충수염 예방적 항생제 [천공되지 않은 충수염과 천공된 충수염에서 예방적 항생제 사용]

 

천공되지 않은 충수염에서 항생제 선택

급성 충수염 환자는 IV 수액, 전해질 이상 시 교정, 통증 조절, 수술 전후 항생제 치료를 필요로 합니다. 예방적 항생제는 충수 절제술 후에 생길 수 있는 복강내 감염과 상처 감염을 예방하는데 중용합니다. 충수의 세균은 대장의 것을 반영하며 그람음성 호기성균과 혐기성균을 포함합니다.

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응급실에 내원한 이후 지체 없이 충수절제술을 위해 바로 수술방으로 이송될 예정인 환자는 초기 피부 절개 전 60분 이내에 예방적 항생제를 투여 받아야 합니다. 일반적으로 수술 상처 감염 예방을 위한 1회 수술 전 항생제 투약이 적절합니다.

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⊙ 세포시틴 2 g, IV

⊙ 세포테탄 2 g, IV

⊙ 세파졸린 2 g + 메트로니다졸 500 mg IV

⊙ 페니실린과 세팔로스포린에 알레르기가 있는 환자에서는

1) 클린다마이신 + 시플로플록사신 또는

2) 클린다마이신 + 레보플록사신 또는

3) 클린다마이신 + 겐타마이신 또는

4) 클린다마이신 + 아즈트레오남

Nature of operation	Common pathogens	Recommended antimicrobials	Usual adult dose*	Redose interval¶
Appendectomy‡
	Enteric gram-negative bacilli, anaerobes, enterococci	CefazolinΔ PLUS metronidazole (preferred)	For cefazolin: <120 kg: 2 g IV ≥120 kg: 3 g IV For metronidazole: 500 mg IV	For cefazolin: 4 hours For metronidazole: N/A
		OR cefoxitinΔ	2 g IV	2 hours
		OR cefotetanΔ	2 g IV	6 hours

* Parenteral prophylactic antimicrobials can be given as a single IV dose begun within 60 minutes before the procedure. If vancomycin or a fluoroquinolone is used, the infusion should be started within 60 to 120 minutes before the initial incision to have adequate tissue levels at the time of incision and to minimize the possibility of an infusion reaction close to the time of induction of anesthesia.

¶ For prolonged procedures (>3 hours) or those with major blood loss or in patients with extensive burns, additional intraoperative doses should be given at intervals one to two times the half-life of the drug.

Δ For patients allergic to penicillins and cephalosporins, clindamycin (900 mg) or vancomycin (15 mg/kg IV; not to exceed 2 g) with either gentamicin (5 mg/kg IV), ciprofloxacin (400 mg IV), levofloxacin (500 mg IV), or aztreonam (2 g IV) is a reasonable alternative. Metronidazole (500 mg IV) plus an aminoglycoside or fluoroquinolone are also acceptable alternative regimens, although metronidazole plus aztreonam should not be used, since this regimen does not have aerobic gram-positive activity.

◊ Morbid obesity, gastrointestinal (GI) obstruction, decreased gastric acidity or GI motility, gastric bleeding, malignancy or perforation, or immunosuppression.

§ Factors that indicate high risk may include age >70 years, pregnancy, acute cholecystitis, nonfunctioning gall bladder, obstructive jaundice, common bile duct stones, immunosuppression.

¥ Cefotetan, cefoxitin, and ampicillin-sulbactam are reasonable alternatives.

‡ For a ruptured viscus, therapy is often continued for approximately 5 days.

† Use of ertapenem or other carbapenems not recommended due to concerns of resistance.

** Due to increasing resistance of Escherichia coli to fluoroquinolones and ampicillin-sulbactam, local sensitivity profiles should be reviewed prior to use.

¶¶ In addition to mechanical bowel preparation, the following oral antibiotic regimen is administered: neomycin (1 g) plus erythromycin base (1 g) OR neomycin (1 g) plus metronidazole (1 g). The oral regimen should be given as 3 doses over approximately 10 hours the afternoon and evening before the operation. Issues related to mechanical bowel preparation are discussed further separately; refer to the UpToDate topic on overview of colon resection.

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수술 후 항생제 투여는 불필요합니다.

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밤에 내원하였고 다음 날 오전까지 충수절제술을 하지 않는다면 수술 전까지 아무 것도 하지 않기보다는 병원에 입원 후 가능한 빨리 IV 항생제를 투여해야 합니다. 이와 같은 상황에서는 항생제 선택을 위에 언급한 항생제 보다는 아래에 언급할 '천공된 충수염에서의 항생제'를 선택할 것을 제안합니다. 이 항생제들이 더 광범위 항생제입니다. 만일 피부 절개 60분 이내에 항생제를 투여받지 못하였다면 추가적 예방적 항새제가 필요할 수도 있습니다.

 

천공된 충수염에서 항생제 선택

천공된 충수염 환자에서 항생제 조합은 그람 음성막대균과 혐기성균에 대한 광범위 치료가 가능한 약제를 선택해야 합니다.

대부분 천공된 충수염 또는 충수 농양은 항생제 저항성 또는 치료 실패에 대한 위험 인자가 없는 mild-to-moderate community-acquired intra-abdominal infections에 해당됩니다. Streptococci, nonresistant Enterobacteriaceae, (in most cases) anaerobes의 항균 범위는 일반적으로 충분합니다.

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Empiric antibiotic regimens for low-risk community-acquired intra-abdominal infections in adults

	Dose
Single-agent regimen
Piperacillin-tazobactam*	3.375 g IV every 6 hours
Combination regimen with metronidazole*
One of the following:
Cefazolin	1 to 2 g IV every 8 hours
or
Cefuroxime	1.5 g IV every 8 hours
or
Ceftriaxone	2 g IV once daily
or
Cefotaxime	2 g IV every 8 hours
or
Ciprofloxacin	400 mg IV every 12 hours or 500 mg PO every 12 hours
or
Levofloxacin	750 mg IV or PO once daily
Plus:
Metronidazole¶	500 mg IV or PO every 8 hours

For empiric therapy of low-risk community-acquired intra-abdominal infections, we cover streptococci, Enterobacteriaceae, and anaerobes. Low-risk community-acquired intra-abdominal infections are those that are of mild to moderate severity (including perforated appendix or appendiceal abscess) in the absence of risk factors for antibiotic resistance or treatment failure. Such risk factors include recent travel to areas of the world with high rates of antibiotics-resistant organisms, known colonization with such organisms, advanced age, immunocompromising conditions, or other major medical comorbidities. Refer to other UpToDate content on the antimicrobial treatment of intra-abdominal infections for further discussion of these risk factors.

The antibiotic doses listed are for adult patients with normal renal function. The duration of antibiotic therapy depends on the specific infection and whether the presumptive source of infection has been controlled; refer to other UpToDate content for details.

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IV: intravenously; PO: orally.

* When piperacillin-tazobactam or one of the combination regimens in the table cannot be used, ertapenem (1 g IV once daily) is a reasonable alternative.

¶ For most uncomplicated biliary infections of mild to moderate severity, the addition of metronidazole is not necessary.

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중증인 천공된 충수염, 안 좋은 결과 또는 저항성 위험이 높은 천공된 충수염 환자에게는 광범위 예방적 항생제가 필요합니다. 우리는 일반적으로 enteric streptococci와 (대부분의 경우) 혐기성균에 대한 항균 범위가 있는 것을 포함하여 nonpseudomonal cephalosporins에 내성을 가진 Pseudomonas aeruginosa와 Enterobacteriaceae에 항균 범위가 있을 정도로 충분히 광범위한 그람 음성 항균력이 있는 약제를 포함합니다.

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Empiric antibiotic regimens for high-risk community-acquired intra-abdominal infections in adults

	Dose
Single-agent regimen
Imipenem-cilastatin	500 mg IV every 6 hours
Meropenem	1 g IV every 8 hours
Doripenem	500 mg IV every 8 hours
Piperacillin-tazobactam	4.5 g IV every 6 hours
Combination regimen with metronidazole
ONE of the following:
Cefepime	2 g IV every 8 hours
OR
Ceftazidime	2 g IV every 8 hours
PLUS:
Metronidazole	500 mg IV or PO every 8 hours

High-risk community-acquired intra-abdominal infections are those that are severe or in patients at high risk for adverse outcomes or antimicrobial resistance. These include patients with recent travel to areas of the world with high rates of antibiotics-resistant organisms, known colonization with such organisms, advanced age, immunocompromising conditions, or other major medical comorbidities. Refer to the UpToDate topic on the antimicrobial treatment of intra-abdominal infections for further discussion of these risk factors.

For empiric therapy of high-risk community-acquired intra-abdominal infections, we cover streptococci, Enterobacteriaceae resistant to third-generation cephalosporins, Pseudomonas aeruginosa, and anaerobes. Empiric antifungal therapy is usually not warranted but is reasonable for critically ill patients with an upper gastrointestinal source.

Local rates of resistance should inform antibiotic selection (ie, agents for which there is >10% resistance among Enterobacteriaceae should be avoided). If the patient is at risk for infection with an extended-spectrum beta-lactamase (ESBL)-producing organism (eg, known colonization or prior infection with an ESBL-producing organism), a carbapenem should be chosen. When beta-lactams or carbapenems are chosen for patients who are critically ill or are at high risk of infection with drug-resistant pathogens, we favor a prolonged infusion dosing strategy. Refer to other UpToDate content on prolonged infusions of beta-lactam antibiotics.

The combination of vancomycin, aztreonam, and metronidazole is an alternative for those who cannot use beta-lactams or carbapenems (eg, because of severe reactions).

The antibiotic doses listed are for adult patients with normal renal function. The duration of antibiotic therapy depends on the specific infection and whether the presumptive source of infection has been controlled; refer to other UpToDate content for details.

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충수염에서 드문 경우이기는 하지만 의료 관련 감염 환자에서는 약제 저항성 가능성이 높습니다. 따라서 streptococci와 anaerobes에 대한 항균력에 더하여 병원균에 대한 경험적 항균 범위를 포함하기 위하여 gram-negative bacilli (nonpseudomonal 3세대 세팔로스포린과 플루오로퀴놀론에 저항성이 있는 P. aeruginosa와 Enterobacteriaceae를 포함)에 대한 광범위 항균력이 있는 약제를 적어도 포함시켜야 합니다. 또는 우리는 의료 관련 복강내 감염 환자에서 antienterococcal activity가 있는 경험적 항생제를 사용합니다. 특히 수술 후 감염, 이전에 세팔로스포린 또는 다른 Enterococcus species에 대한 항균력이 있는 항생제를 투약받은 환자, 면역저하자, 심장 판막 질환 또는 인공 혈관내 물질이 있는 환자에서 그렇습니다.

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Empiric antibiotic regimens for health care-associated intra-abdominal infections in adults

	Dose
Single-agent regimen
Imipenem-cilastatin	500 mg IV every 6 hours
Meropenem	1 g IV every 8 hours
Doripenem	500 mg IV every 8 hours
Piperacillin-tazobactam	4.5 g IV every 6 hours
Combination regimen
ONE of the following:
Cefepime	2 g IV every 8 hours
OR
Ceftazidime	2 g IV every 8 hours
PLUS:
Metronidazole	500 mg IV or PO every 8 hours
PLUS ONE of the following (in some cases*):
Ampicillin	2 g IV every 4 hours
OR
Vancomycin	15 to 20 mg/kg IV every 8 to 12 hours

For empiric therapy of health care-associated intra-abdominal infections, we cover streptococci, enterococci, Enterobacteriaceae that are resistant to third-generation cephalosporins and fluoroquinolones, Pseudomonas aeruginosa, and anaerobes. We include coverage against methicillin-resistant Staphylococcus aureus (MRSA) with vancomycin in those who are known to be colonized, those with prior treatment failure, and those with significant prior antibiotic exposure. Empiric antifungal coverage is appropriate for patients at risk for infection with Candida spp, including those with upper gastrointestinal perforations, recurrent bowel perforations, surgically treated pancreatitis, heavy colonization with Candida spp, and/or yeast identified on Gram stain of samples from infected peritoneal fluid or tissue. Refer to other UpToDate content on treatment of invasive candidiasis.

If the patient is at risk for infection with an extended-spectrum beta-lactamase (ESBL)-producing organism (eg, known colonization or prior infection with an ESBL-producing organism), a carbapenem should be chosen. For patients who are known to be colonized with highly resistant gram-negative bacteria, the addition of an aminoglycoside, polymyxin, or novel beta-lactam combination (ceftolozane-tazobactam or ceftazidime-avibactam) to an empiric regimen may be warranted. In such cases, consultation with an expert in infectious diseases is advised.

When beta-lactams or carbapenems are chosen for patients who are critically ill or are at high risk of infection with drug-resistant pathogens, we favor a prolonged infusion dosing strategy. Refer to other UpToDate content on prolonged infusions of beta-lactam antibiotics.

The combination of vancomycin, aztreonam, and metronidazole is an alternative for those who cannot use beta-lactams or carbapenems (eg, because of severe reactions).

The antibiotic doses listed are for adult patients with normal kidney function. The duration of antibiotic therapy depends on the specific infection and whether the presumptive source of infection has been controlled; refer to other UpToDate content for details.

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IV: intravenous; PO: orally.

* We add ampicillin or vancomycin to a cephalosporin-based regimen to provide enterococcal coverage, particularly in those with postoperative infection, prior use of antibiotics that select for Enterococcus, immunocompromising condition, valvular heart disease, or prosthetic intravascular materials. Coverage against vancomycin-resistant enterococci (VRE) is generally not recommended, although it is reasonable in patients who have a history of VRE colonization or in liver transplant recipients who have an infection of hepatobiliary source.

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초기 경험적 항생제와 무관하게 이후 배양과 감수성 결과가 나오게 되면 수정해야 합니다. 한 가지 이상의 병원균이 검출된 경우 그 목록에 혐기성균이 없더라도 혐기성균을 포함한 polymicrobial infection으로 간주합니다. 이러한 경우 혐기성균주를 포함한 항생제는 유지해야 합니다.

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REF. UpToDate 2022.06.19

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