empiric antimicrobial therapy for different types of gall...
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Empiric Antimicrobial therapy for different types of Gall bladder pathologies based on
Bacterial etiology
S.Rohra**, KP Balsara*, AA Poojary**, Vardhini W*, T.E.Udwadia*, N.Doctor*, K.Kapadia
*Dept of Surgery **Dept. of Pathology & Microbiology
Breach Candy Hospital Trust
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Introduction
Laura M. Stintont et al, Gut and Liver, Vol. 6, No. 2, April 2012, 172-187
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Introduction
Symptomatic Cholelithiasis - Cholecystectomy
Bactobilia 20 - 46 %
Varies with different gall bladder pathologies
Relation ship between bactobilia, wound infection and post operative wound complication
Post-operative wound infection 7-20 %
Mohammad Moazeni-Bistgani, et al. Acta Medica Iranica, 2013; 51(11): 779-783 A Suri, et al. The Internet Journal of Surgery Volume 22 Number 2 Vasitha Abeysuriya, et al. Hepatobiliary Pancreat Dis Int 2008; 7: 633-637 Faraz Ahmad,et al . International Journal of Scientific Study | July 2014 | Vol 2 | Issue 4
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Objective of the study
To identify aerobic & anaerobic bacteria in patients with gall bladder disease
Perform susceptibility tests
Formulate an empiric policy for antimicrobials agents
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Ethics & Disclosures
The study was approved by the Institutional Review Board & the Ethics Committee at Breach Candy Medical Research Center (BCMRC)
Grant for conducting the study was given by BCMRC
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Inclusion Criteria
All cases where cholecystectomy was performed for gall bladder disease due to any cause
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Diagnosis of cholecystitis
1. Acute Cholecystitis was diagnosed by
Clinical evaluation
WBC count >10,000
elevated CRP
USG/ CT scan / MRCP
CBD stones diagnosed on MRCP / ERCP
2. Acalculous cholecystitis was diagnosed when inflammatory existed without stones
3. Chronic cholecystitis, when pts. had recurrent attacks of pain and imaging was s/o of chronic disease
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Material and Methods
Prospective study: April 2014 to May 2015
Samples accepted : Bile
Pus
Swab
Demographic and clinical details of the patient was recorded
from GB
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Materials and Methods
Aerobic culture
Specimens were inoculated onto 5% sheep blood, chocolate and MacConkey agar plates for aerobic and facultative organisms.
The plates were incubated aerobically (MacConkey agar) or under 5% C02 (5% sheep blood and chocolate agars) at 37C and examined at 24 and 48 h.
Culture positive samples were processed using the automated Vitek 2 Compact system for identification & susceptibility
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Materials and Methods
Anaerobic culture
Specimens were processed on SBA & anaerobic agar
The plates were incubated in anaerobic pouches with reagent & indicator (Merck mini) & anaerobic jars (Merck)
All plates were incubated at 37 C in a CO2 environment and examined at 72 hrs.
For culture positive samples , smear & aero tolerance was performed
Aero tolerance negative cultures were put for identification using the anaerobic (ANC) cards on Vitek 2 Compact
Susceptibility testing were performed using standard methods using Minimal Inhibitory Concentration (MIC) methods
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Results & Discussion
Total of 91 specimens were received and processed
50 bile
36 swab from gall bladder
5 pus
Study group : 46 M, 45 F
Mean age : 56.1 yrs.
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Results & Discussion
Overall, 42% (38/91) specimens were culture positive
73% (28/71) specimens were monomicrobial
27% (10/38) specimens had >=2 organisms
Isolates
47 aerobic organisms & 2 anaerobic organisms
Anaerobes in 2 pts. Prevotella & Bacteroides sp.
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Gram negative bacilli (N=35)
0
5
10
15
20
25
E.coli Klebsiella Enterobacter Kluyvera Serratia
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% Susceptibility of Gram Negative Bacilli
21
35
59
38
50
68
56
29
76
74
79
94
82
68
0 10 20 30 40 50 60 70 80 90 100
Ampicillin
Cefuroxime
Cefipime
Ceftriaxone
Amox+ Clav
Cefo+ Sulbactum
Pip+Tazo
Ciprofloxacin
Gentamicin
Amikacin
Ertapenam
Imipenam
Meropenam
Tigecyline
Options for Empiric therapy: Amoxicillin clavulanic acid Gentamicin Piperacillin Tazobactam
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Gram Positive Cocci (n= 12)
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Nu
mb
ers
of
iso
late
s
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% Susceptibility of Gram Positive Cocci
0
0
0
50
80
100
100
100
100
100
100
100
50
100
100
100
100
100
0 20 40 60 80 100 120
Ampicillin
Amox+ Clav
Ceftriaxone
Ciprofloxacin
Gentamicin
Linezolid
Tecioplanin
Vancomycin
Tigecycline
Streptococci
Enterococci
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Results & Discussion
Clinical diagnosis Nos. AMA (%)
Culture positivity
(%)
Reference
Acute Calculous cholecystitis 56 75 41 32% MR Capoor 2008, Braz J
Infect Dis
Chronic Calculous cholecystitis 13 14 46
Asymptomatic cholelithiasis 10 0 0
With Gangrenous cholecystitis 5 50 80
Associated CBD calculus 3 0 66 52% MR Capoor 2008, Braz J
Infect Dis
With Perforation of GB* 2 100 100
Acalculous cholecystitis 1 0 0
Xanthogranulomatous cholecystitis
1 100 100
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Risk Stratification
Type 1 Type 2 Type 3 E.g.
Health Care Contact No Yes Prolonged Hospitalization
Procedures No Minimum
Major invasive Procedures
Invasive bilary procedures,
stenting
Antibiotic Rx History Patients
No in last 90 days No in last 90 days Repeat multiple
antibiotics Oral or IV
Characteristics Young No co-
morbid conditions.
Elderly Few Co-morbid
conditions
Immunocompromised, or with many co-morbid conditions
DM,CKD, immunosuppre
ssion
Causative Pathogen could be
Susceptible to Common narrow
spectrum antibiotics
ESBLs ESBLs / NDM/ VRE
/MRSA
Carmelli Score A.Salvovici et al Therapeutics, Pharmacology & Clinical Toxicology 2009
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Limitations of the study
Sample small size
Swabs from gall bladder
Anaerobes specific media
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For different pathologies: different rates of bactobilia
Empiric antibiotic : risk stratification
Gram negatives were commonly isolated followed by gram positive and anaerobes.
60% of GNB were ESBL. 20% were Carbapenamase producers
Empiric antibiotic : Local susceptibility pattern
Among Gram positive, Enterococcus outnumbered Streptococci
Empiric antibiotic : common organism associated with disease
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Antimicrobial Stewardship Policy
For prophylaxis : Cefazolin/Cefuroxime/Aminoglycosides (single dose)
For empiric therapy:
o Gentamicin o Piperacillin Tazobactam o Amoxicillin clavulanic acid and gentamicin
For de-escalation/targeted therapy:
Based on culture results
Carbapenems should be reserved for critically ill patients
Fluroquinolones no role to play in treatment of biliary pathology
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