Rational Initial Antibacterial Therapy in Multimodality Therapy of Patients with Diffuse Purulent Peritonitis
Patients and Methods. The results of treatment of 106 patients, operated on for a diffuse purulent peritonitis, are adduced. The age of the patients varied from 18 to 90 years old. The patients were managed from 2000 to 2012. Index of abdominal cavity of all the patients was more than 13 points.
All the patients had complex treatment with the method of laparostomy. The intra-abdominal pressure was not more then 8–10 mm of mercury column or 11–14 cm of water column. In the postoperative period staged sanations of the abdominal cavity were performed until complete peritonitis stopping. The interval between staged sanations was from 24 to 72 hours.
During the operation the patients were taken samples (biopsy, aspiration) with the further microbial analysis with the obligatory identification of microorganism and estimation of sensitivity of clinically significant aerobic strains to antibacterial drugs.
The Results and Consideration. The study proved the polymicrobial nature of acute diffuse purulent peritonitis.
The estimation of sensitivity of the seeded bacterial flora to antibiotic showed that in relation to aerobes the most effective is meropenem (94 % of positive results). In the range from 75 to 50 % were levofloxacin (72 %), amikacin (63 %), cefoperazone (61 %), ciprofloxacin (56 %), ceftazidime (55 %), cefepime (55 %), cefoperazone + sulbactam (54 %). The sensitivity of the seeded bacterial flora to antibiotic less than 50 % was noted with ceftriaxone (44 %) and amoxicillin in combination with clavulanic acid (44 %).
The absolute resistance of Streptococcus to amikacin, ciprofloxacin, ceftazidime, cefepime, ceftriaxone, and amoxicillin in combination with clavulanic acid was detected. And ceftazidime, cefepimeand amoxicillin in combination with clavulanic acid showed very low activity in relation Ps.aeruginosa.
Different schemes of initial empirical antibacterial therapy were applied to the106 patients with diffuse purulent peritonitis. The first group included 62 patients who were treated with the help of fluoroquinolones (levofloxacin, ciprofloxacin), cephalosporins of the 3rd — 4th generation (cefoperazone, ceftazidime, cefoperazone + sulbactam, ceftriaxone, cefepime), aminoglycosides (amikacin), semisynthetic inhibitor protected amino penicillin (amoxicillin in combination with clavulanic acid).
The second group included 44 patients who were treated with the help of carbapenems (meropenem). This group also included 13 patients who had initial empirical antibacterial therapy using medicines of different group. However, carbapenems had to be used instead due to low efficiency of the medicines. As mentioned before, all the patients had absolutely the same surgical treatment approach.
In the first group 6 patients (9.7 %) had complications of early postoperative period: 2 patients had anastomotic suture failure, 2 — eventration, 1 — acute perforation of intestinal ulcer and 1 — wound abscess. Duration of hospital stay was 14–76 days, which is 20.5 days on the average. 17 patients died. Lethality formed 27.4 %.
In the second group 31 patients were treated with the help of carbapenems. 3 patients (9.7 %) had complications of early postoperative period. In all cases wound abscess occurred. 3 patients (23.1 %) out of the 13 who had treatment with the help of carbapenems due to inefficiency of other antibiotics, had complications of early postoperative period: 2 patients had wound abscess, 1 — abdominal cavity abscess. In general in the second group complications of early postoperative period occurred in 6 patients (13.6 %). Duration of hospital stay was 10–30 days, which is 11.9 days on the average. 7 patients died. Lethality formed 15.9 %.
Conclusion. This study formed the basis for development of various antibacterial therapy schemes which are used with diffuse purulent peritonitis treatment. The study regards meropenem the best antibiotic in this case. It can be used alone as well as in combination with antianaerobic medicines (clindamycin). It is also possible to use a combination of levofloxacin with clindamycin or derivatives of imidazole (metronidazol, ornidazole), that create additional bactericidal concentrations in blood and peritoneum for anaerobic microflora suppressing. The first scheme correction should be done after 36–48 hours, repeated one — after 4–5 days after acute attack. During long antibiotics intake it is reasonable to include antifungal drugs (fluconazole), probiotics (lacium, bifiform, linex) and prebiotic (lactose, lactulose).
Cephalosporins of the 3rd — 4th generation, aminoglycosides and semisynthetic inhibitor protected amino penicillin are proved to be significantly less effective antibacterial medicines in treatment of diffuse purulent peritonitis.
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