Abstract
Although single antimicrobials with broad-spectrum aerobic and anaerobic coverage are effective in patients with appendicitis, many general surgeons continue to use multiple agents. A prospective, doubleblind, randomized trial was designed to detect any clinical correlate of in vitro susceptibility advantage of multiple antimicrobials as adjunctive therapy for 114 patients undergoing operation for complicated appendicitis. There was clinical resolution of intraabdominal infections with no occurrence of postoperative infectious complications in 90% (36 of 40) of the cefotetan group and 86% (31 of 36) of the clindamycin/amikacin group (p=0.11). The number of patients who had changes in antibiotic therapy due to postoperative complications was higher in the clindamycin/amikacin group: five (12.5%), compared to one (2.8%) in the cefotetan group (p=0.07). Although Bacteroides fragilis group organisms resistant to cefotetan were identified, none was responsible for the postoperative infections. Adverse drug events in 28% of the cefotetan group and 26% of the clindamycin/amikacin group consisted primarily of transient elevations of liver function tests. Monotherapy with a second-generation, broad-spectrum cephalosporin, such as cefotetan, given twice a day is an economical and effective adjunctive regimen in patients with complicated appendicitis for which operation is the definitive treatment. Aminoglycosides and other, more potent antimicrobials should be reserved for resistant organisms or nosocomial infections.
Résumé
Bien qu'un seul antibiotique avec un large spectre couvrant les germes aérobies et anaérobies soit reconnu comme efficace dans l'appendicite, beaucoup de chirurgiens continuent d'utiliser une polyantibiothérapie. Dans un essai contrôlé en double aveugle, nous avons testé la corrélation clinique avec la sensibilité in vitro d'une association de plusieurs antibiotiques comme traitement complémentaire chez 114 patients ayant eu une appendicite compliquée. Quatre-vingt pour-cent (36/40) des patients ayant eu du céfotétan et 86% (31/36) des patients ayant eu l'association clindamycine/amikacíne n'ont pas eu de complications infectieuses postopératoires (p=0.11). II a été nécessaire de changer les antibiotiques en raison d'une complication postopératoire plus souvent chez les patients ayant eu l'association clindamycine/amikacine, 5 (12%) comparé à 1 (2%) dans le groupe céfotétan (p=0.07). On a identifié des organismes Bacteroides fragilis résistants au céfotétane mais aucun n'était responsable d'infection postopératoire. II y a eu des effets secondaires non désirables, essentiellement une perturbation des tests de la fonction hépatique, chez 28% et chez 26% des patients ayant pris respectivement du céfotétane et l'assocíation clindamycine/amikacine, respectivement. Une monothérapie avec une céphalosporine de deuxième génération du type céfotétan, donnée deux fois par jour, est ffficace et économique dans le traitement de l'appendicite compliquée mais opéréc. Les aminosides et les autres antibiotiques plus puissants doivent être réservés pour les germes résistants ou les infections nosocomiales.
Resumen
Aunque los antibióticos únicos de amplio espectro de cobertura aeróbica y anaeróbica son eficaces en la apendicitis, muchos cirujanos continúan utilizando agentes múltiples. Se diseñó un ensayo clínico prospectivo, doble ciego y aleatorizado con el fin de correlacionar la susceptibilidad in vitro de agentes antimicrobianos múltiples como terapia adyuvante en el manejo de 114 pacientes sometidos a operación por apendicitis complicada. 90% (36/40) de los pacientes en el Grupo de cefotetan y 86% (31/36) en el Grupo que recibió clindamicina/amikacina tuvieron resolución clínica de sus infecciones intraabdominales sin recurrencia de complicaciones sépticas postoperatorias (P=0.11). El número de pacientes que tuvieron cambio en la terapia antibiótica por complicaciones postoperatorias fue más alto en el Grupo clindamicina/amikacina, 5 (12%) comparados con 1 (2%) en el Grupo cefotetan (P=0.07). Aunque se identifícaron microorganismos del Grupo de los Bacteroides fragilis resistentes a cefotetan, ninguno fue responsable de infecciones postoperatorias. Se presentaron reacciones farmacológicas adversas en 28% del Grupo cefotetan y en 26% del Grupo clindamicina/amikacina, las cuales consistieron primordialmente en elevaciones pasajeras de los valores de las pruebas de función hepática. La monoterapia con una cefalosporina de amplio espectro de segunda generación, tal como el cefotetan, administrado en dos dosis diarias constituye un régimen económico y eficaz en la apendicitis complicada en la cual la cirugía representa el tratamiento definitivo. Los aminoglucósidos y otros agentes antimicrobianos más potentes deben ser reservados para el tratamiento de infecciones nosocomiales por microorganismos resistentes.
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Hopkins, J.A., Wilson, S.E. & Bobey, D.G. Adjunctive antimicrobial therapy for complicated appendicitis: Bacterial overkill by combination therapy. World J. Surg. 18, 933–938 (1994). https://doi.org/10.1007/BF00299113
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DOI: https://doi.org/10.1007/BF00299113