闌尾炎:使用較長期的抗生素治療可能沒有幫助


  【24drs.com】根據一篇新研究的結果,急性複雜性闌尾炎患者在腹腔鏡闌尾切除術手術之後,相較於接受3天術後抗生素治療者,接受5天術後抗生素治療並無法減少感染性併發症。
  
  研究作者表示,給予較多天的抗生素並無法預防腹腔內膿瘍,因此,建議根據病人的臨床狀況採取反應性策略。
  
  荷蘭Tergooi醫院的Charles C. van Rossem醫師與「Snapshot闌尾炎協同合研究小組」的研究夥伴,在11月18日的JAMA Surgery期刊線上發表他們的全國性多中心前瞻研究結果。
  
  研究者評估了62間荷蘭醫院的1,975名患者,大部份(96.3%)因為急性闌尾炎進行了闌尾切除術,四分之三採用腹腔鏡手術。研究者指出,雖然這篇研究包括了急性複雜性闌尾炎患者,在臨床評估複雜的案例中,病理嚴重程度與臨床嚴重程度並不相關。
  
  3天抗生素療程(而不是5天)對任何感染性併發症無顯著影響(勝算比為0.93;95%信賴區間為0.38 - 2.32;P = .88)。闌尾穿孔是唯一確定、與感染性併發症有關的風險因素(勝算比為4.90;95%信賴區間為1.41 - 17.06;P = .01)。這些研究結果與之前發表的世代研究以及一篇小型隨機臨床研究的結果一致。
  
  在荷蘭,急性闌尾炎患者主要是以腹腔鏡手術治療,抗生素處方的使用期間通常是根據對患者的臨床評估而定。新資料認為,這類調整治療期間的方法並不會影響疾病嚴重度或結果。
  
  目前的研究增加了有關急性闌尾炎患者的最佳治療為何,以及抗生素之角色的討論。今年初,JAMA期刊發表了「Appendicitis Acuta」這篇大型多中心隨機臨床試驗的結果,依據電腦斷層確認非複雜性的闌尾炎,然後用抗生素或闌尾切除術加抗生素治療這些病患。如同之前的報導,研究結果指出,單純使用抗生素治療對於非複雜性闌尾炎即有足夠療效。
  
  密西根大學醫學院Steven J. Hasday等人在對van Rossem醫師之研究的編輯評論指出,前述這些研究結果引起媒體的廣泛報導,並引起外科醫生們的熱烈回應。
  
  這些資料被媒體解釋為,闌尾炎可藉由單用抗生素治療。相對的,外科醫師則是反對放棄使用手術治療闌尾炎的想法。
  
  在隨後的討論中,主要集中在研究結果的爭議,許多案例中,並未顧慮病患需求。
  
  編輯們寫道,外科醫師們與其專注於辯論抗生素是否有效,不如討論如何讓外科醫師們能最佳地與患者共同決策、制定闌尾炎治療方案。共同醫療決策,是由醫生和患者一起考慮患者的價值觀和偏好、以及治療選項的特定風險和好處,然後達成雙方皆同意之決定的過程。
  
  透過共同決策,我們可以回答這個問題:我們應該問的問題是,對於這名患者,這是正確的選擇嗎?
  
  他們指出,這次的新研究結果,提供外科醫師與其患者對話的另一個機會。
  
  資料來源: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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