Bartlett J G
Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Med Clin North Am. 1995 May;79(3):599-617. doi: 10.1016/s0025-7125(16)30059-1.
This article addresses controversial issues in the field of intra-abdominal sepsis with particular attention to major changes in management that have evolved during the past decade. In the area of diagnostics, scanning techniques have revolutionized the ability to detect loculated collections, although many of these techniques are of limited value in the early stages of inflammation. The greatest debate concerns the relative merits of scanning techniques; the author's choice is CT scans with contrast, although ultrasonography is preferred in patients who cannot be transported and is probably preferred for pelvic infections. In the area of therapeutics, virtually all studies seem to show that single-drug treatment is as effective as dual combinations or triple-combination therapy that has been standard practice in the past with the proviso that the drug used has activity versus Enterobacteriaceae and B. fragilis. The role of enterococcus remains enigmatic; this organism was readily discounted as an important pathogen in the great majority of cases 10 years ago, but it has subsequently become a major nosocomial pathogen that now commands newfound respect. P. aeruginosa is also controversial, but most studies show that antipseudomonad treatment is not necessary in the empiric selection of drugs and may not be necessary even when P. aeruginosa is found at infected sites; the corollary to this is that aminoglycosides may no longer be required in the dual drug treatment regimens. There is increasing resistance by B. fragilis and some other species of Bacteroides to some of the drugs considered "standard" in the past, including clindamycin, cefoxitin, and cefotetan; nevertheless, it has been difficult to demonstrate that resistance of these organisms correlates with antibiotic failure. It was demonstrated 20 years ago that elective colon surgery must be accompanied by preoperative antibiotics, and erythromycin plus neomycin has evolved as the regimen of choice according to recommendations of authoritative sources for the past 20 years. Nevertheless, surveys of practicing surgeons indicate that most actually combine this oral preparation with parenteral agents as well. The final controversy concerns percutaneous drainage, which has now become a standard technique for dealing with intra-abdominal abscesses in 50% to 90% of cases. This controversy has sometimes been seen as a territorial battle between surgeons and radiologists, and most cases are clearly the prerogative of one discipline or the other, but many are in a gray zone in which clearly defined indications are not readily available.
本文探讨了腹腔内脓毒症领域存在争议的问题，尤其关注了过去十年中管理方面的重大变化。在诊断领域，扫描技术彻底改变了检测局限性积液的能力，尽管其中许多技术在炎症早期阶段价值有限。最大的争论在于扫描技术的相对优势；作者的选择是增强CT扫描，不过对于无法转运的患者，超声检查更受青睐，对于盆腔感染可能也是首选。在治疗领域，几乎所有研究似乎都表明，单药治疗与过去作为标准做法的双联或三联联合治疗效果相当，前提是所用药物对肠杆菌科细菌和脆弱拟杆菌有活性。肠球菌的作用仍然难以捉摸；十年前，在大多数情况下，这种微生物很容易被排除为重要病原体，但后来它已成为主要的医院感染病原体，如今受到了新的重视。铜绿假单胞菌也存在争议，但大多数研究表明，在经验性选择药物时，抗假单胞菌治疗并非必要，甚至在感染部位发现铜绿假单胞菌时可能也不必要；由此推断，在双联药物治疗方案中可能不再需要氨基糖苷类药物。脆弱拟杆菌和其他一些拟杆菌属对过去被视为“标准”的一些药物，包括克林霉素、头孢西丁和头孢替坦，耐药性日益增加；然而，很难证明这些微生物的耐药性与抗生素治疗失败有关。二十年前就已证明，择期结肠手术必须术前使用抗生素，根据权威资料的建议，在过去二十年中，红霉素加新霉素已成为首选方案。然而，对执业外科医生的调查表明，大多数人实际上也将这种口服制剂与胃肠外用药联合使用。最后的争议涉及经皮引流，目前这已成为处理50%至90%腹腔内脓肿的标准技术。这场争议有时被视为外科医生和放射科医生之间的地盘之争，大多数病例显然属于其中一个学科的权限范围，但许多病例处于灰色地带，缺乏明确的适用指征。
