Antibiotic regimens for secondary peritonitis of gastrointestinal origin in adults

 

Abstract

Background

Secondary peritonitis is associated with a high mortality rate and if not treated successfully leads to development of abscesses, severe sepsis and multi-organ failure. Source control and adjunctive antibiotics are the mainstay of treatment. However, no conclusive evidence suggest that one antibiotic regimen is better than any other but at the same time have a lower toxicity.

Objectives

To ascertain the efficacy and adverse effects of different antibiotic regimens in treating intra-abdominal infections in adults. Outcomes were divided into primary (clinical success and effectiveness in reducing mortality) and secondary (microbiological success, preventing wound infection, intra-abdominal abscess, clinical sepsis, remote infection, superinfection, adverse reactions, duration of treatment required, effectiveness in reducing hospitalised stay, and time to defervescence).

Search methods

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, Issue 4, 2004), MEDLINE (from 1966 to November 2004), EMBASE (from 1980 to November 2004) and Cochrane Colorectal Cancer Group specialised register SR-COLOCA.
Bibliographies of identified studies were screened for further relevant trials.

Selection criteria

Randomised and quasi-randomised controlled trials comparing different antibiotic regimens in the treatment of secondary peritonitis in adults were selected. Trials reporting gynaecological or traumatic peritonitis were excluded from this review. Ambiguity regarding suitability of trials were discussed among the review team.

Data collection and analysis

Six reviewers independently assessed trial quality and extracted data. Data collection was standardised using data collection form to ensure uniformity among reviewers. Statistical analyses were performed using the random effects model and the results expressed as odds ratio for dichotomous outcomes, or weight mean difference for continuous data with 95% confidence intervals.

Main results

Fourty studies with 5094 patients met the inclusion criteria. Sixteen different comparative antibiotic regimens were reported. All antibiotics showed equivocal comparability in terms of clinical success. Mortality did not differ between the regimens. Despite the potential high toxicity profile of regimens using aminoglycosides, this was not demonstrated in this review. The reason for this could be the inherent bias within clinical trials in the form of patient selection and stringency in monitoring drug levels.

Authors' conclusions

No specific recommendations can be made for the first line treatment of secondary peritonitis in adults with antibiotics, as all regimens showed equivocal efficacy. Other factors such as local guidelines and preferences, ease of administration, costs and availability must therefore be taken into consideration in deciding the antibiotic regimen of choice. Future trials should attempt to stratify patients and perform intention-to-treat analysis to allow better external validity.

 

Plain language summary

Antibiotics are effective in preventing post-operative complications following infection of the peritoneum (peritonitis), but there is no evidence to support that one regimen is superior to another, and at the same time has less side effects.

Patients with peritonitis originated from the gut will often require surgery. Antibiotics are useful in the treatment of the ongoing infection and for prevention of post-operative complications.
This review does not result in specific recommendations for any antibiotic regimen for the first line treatment of secondary peritonitis in adults, as all regimens showed equivocal efficacy. Other factors such as local guidelines and preferences, ease of administration, costs and availability must therefore be taken into consideration in deciding the antibiotic regimen of choice. More large scale trials are needed, and future trials should attempt to stratify patients and perform intention-to-treat analysis to allow better external validity.

 

摘要

背景

對成人胃腸繼發性腹膜炎抗生素療法

繼發性腹膜炎是一個高死亡率疾病如果沒有成功治療會導致成膿瘍,嚴重敗血症和多重器官衰竭.主要的治療是控制起源和輔助抗生素.然而,並沒有證據證明哪一個低毒性抗生素療法優於其他抗生素療法.

目標

成人,成果分主要(減低死亡率上的有效性和成功性)和次要(微生物學的成功，防止傷口感染，腹內膿瘍，臨床敗血症，遠程感染，重覆感染，不良反應，治療所需的時間，減少住院期間的效率，和退燒時間)

搜尋策略

我們搜尋 Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, Issue 4, 2004), MEDLINE (from 1966 to November 2004), EMBASE (from 1980 to November 2004) and Cochrane Colorectal Cancer Group specialised register SRCOLOCA.進一步的相關試驗,確定書目,研究,篩選.

選擇標準

隨機和半隨機對照試驗,比較選擇繼發性腹膜炎的成人接受不同的抗生素療法。審查試驗報告中排除婦科或創傷性腹膜炎. 審查中討論了試驗的不明朗.

資料收集與分析

六個審查獨立評估試驗質量和提取數據.使用數據收集表格是收標準化的數據，以確保評論之間的統一性。進行統計分析採用隨機效應模式，其結果表現為比值比為二分的結果,或重量平均差連續數據95％的置信區間

主要結論

四十個研究5094病例符合納入標準.比較16個不同的抗生素治療方案報告.臨床成功的條件下,所有的抗生素顯示模稜兩可的可比性.在治療方案間死亡率沒有差異.儘管治療使用aminoglycosides 有潛在的高毒性,但在這個審查中並沒有顯示.理由很可能是在臨床試驗中選擇病人的形式和嚴格監測藥物的水平的與生俱來的偏差

作者結論

對於成人繼發性腹膜炎的第一線抗生素療法沒有提出任何具體的建議.因為所有治療方案顯示，模棱兩可的療效.其他因素像局部指引和偏好,易於管理,成本和可用性,在決定選擇抗生素療法時都必須考慮在內.未來的試驗應該注意到患者的分層,並進行意向性治療分析,以便有更好的有效性

翻譯人

本摘要由國泰綜合醫院張世昌翻譯

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌

總結

抗生素能有效的預防手術後合併症腹膜感染(腹膜炎),但沒有證據支持這個治療法優於其他的方法,以及在相同的時間內有較少的合併症.患者起源於腸道的腹膜炎經常需要手術治療.治療正在發生的感染和預防術後合併症,抗生素是有用的.對於成人繼發性腹膜炎任何第一線治療的抗生素療法,本次審查沒有產生具體的建議.因為所有治療方案顯示模棱兩可的療效.其他因素像局部指引和偏好,易於管理,成本和可用性,在決定選擇抗生素療法時都必須考慮在內.更大規模的臨床試驗是必需的,未來的試驗應該注意到患者的分層,並進行意向性治療分析,以便有更好的有效性.