Antibacterial Therapy of Acute Cholecystitis and Cholangitis (According to Tokyo Guidelines2013)

Abstract

Gallstone disease and inflammatory diseases of the biliary tract is a serious problem in health protection in developed countries. Acute cholecystitis is the third major cause of the urgent hospitalization to the surgical department, and its incidence increases with age. Acute cholecystitis is defined as an acute inflammation of the gallbladder, which is often observed in the presence of gallstones. There are a variety of methods for acute cholecystitis treatment in different medical centers around the world. In some hospitals, mainly in the USA, the most common method of treatment is early laparoscopic cholecystectomy within 72 hours from the onset of symptoms or hospitalization. However, the treatment of acute cholecystitis is conservative (bowel rest, intravenous administration of fluids and antibiotics) in the UK and many other European countries, laparoscopic cholecystectomy is delayed in this case. The causes of delayed surgery are different between institutions and are based on the assumption about the reduction of complications during surgery, information about available beds and surgery schedule, costs and hospital policy. Over the years this approach has shown a relatively low rate of complications, mainly those related to bile duct injury, — < 1 %. But current approaches based on the principles of evidence-based medicine have proven the safety and effectiveness of early laparoscopic cholecystectomy that is the similar to delayed one. In the last five years, there were developed several guidelines on the management of infection of the biliary tract. They include the Surviving Sepsis Campaign, 2008, and recommendations for the treatment of complicated intraabdominal infections, that have been developed by Surgical Infection Society of North America, and the Infectious Diseases Society of America, 2010. In addition, new drugs and dosing regimens have been approved, including schemes with higher doses for piperacillin/tazobactam, meropenem, levofloxacin and doribax. The issues of pharmacokinetics and pharmacodynamics of antibacterial drugs have been clarified. Since the release of Tokyo Guidelines 2007, the emergence of antibacterial resistance among clinical strains of enterobacteria in patients with community-acquired intraabdominal infection has been reported, and it led to the appearance of extended spectrum beta-lactamase and carbapenems. Finally, the updated Tokyo Guidelines 2013 revised the diagnostic criteria and severity of acute cholecystitis and cholangitis according to the new pattern of antibiotic therapy. Antibiotics should be used wisely in antimicrobial therapy in each institution, region and country. The recent global spread of antibiotic resistance gives us a warning in the modern practice. Tokyo Guidelines 2013 provide practical guidance for physicians and surgeons involved in the treatment of community-acquired and hospital acute biliary infection. Much remains uncertain in this view. Continuous monitoring of local resistance to antibiotics and further studies in acute cholecystitis and cholangitis should be justified.