阑尾炎:使用较长期的抗生素治疗可能没有帮助


  【24drs.com】根据一篇新研究的结果,急性复杂性阑尾炎患者在腹腔镜阑尾切除术手术之后,相较于接受3天术后抗生素治疗者,接受5天术后抗生素治疗并无法减少感染性并发症。
  
  研究作者表示,给予较多天的抗生素并无法预防腹腔内脓疡,因此,建议根据病人的临床状况采取反应性策略。
  
  荷兰Tergooi医院的Charles C. van Rossem医师与「Snapshot阑尾炎协同合研究小组」的研究伙伴,在11月18日的JAMA Surgery期刊在线发表他们的全国性多中心前瞻研究结果。
  
  研究者评估了62间荷兰医院的1,975名患者,大部份(96.3%)因为急性阑尾炎进行了阑尾切除术,四分之三采用腹腔镜手术。研究者指出,虽然这篇研究包括了急性复杂性阑尾炎患者,在临床评估复杂的案例中,病理严重程度与临床严重程度并不相关。
  
  3天抗生素疗程(而不是5天)对任何感染性并发症无显著影响(胜算比为0.93;95%信赖区间为0.38 - 2.32;P = .88)。阑尾穿孔是唯一确定、与感染性并发症有关的风险因素(胜算比为4.90;95%信赖区间为1.41 - 17.06;P = .01)。这些研究结果与之前发表的世代研究以及一篇小型随机临床研究的结果一致。
  
  在荷兰,急性阑尾炎患者主要是以腹腔镜手术治疗,抗生素处方的使用期间通常是根据对患者的临床评估而定。新资料认为,这类调整治疗期间的方法并不会影响疾病严重度或结果。
  
  目前的研究增加了有关急性阑尾炎患者的最佳治疗为何,以及抗生素之角色的讨论。今年初,JAMA期刊发表了「Appendicitis Acuta」这篇大型多中心随机临床试验的结果,依据计算机断层确认非复杂性的阑尾炎,然后用抗生素或阑尾切除术加抗生素治疗这些病患。如同之前的报导,研究结果指出,单纯使用抗生素治疗对于非复杂性阑尾炎即有足够疗效。
  
  密西根大学医学院Steven J. Hasday等人在对van Rossem医师之研究的编辑评论指出,前述这些研究结果引起媒体的广泛报导,并引起外科医生们的热烈回应。
  
  这些资料被媒体解释为,阑尾炎可藉由单用抗生素治疗。相对的,外科医师则是反对放弃使用手术治疗阑尾炎的想法。
  
  在随后的讨论中,主要集中在研究结果的争议,许多案例中,并未顾虑病患需求。
  
  编辑们写道,外科医师们与其专注于辩论抗生素是否有效,不如讨论如何让外科医师们能最佳地与患者共同决策、制定阑尾炎治疗方案。共同医疗决策,是由医生和患者一起考虑患者的价值观和偏好、以及治疗选项的特定风险和好处,然后达成双方皆同意之决定的过程。
  
  透过共同决策,我们可以回答这个问题:我们应该问的问题是,对于这名患者,这是正确的选择吗?
  
  他们指出,这次的新研究结果,提供外科医师与其患者对话的另一个机会。
  
  资料来源:http://www.24drs.com/
  
  Native link:Appendicitis: Longer Antibiotic Treatment May Not Help

Appendicitis: Longer Antibiotic Treatment May Not Help

By Lara C. Pullen, PhD
Medscape Medical News

Patients with acute complicated appendicitis who received 5 days of postoperative antibiotic treatment after laparoscopic appendectomy surgery did not have a reduction in infectious complications relative to patients receiving only 3 days of postoperative antibiotic treatment, according to the results of a new study.

"Longer administration of antibiotics was not associated with prevention of intra-abdominal abscesses and a reactive strategy based on clinical condition of the patient is therefore advised," the study authors say.

Charles C. van Rossem, MD, from Tergooi Hospital in the Netherlands, and colleagues from the Snapshot Appendicitis Collaborative Study Group published the results of their national, multicenter prospective study online November 18 in JAMA Surgery.

The researchers evaluated 1975 patients from 62 Dutch hospitals. The majority (96.3%) underwent an appendectomy for acute appendicitis, and three quarters of these had laparoscopy. Although the study included patients with acute complicated appendicitis, the investigators note that histological severity did not correlate with clinical severity in clinically assessed complicated cases.

Three days of antibiotics (instead of 5 days) had no significant effect on any infectious complication (odds ratio, 0.93; 95% confidence interval, 0.38 - 2.32; P = .88). Perforation of the appendix was the only identified risk factor associated with infectious complication (odds ratio, 4.90; 95% confidence interval, 1.41 - 17.06; P = .01). The results are consistent with findings from a previously published cohort study and a previously published small, randomized clinical trial.

In the Netherlands, patients with acute appendicitis are primarily treated by laparoscopic surgery. The length of antibiotic prescription is often dictated by clinical evaluation of the patient. The new data suggest that such a modification of length does not affect disease severity or outcome.

Antibiotics vs Surgery

The current study adds to the discussion of how best to treat patients with acute appendicitis and of the role of antibiotics. Earlier this year, JAMA published the results of the Appendicitis Acuta trial, a large, multicenter, randomized clinical trial that relied on computed tomography to confirm the presence of uncomplicated appendicitis and that treated these patients with either antibiotics or appendectomy plus antibiotics. As previously reported by Medscape Medical News, the study results indicated that antibiotic therapy alone may be sufficient for uncomplicated appendicitis.

The findings attracted extensive media coverage and prompted strong responses from surgeons, note Steven J. Hasday, BS, from the University of Michigan Medical School in Ann Arbor, and colleagues in an editorial accompanying the current paper by Dr van Rossem and colleagues.

The data were interpreted by the media to mean that appendicitis can be treated by antibiotics alone. Surgeons, in contrast, were resistant to the idea of forgoing surgery in the treatment of appendicitis.

The ensuing discussion largely focused on the controversy of the results. In many cases, the needs of the patients were sidelined.

"Rather than a surgeon-centric debate about whether antibiotics are 'valid,' the discussion we need to have is about how surgeons can best engage in shared decision making with patients on treatment options for appendicitis," the editorialists write. "Shared medical decision making is the process by which physicians and patients reach a mutually agreeable decision for treatment by considering patient values and preferences along with the specific risks and benefits of treatment options. Through shared decision making we can answer the question that we should be asking: which is the right option for this patient?"

They add that the new data provide yet another opportunity for the surgeon to engage in conversation with their patients.

The authors have disclosed no relevant financial relationships. One editorialist is a cofounder of ArborMetrix Inc, a company that makes software for profiling hospital quality and efficiency.

JAMA Surg. Published online November 18, 2015.

    
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