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Perforated and gangrenous appendicitis: an analysis of antibiotic failures
Abstract:
The relationships between resistant pathogens, serum levels of gentamicin, and the outcomes of gangrenous or perforated appendicitis were analyzed in 147 patients. Failure to cure the infection occurred significantly more frequently among patients treated with cefoperazone or cefamandole than among those treated with clindamycin and gentamicin in combination. The failures were associated with recovery of resistant Bacteroides fragilis from intraoperative cultures. Pseudomonas species were also associated with failures, their in vitro susceptibility not correlating with clinical cure. Patients with gentamicin peak serum levels of less than 6 micrograms/ml in the first three days were not more likely to be associated with failure than were patients with higher levels. These clinical observations indicate that antibiotic therapy of intra-abdominal sepsis should include antibiotics with in vitro activity against B fragilis and that precise adjustments of gentamicin levels may not improve outcome. In addition, Pseudomonas species may play a significant role in some of these infections.
Insights
Antibiotic choice significantly impacts appendicitis outcomes. Clindamycin and gentamicin combination therapy is more effective than cefoperazone or cefamandole for treating resistant pathogens like Bacteroides fragilis.
Area of Science:
- Infectious Diseases
- Clinical Microbiology
- Surgical Infections
Background:
- Appendicitis, particularly gangrenous or perforated types, presents a significant challenge due to potential for resistant bacterial infections.
- Empirical antibiotic selection is crucial for managing intra-abdominal sepsis, but optimal regimens remain debated.
Purpose of the Study:
- To analyze the relationship between resistant pathogens, gentamicin serum levels, and treatment outcomes in patients with gangrenous or perforated appendicitis.
- To evaluate the efficacy of different antibiotic regimens against specific resistant bacteria implicated in appendicitis complications.
Main Methods:
- Retrospective analysis of 147 patients with gangrenous or perforated appendicitis.
- Correlation of treatment outcomes (cure rates) with causative pathogens (including resistant strains like Bacteroides fragilis and Pseudomonas species) and gentamicin serum levels.
- Comparison of clinical outcomes between patients receiving clindamycin-gentamicin combination versus cefoperazone or cefamandole.
Main Results:
- Higher infection cure rates were observed with clindamycin-gentamicin combination therapy compared to cefoperazone or cefamandole.
- Treatment failures were significantly associated with the isolation of resistant Bacteroides fragilis from intraoperative cultures.
- Pseudomonas species were also linked to treatment failures, irrespective of in vitro susceptibility.
- Gentamicin peak serum levels below 6 mcg/ml in the first three days did not correlate with increased likelihood of treatment failure.
Conclusions:
- Antibiotic regimens for intra-abdominal sepsis, including appendicitis, must incorporate agents with proven in vitro activity against Bacteroides fragilis.
- Optimizing gentamicin serum levels may not be a critical factor in improving clinical outcomes for these infections.
- Pseudomonas species warrant consideration as significant contributors to treatment failures in complex appendicitis cases.