy of empirical antibiotic therapy on complication and mortality rates in ACC. METHODS: This observational retrospective cohort chart-based single-center study was conducted between 2012 and 2016. A total of 963 consecutive patients were included, and pure ACC was selected. General, clinical, postoperative, and microbiological variables were collected, and risk factors and consequences of inadequate treatment were analyzed. RESULTS: Bile, blood, and/or exudate cultures were obtained in 76.3% of patients, more often in old, male, and severely ill patients (P < 0.001). Patients who were cultured had a higher overall rate of postoperative complications (47.4% vs. 29.7%; P < 0.001), as well as of severe complications (11.6% vs. 4.7%; P = 0.008). Patients with positive cultures had more overall complications (54.8% vs. 39.6%; P = 0.001), more severe complications (16.3% vs. 6.7%; P = 0.001), and higher mortality rates (6% vs. 1.9%; P = 0.012). Patients who received inadequate empirical antibiotic therapy had a fourfold higher mortality rate than those receiving adequate therapy (n = 283; 12.8% vs. 3.4%; P = 0.003). This association was especially marked in severe ACC TG-III patients (n = 132; 18.2 vs. 5.1%; P = 0.018) and remained a predictor of mortality in a binary logistic regression (OR 4.4; 95% CI 1.3-15.3). CONCLUSION: Patients with positive cultures developed more complications and faced higher mortality. Adequate empirical antibiotic therapy appears to be of paramount importance in ACC, particularly in severely ill patients.

Cost-effectiveness analysis of antibiotic prophylaxis versus no antibiotic prophylaxis for acute cholecystectomy.

OBJECTIVE: For acute cholecystitis, the treatment of choice is laparoscopic cholecystectomy. In mild-to-moderate cases, the use of antibiotic prophylaxis for the prevention of postoperative infectious complications (POICs) lacks evidence regarding its cost-effectiveness when compared with no prophylaxis. In the context of rising antimicrobial resistance, there is a clear rationale for a cost-effectiveness analysis (CEA) to determine the most efficient use of National Health Service resources and antibiotic routine usage. DESIGN: 16 of 226 patients (7.1%) in the single-dose prophylaxis group and 29 of 231 (12.6%) in the non-prophylaxis group developed POICs. A CEA was carried out using health outcome data from thePerioperative antibiotic prophylaxis in the treatment of acute cholecystitis (PEANUTS II) multicentre, randomised, open-label, non-inferiority, clinical trial. Costs were measured in monetary units using pound sterling, and effectiveness expressed as POICs avoided within the first 30 days after cholecystectomy. RESULTS: This CEA produced an incremental cost-effectiveness ratio of -£792.70. This suggests a modest cost-effectiveness of antibiotic prophylaxis being marginally less costly and more effective than no prophylaxis. Three sensitivity analyses were executed considering full adherence to the antibiotic, POICs with increased complexity and break-point analysis suggesting caution in the recommendation of systematic use of antibiotic prophylaxis for the prevention of POICs. CONCLUSION: The results of this CEA point to greater consensus in UK-based guidelines surrounding the provision of antibiotic prophylaxis for mild-to-moderate cases of acute cholecystitis.

Laparoscopic cholecystectomy versus antibiotic therapy for acute cholecystitis in patients over 75 years: Randomized clinical trial and retrospective cohort study.

BACKGROUND AND OBJECTIVE: The prevalence of acute cholecystitis among elderly patients is increasing. The aim of this study was to compare laparoscopic cholecystectomy (LC) to antibiotics in elderly patients with acute cholecystitis. METHODS: A randomized multicenter clinical trial including patients over 75 years with acute calculous cholecystitis was conducted in four hospitals in Finland between January 2017 and December 2019. Patients were randomized to undergo LC or antibiotic therapy. Due to patient enrollment challenges, the trial was prematurely terminated in December 2019. To assess all eligible patients, we performed a retrospective cohort study including all patients over 75 years with acute cholecystitis during the study period. The primary outcome was morbidity. Predefined secondary outcomes included mortality, readmission rate, and length of hospital stay. RESULTS: Among 42 randomized patients (LC n = 24, antibiotics n = 18, mean age 82 years, 43% women), the complication rate was 17% (n = 4/24) after cholecystectomy and 33% (n = 6/18, 5/6 patients underwent cholecystectomy due to antibiotic treatment failure) after antibiotics (p = 0.209). In the retrospective cohort (n = 630, mean age 83 years, 49% women), 37% (236/630) of the patients were treated with cholecystectomy and 63% (394/630) with antibiotics. Readmissions were less common after surgical treatment compared with antibiotics in both randomized and retrospective cohort patients (8% vs 44%, p < 0.001% and 11 vs 32%, p < 0.001, respectively). There was no 30-day mortality within the randomized trial. In the retrospective patient cohort, overall mortality was 6% (35/630). CONCLUSIONS: LC may be superior to antibiotic therapy for acute cholecystitis in the selected group of elderly patients with acute cholecystitis.

Análisis de los factores de riesgo para complicaciones en la colecistitis aguda litiásica. Deconstrucción de las Tokyo Guidelines / Risk factors for complications in acute calculous cholecystitis. Deconstruction of the Tokyo Guidelines

Introducción: Analizar los factores de riesgo de complicaciones para colecistitis aguda litiásica confrontándolos a las Tokyo Guidelines. Métodos: Estudio retrospectivo de 963 pacientes con colecistitis aguda durante 5 años. Se seleccionaron 725 pacientes con colecistitis aguda litiásica «pura», y analizaron 166 variables mediante regresión logística, incluyendo todos los factores de riesgo de las Tokyo Guidelines. Mediante el Propensity Score Matching, se seleccionaron subpoblaciones comparables de 75 pacientes y se analizaron las complicaciones según el tratamiento realizado (quirúrgico/no quirúrgico) y se utilizó el fallo en el rescate como indicador de calidad del tratamiento en la colecistitis aguda litiásica. Resultados: La mediana de edad fue de 69 años (RIQ 53-80). La mayoría de los pacientes fueron ASA II o III (85,1%). El 21% de las colecistitis fueron leves, el 39% moderadas y el 40% graves. Se colecistectomizó al 95% de los pacientes. El 43% de los pacientes se complicaron y la mortalidad fue del 3,6%. Los factores de riesgo independientes para complicaciones graves fueron ASA>II, tumor sólido sin metástasis e insuficiencia renal. El fallo en el rescate (8%) fue mayor en los no operados (32% vs. 7%; P=0,002). Tras realizar el Propensity Score Matching, la tasa de complicaciones graves fueron comparables entre operados y no operados (48,5% vs. 62,5%; P=0,21). Conclusiones: La colecistectomía precoz es el tratamiento preferente para la colecistitis aguda litiásica. Solo tres de los factores de las Tokyo Guidelines son variables independientes para predecir complicaciones graves. El fallo en el rescate es mayor en los pacientes no intervenidos quirúrgicamente. (AU)

Introduction: To challenge the risk factors described in Tokyo Guidelines in acute calculous cholecystitis. Methods: Retrospective single center cohort study with 963 patients with acute cholecystitis during a period of 5 years. Some 725 patients with a “pure” Acute calculous cholecystitis were selected. The analysis included 166 variables encompassing all risk factors described in Tokyo Guidelines. The Propensity Score Matching method selected two subgroups of patients with equal comorbidities, to compare the severe complications rate according to the initial treatment (Surgical vs. non-surgical). We analyzed the failure-to-rescue as a quality indicator in the treatment of acute calculous cholecystitis. Results: The median age was 69 years (IQR 53-80). 85.1% of the patients were ASA II or III. The grade of the acute calculous cholecystitis was mild in a 21%, moderate in 39% and severe in 40% of the patients. Cholecystectomy was performed in 95% of the patients. The overall complications rate was 43% and the mortality was 3.6%. The Logistic Regression model isolated 3 risk factor for severe complication: ASA>II, cancer without metastases and moderate to severe renal disease. The failure-to-rescue (8%) was higher in patients with non-surgical treatment (32% vs. 7%; P=.002). After Propensity Score Matching, the number of severe complications was similar between Surgical and Non-Surgical treatment groups (48.5% vs 62.5%; P=.21). Conclusions: The recommended treatment for acute calculous cholecystitis is the laparoscopic cholecystectomy. Only three risk factors from the Tokyo Guidelines list appeared as independent predictors of severe complications. The failure-to-rescue is higher in non-surgically treated patients. (AU)

Suggested use of empirical antibiotics in acute cholecystitis based on bile microbiology and antibiotic susceptibility.

BACKGROUND: Bacterial infection is common in acute cholecystitis (AC). To identify appropriate empirical antibiotics, we investigated AC-associated microorganisms and their susceptibilities to antibiotics. We also compared preoperative clinical findings of patients grouped according to specific microorganisms. METHODS: Patients who underwent laparoscopic cholecystectomy for AC between 2018 and 2019 were enrolled. Bile cultures and antibiotic susceptibility tests were performed, and clinical findings of patients were noted. RESULTS: A total of 282 patients were enrolled (147 culture-positive and 135 culture-negative). The most frequent microorganisms were Escherichia (n = 53, 32.7%), Enterococcus (n = 37, 22.8%), Klebsiella (n = 28, 17.3%), and Enterobacter (n = 18, 11.1%). For Gram-negative microorganisms, second-generation cephalosporin (cefotetan: 96.2%) was more effective than third-generation cephalosporin (cefotaxime: 69.8%). Vancomycin and teicoplanin (83.8%) were the most effective antibiotics for Enterococcus. Patients with Enterococcus had higher rates of CBD stones (51.4%, p = 0.001) and biliary drainage (81.1%, p = 0.002), as well as higher levels of liver enzymes, than patients with other microorganisms. Patients with ESBL-producing bacteria had higher rates of CBD stones (36.0% vs. 6.8%, p = 0.001) and biliary drainage (64.0% vs. 32.4%, p = 0.005) than those without. DISCUSSION: Preoperative clinical findings of AC are related to microorganisms in bile samples. Periodic antibiotic susceptibility tests should be conducted to select appropriate empirical antibiotics.

Clinical significance of preoperative antibiotic use in mild to moderate acute inflammatory gallbladder disease: A randomized controlled trial.

BACKGROUND: Many patients receive empirical antibiotics for the prevention of postoperative infectious complications following cholecystectomy due to acute cholecystitis (AC). The purpose of this study was to investigate the clinical significance of preoperative antibiotics in mild to moderate AC patients undergoing emergency laparoscopic cholecystectomy. METHODS: This was a double-blind, placebo-controlled, randomized study. Patients with AC eligible for emergency laparoscopic cholecystectomy were randomly assigned to an antibiotic or a placebo group. Clinical outcomes including infectious complications were reviewed. RESULTS: An imputed per-protocol analysis of 234 patients showed that the postoperative infection rate was 8.6% (10 of 116 patients) in the antibiotic group and 7.6% (9 of 118 patients) in the placebo group (absolute difference, 1%; 95% CI: -8.1% to 6.1%; P = .815). Based on a noninferiority margin of 10%, the lack of preoperative antibiotic treatment was not associated with worse clinical outcomes than antibiotic treatment. Surgical site infection was the most common complication among the infectious complications, and there was no significant difference between the two groups (7.8% in the antibiotic group vs 7.6%, in the placebo group, P = .53). CONCLUSIONS: The absence of prophylactic antibiotics has no significant impact on the incidence of infectious complications in mild to moderated AC.

Acute Cholecystitis Associated with Eosinophilic Granulomatosis with Polyangiitis That Responded to Glucocorticoid Therapy.

Eosinophilic granulomatosis with polyangiitis (EGPA) is a systemic disorder characterized by tissue eosinophilic infiltration and vasculitis. Although EGPA causes multiple organ damage, it causes cholecystitis less frequently. We herein report a case of acute cholecystitis associated with EGPA in which successful treatment with glucocorticoid therapy allowed surgery to be avoided. EGPA can present as acute cholecystitis. It is important not to overlook acute cholecystitis associated with EGPA in patients with abdominal pain with peripheral eosinophilia. Furthermore, in cases of mild cholecystitis associated with EGPA that are diagnosed preoperatively, cholecystectomy might be avoided with conservative glucocorticoid treatment.

A case report and review of acute cholangitis with septic shock induced by Edwardsiella tarda.

BACKGROUND: Edwardsiella tarda (E. tarda) is a gram-negative facultative anaerobic bacterium. Gastroenteritis is the most common manifestation of E. tarda infection. However, parenteral infections can occur in immunodeficient hosts, as well as hepatobiliary diseases, malignancies, and/or diabetes. The prognosis of sepsis caused by E. tarda is very worse, with a mortality rate of 38%. We report the occurrence of acute cholecystitis with septic shock and E. tarda bloodstream infection. CASE PRESENTATION: A 64-year-old male with acute cholecystitis secondary to hepatitis B virus infection showed fever and sudden upper abdominal pain. On arrival, right upper abdominal pain, nausea, vomiting, fever, and jaundice were observed. Computed tomography showed common bile duct stones and gallbladder stones. Choledocholithiasis with acute cholangitis was diagnosed and treated surgically. Due to septic shock, a blood culture was assessed showing E. tarda as the main pathogen. Choledocholithotomy, T-tube drainage, cholecystectomy, and intravenous antibiotic treatment after the operation. The patient recovered smoothly after the operation. CONCLUSIONS: Although E. tarda infection is extremely rare, it can cause rapid episodes of rapidly progressive and life-threatening disease, as well as intestinal and parenteral infections. If necessary, early surgical treatment of parenteral infection should be considered and antibiotics should be used in time.

Aplicación de «Point-Of-Care-Ultrasound» (POCUS) en Atención Geriátrica a Domicilio (AGD): a propósito de un caso / Application of “Point-Of-Care-Ultrasound” (POCUS) in a Geriatric Home Care (AGD): A case report

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Association between glucagon-like peptide-1 receptor agonists and biliary-related diseases in patients with type 2 diabetes: A nationwide cohort study.

STUDY OBJECTIVE: Clinical trials have suggested that glucagon-like peptide-1 receptor agonists (GLP-1RAs) may be associated with a higher risk of biliary-related diseases in patients with type 2 diabetes. Limited real-world studies have examined the comparative biliary safety of GLP-1RAs versus other antihyperglycemic drugs. We aimed to estimate the comparative risk of biliary-related diseases between GLP-1RAs and sodium glucose cotransporter 2 inhibitors (SGLT2is), which are indicated for patients with similar diabetes severity in Taiwan. DESIGN: Retrospective cohort study. DATA SOURCE: Taiwan National Health Insurance Database during 2011 to 2018. PATIENTS: Patients with type 2 diabetes who initiated GLP-1RAs or SGLT2is. INTERVENTION: GLP-1RAs versus SGLT2is. MEASUREMENTS AND MAIN RESULTS: We used an on-treatment approach to examine the effect of continuous use and an intention-to-treat approach to assess the effect of initiation of GLP-1RAs versus SGLT2is. We used Coxregression models to estimate the hazard ratios (HRs) and 95% confidenceintervals (CIs) for the composite hospitalized biliary-related diseases, including acute cholecystitis or cholecystectomy, choledocholithiasis, and acute cholangitis, after matching each GLP-1RA initiator to up to 10 SGLT2iinitiators using propensity scores (PSs). Among 78,253 PS-matched patients, GLP-1RA use was associated with a numerically higher risk of biliary-related diseases versus SGLT2i use in the on-treatment analysis, with an HR of 1.20 (95% CI, 0.93-1.56) for the composite outcome, an HR of 1.22 (95% CI, 0.92-1.62) for acute cholecystitis or cholecystectomy, an HR of 1.20 (95% CI, 0.69-2.07) for choledocholithiasis, and an HR of 1.14 (95% CI,0.82-2.42) for acute cholangitis. The HRs were more pronounced in theintention-to-treat analysis (1.27 [95% CI, 1.05-1.53] for the composite outcome, 1.29 [95% CI, 1.04-1.58] foracute cholecystitis or cholecystectomy, 1.74 [95% CI, 1.23-2.46] for choledocholithiasis, and 1.31 [95% CI, 0.89-1.94] for acute cholangitis). The increased risk of the composite outcome associated with GLP-1RAs was more evident in patients aged 〉60 years, women, and 120 days after treatment initiation. Liraglutide, but not dulaglutide, was associated with an elevated risk. CONCLUSIONS: GLP-1RAs might be associated with an elevated risk of biliary-related diseases compared to SGLT2is in Asian patients with type 2 diabetes.

Surgical Infection Society Guidelines for Antibiotic Use in Patients Undergoing Cholecystectomy for Gallbladder Disease.

Background: Manifestations of gallbladder disease range from intermittent abdominal pain (symptomatic cholelithiasis) to potentially life-threatening illness (gangrenous cholecystitis). Although surgical intervention to treat acute cholecystitis is well defined, the role of antibiotic administration before or after cholecystectomy to decrease morbidity or mortality is less clear. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee convened to develop guidelines for antibiotic use in patients undergoing cholecystectomy for gallbladder disease to prevent surgical site infection, other infection, hospital length of stay, or mortality. PubMed, Embase, and the Cochrane Database were searched for relevant studies. Evaluation of the published evidence was performed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. Using a process of iterative consensus, all authors voted to accept or reject each recommendation. Results: We recommend against routine use of peri-operative antibiotic agents in low-risk patients undergoing elective laparoscopic cholecystectomy. We recommend use of peri-operative antibiotic agents for patients undergoing laparoscopic cholecystectomy for acute cholecystitis. We recommend against use of post-operative antibiotic agents after elective laparoscopic cholecystectomy for symptomatic cholelithiasis. We recommend against use of post-operative antibiotic agents in patients undergoing laparoscopic cholecystectomy for mild or moderate acute cholecystitis. We recommend a maximum of four days of antibiotic agents, and perhaps a shorter duration in patients undergoing cholecystectomy for severe (Tokyo Guidelines grade III) cholecystitis. Conclusions: This guideline summarizes the current Surgical Infection Society recommendations for antibiotic use in patients undergoing cholecystectomy for gallbladder disease.

Acute Cholecystitis: A Review.

Importance: Gallbladder disease affects approximately 20 million people in the US. Acute cholecystitis is diagnosed in approximately 200 000 people in the US each year. Observations: Gallstone-associated cystic duct obstruction is responsible for 90% to 95% of the cases of acute cholecystitis. Approximately 5% to 10% of patients with acute cholecystitis have acalculous cholecystitis, defined as acute inflammation of the gallbladder without gallstones, typically in the setting of severe critical illness. The typical presentation of acute cholecystitis consists of acute right upper quadrant pain, fever, and nausea that may be associated with eating and physical examination findings of right upper quadrant tenderness. Ultrasonography of the right upper quadrant has a sensitivity of approximately 81% and a specificity of approximately 83% for the diagnosis of acute cholecystitis. When an ultrasound result does not provide a definitive diagnosis, hepatobiliary scintigraphy (a nuclear medicine study that includes the intravenous injection of a radiotracer excreted in the bile) is the gold standard diagnostic test. Following diagnosis, early (performed within 1-3 days) vs late (performed after 3 days) laparoscopic cholecystectomy is associated with improved patient outcomes, including fewer composite postoperative complications (11.8% for early vs 34.4% for late), a shorter length of hospital stay (5.4 days vs 10.0 days), and lower hospital costs. During pregnancy, early laparoscopic cholecystectomy, compared with delayed operative management, is associated with a lower risk of maternal-fetal complications (1.6% for early vs 18.4% for delayed) and is recommended during all trimesters. In people older than 65 years of age, laparoscopic cholecystectomy is associated with lower mortality at 2-year follow-up (15.2%) compared with nonoperative management (29.3%). A percutaneous cholecystostomy tube, in which a drainage catheter is placed in the gallbladder lumen under image guidance, is an effective therapy for patients with an exceptionally high perioperative risk. However, percutaneous cholecystostomy tube placement in a randomized trial was associated with higher rates of postprocedural complications (65%) compared with laparoscopic cholecystectomy (12%). For patients with acalculous acute cholecystitis, percutaneous cholecystostomy tube should be reserved for patients who are severely ill at the time of diagnosis; all others should undergo a laparoscopic cholecystectomy. Conclusions and Relevance: Acute cholecystitis, typically due to gallstone obstruction of the cystic duct, affects approximately 200 000 people in the US annually. In most patient populations, laparoscopic cholecystectomy, performed within 3 days of diagnosis, is the first-line therapy for acute cholecystitis.

Effectiveness of Short-Course Antibacterial Therapy on Acute Cholecystitis after Successful Percutaneous Transhepatic Gallbladder Drainage: A Retrospective Study.

Background: The aim of this study was to evaluate the outcome of short- and long-course antibacterial therapy after successful percutaneous transhepatic gallbladder drainage in patients with mild to moderate acute cholecystitis. Patients and Methods: We compared the effect of short-course antibacterial therapy retrospectively (SCT; ≤3 days) and long-course antibacterial therapy (LCT; ≥4 days) after successful drainage of acute cholecystitis. The study outcomes involved three-month recurrence and 30-day mortality rates, as well as hospital stay length. Results: We included 132 patients with acute cholecystitis who underwent successful percutaneous transhepatic gallbladder drainage (PTGBD) and excluded 174 patients. We then grouped these patients (78 males and 54 females), according to the duration of antibacterial therapy. Short- and long-course antibacterial therapy groups comprised 54 (40.9%) and 78 (59.1%) patients, respectively. We did not observe significant differences in the three-month recurrence (p = 0.761) and 30-day mortality (p = 0.151) rates between these groups and observed only two deaths in the LCT group. The median hospital stay for the SCT group was six days (interquartile range [IQR], 5-7 days), compared with nine days (IQR, 8-10 days) for the LCT group (p < 0.001). Conclusions: A duration of three days or less of antibacterial therapy may be adequate for patients with mild to moderate acute cholecystitis after successful PTGBD.

THE USE OF MICROBIOLOGICAL AND LABORATORY DATA IN THE CHOICE OF EMPIRICAL ANTIBIOTIC THERAPY IN PATIENTS UNDERGOING LAPAROSCOPIC CHOLECYSTECTOMY - THE ROLE OF LOCAL ANTIBIOGRAMS.

Antibiotic therapy is indicated during acute cholecystitis. However, in the treatment of uncomplicated cholelithiasis, prophylactic use of antibiotics is controversial. Microbiological and laboratory data are the basis for the choice of antibiotic treatment. However, monitoring and updating local antibiograms is important because they ensure effective therapy in the given clinical environment. The study included 110 consecutive patients who underwent laparoscopic cholecystectomy, divided into the group of uncomplicated cholelithiasis (n=60) and the group of acute cholecystitis (n=50). Preoperative data included age, sex, body mass index, leukocytes, C-reactive protein, and ultrasound examination. Bile samples for bacteriological testing were obtained under aseptic conditions during the surgery. Cultures were evaluated for aerobic, anaerobic and fungal organisms using routine tests. After the surgery, gallbladder specimens were sent for histopathological examination. In the group of uncomplicated cholelithiasis, 6/60 positive samples were found, and in the group of acute cholecystitis, there were 25/50 positive microbiological findings. Citrobacter sp. and Enterococcus faecalis predominated in the group of uncomplicated cholelithiasis, and Escherichia coli, Enterococcus faecalis, Proteus mirabilis and Citrobacter sp. in the group of acute cholecystitis. Antibiotics were administered to 49/50 patients with acute cholecystitis and to 32/60 patients with uncomplicated cholelithiasis. Cefazolin was the most frequently used antibiotic and also the most resistant antibiotic. To conclude, the administration of antibiotics in elective patients is not justified. The results of this study indicate that third-generation cephalosporin or ciprofloxacin + metronidazole should be administered in mild and moderate acute cholecystitis, and fourth-generation cephalosporin + metronidazole in severe acute cholecystitis in this local setting. The appropriate use of antibiotic agents is crucial and should be integrated into good clinical practice and standards of care.

Is combined rather than single antibiotic therapy actually reasonable in patients with acute calculous cholecystitis?

OBJECTIVE: Acute calculous cholecystitis (AC) is a frequently encountered emergency surgery disease and its standard treatment is cholecystectomy. In patients with high risk in surgery, antibiotic treatment (AT) is important. In routine clinical practices, antibiotics are frequently used either as single or in combination in the treatment of AC. This study examined whether or not combined antibiotic treatment (CAT) had superiority over single antibiotic treatment (SAT) in AC. METHODS: Patients with cholecystitis who received treatment in the period of 2016-2019 were retrospectively examined. The treatment procedures applied, patient findings, and laboratory data were analyzed using relevant statistical software. The patients were categorized into groups based on the treatment approaches applied, and the effects of SAT and CAT on infection parameters were analyzed. RESULTS: In all, 184 patients received treatment for AC, with a mean age of 57.7, and the female-to-male ratio was 77:107. Of these, 139 patients received SAT and 45 received CAT. No significant difference was found in terms of effectiveness between the SAT and CAT in the patients who received early cholecystectomy treatment and those who received medical treatment with noninvasive intervention. CONCLUSIONS: In patients with AC, antibiotics are commonly used either as single or in combination for prophylaxis and therapeutic purposes. As no significant difference was observed between single and combined use in terms of treatment effectiveness and hospitalization duration, CAT is not recommended due to its possibility of allergic side effects, toxicity, and cost-increasing effects.

Is combined rather than single antibiotic therapy actually reasonable in patients with acute calculous cholecystitis?

SUMMARY OBJECTIVE Acute calculous cholecystitis (AC) is a frequently encountered emergency surgery disease and its standard treatment is cholecystectomy. In patients with high risk in surgery, antibiotic treatment (AT) is important. In routine clinical practices, antibiotics are frequently used either as single or in combination in the treatment of AC. This study examined whether or not combined antibiotic treatment (CAT) had superiority over single antibiotic treatment (SAT) in AC. METHODS Patients with cholecystitis who received treatment in the period of 2016-2019 were retrospectively examined. The treatment procedures applied, patient findings, and laboratory data were analyzed using relevant statistical software. The patients were categorized into groups based on the treatment approaches applied, and the effects of SAT and CAT on infection parameters were analyzed. RESULTS In all, 184 patients received treatment for AC, with a mean age of 57.7, and the female-to-male ratio was 77:107. Of these, 139 patients received SAT and 45 received CAT. No significant difference was found in terms of effectiveness between the SAT and CAT in the patients who received early cholecystectomy treatment and those who received medical treatment with noninvasive intervention. CONCLUSIONS In patients with AC, antibiotics are commonly used either as single or in combination for prophylaxis and therapeutic purposes. As no significant difference was observed between single and combined use in terms of treatment effectiveness and hospitalization duration, CAT is not recommended due to its possibility of allergic side effects, toxicity, and cost-increasing effects.

Acute Cholecystitis, Sepsis, and Disseminated Intravascular Coagulation Caused by Edwardsiella tarda in an Elderly Woman.

Edwardsiella tarda is a gram-negative bacillus associated with gastrointestinal diseases. It is rarely responsible for sepsis; however, the fatality is very high. Only two cases of E. tarda infections in patients over 90 years of age have been reported; these are not cases of sepsis associated with acute cholecystitis. We report a case of acute cholecystitis, sepsis, and disseminated intravascular coagulation (DIC) caused by E. tarda in a super-elderly woman aged over 90 years. There could be a possibility for recovery from sepsis and DIC if antimicrobial treatment responsiveness is ensured in the super-elderly.