Results of a clinical trial of clinafloxacin versus imipenem/cilastatin for intraabdominal infections.

OBJECTIVE: Clinafloxacin is a novel quinolone with wide activity against the plethora of microorganisms encountered in intraabdominal infections. This trial was performed to examine its clinical efficacy. SUMMARY BACKGROUND DATA: Clinafloxacin is representative of a new class of quinolones with considerable antimicrobial activity resulting from their mechanisms of action and pharmacodynamics. There is, however, concern about specific potential toxicities, including photosensitivity. METHODS: This prospective, randomized, double-blind trial was conducted to compare clinafloxacin with imipenem/cilastatin as adjuncts in the management of complicated intraabdominal infections. RESULTS: Five hundred twenty-nine patients were included in the intent-to-treat population, with 312 meeting all criteria for the valid population. Patients with a wide range of infections were enrolled; perforated or abscessed appendicitis was the most common (approximately 50%). One hundred twenty-three of the 150 valid patients treated with clinafloxacin (82%) had successful outcomes, as did 130 of the 162 (80%) treated with imipenem. For the intent-to-treat groups, 219 of 259 patients treated with clinafloxacin (85%) had successful outcomes, as did 219 of 270 patients treated with imipenem/cilastatin (81%). Treatment failure occurred in 39 patients who underwent drainage. There were substantially more gram-negative organisms recovered from the patients with treatment failure who were initially treated with imipenem/cilastatin. CONCLUSIONS: The results of this study clearly demonstrate the safety and efficacy of clinafloxacin in the treatment of a range of intraabdominal infections, and in patients with a broad range of physiologic disturbances.

Ileocecectomy is definitive treatment for advanced appendicitis.

Although appendectomy is the most commonly performed emergency operation septic complications of appendectomy remain a major source of morbidity. Historically, advanced appendicitis has been treated by appendectomy with cecostomy and/or drainage tubes. Our objective was to evaluate the use of ileocecal resection for the immediate treatment of advanced appendicitis. We examined the cases of all patients undergoing ileocecal resection for appendicitis from August 1989 through April 2000. There were 92 patients (60 male and 32 female) with a median age of 34 (range 6-71). Abdominal pain was present in 98 per cent of patients with duration of 5.1+/-0.6 days. Right lower quadrant tenderness was present in 91 per cent with accompanying right lower quadrant mass in 30 per cent. Temperature on admission was 38.0+/-0.1 degrees C with a white blood cell count of 15,300+/-500. Preoperative radiological studies included abdominal X-rays (33), contrast enemas (two), CT scans (41), and abdominal ultrasound (17); these studies yielded a correct preoperative diagnosis in 89 per cent. Previous appendectomy had been performed in six patients with failed percutaneous drainage of intra-abdominal abscesses in five. There were 94 cecal resections performed in 92 patients. The extent of surgical resection varied between patients and ranged from partial cecectomy (34) to ileocecectomy (55) to ileocecectomy with diverting ileostomy (five). Intra-abdominal abscesses were present at operation in 46 cases (50%), and drains were placed in 38 (41%). Skin incisions were packed open in most cases (65); there was skin closure in 27. There was no mortality encountered in this period. There were 25 complications in 23 patients (25%). Complications included postoperative abscess (10; 11%), wound infection (10; 11%), partial small bowel obstruction (two) and pulmonary embolus (one). Reoperation was required in seven patients and CT-guided percutaneous drainage in five patients. Anastomic leaks occurred in two cases of partial cecectomy and required conversion to ileocecectomy. Mean hospital stay was 10.5+/-1.0 days with adjusted hospital costs of $31,689+/-3018. We conclude that definitive treatment of advanced appendicitis can be performed by resection of the involved areas of the ileocecum. This can be accomplished with a primary anastomosis obviating the need for ileostomy and secondary operation. This aggressive surgical approach may reduce infectious complications and reduce hospital costs.

Surgical diverticulitis: treatment options.

Acute diverticulitis requiring surgical intervention has conventionally been treated by resection with colostomy or delayed resection with primary anastomosis at a second admission. Our objective was to determine the outcome for treatment of diverticulitis with resection and primary anastomosis during the same hospitalization. We conducted a retrospective review of patients (n = 74) undergoing surgery for diverticulitis. Groups included: 1) resection with primary anastomosis (n = 33), 2) resection with colostomy followed by a takedown colostomy (n = 32), and 3) delayed resection with primary anastomosis at a second admission (n = 9). Despite local perforation primary anastomosis was often performed unless patients were clinically unstable or had fecal contamination. The operation was urgent in five (15%) patients in Group 1 as compared with 26 patients (88%) in Group 2. Serious intra-abdominal complications occurred in two patients (6%) in Group 1 as compared with nine patients (28%) in Group 2 and one patient (11%) in Group 3. Postoperative abscesses occurred in two patients in Group 1, five patients in Group 2, and one patient in Group 3. We have shown that resection with primary anastomosis for acute diverticulitis--even in selected patients requiring urgent operation--can be safely performed during the same hospital admission with a low complication rate.

Same admission colon resection with primary anastomosis for acute diverticulitis.

Current standard of care for complicated diverticulitis includes urgent resection with colostomy versus antibiotic treatment, followed by delayed resection with primary anastomosis at a second admission. In certain circumstances, it is possible to perform resection and anastomosis on the same admission for acute diverticulitis. A retrospective review was completed for patients undergoing surgery for diverticulitis from 1991 to 1998. Groups included: 1) sigmoid resection with primary anastomosis on same admission (n = 18); 2) resection with protective end colostomy (n = 16); and 3) in-patient antibiotic treatment alone, followed by a second admission for resection with primary anastomosis (n = 5). Four patients initially treated with antibiotics worsened symptomatically or developed radiographic evidence of perforation and required resection with colostomy. Five patients in Group 1 had abscesses or contained perforations based on radiographic studies. Findings on CT scans did not predict treatment. Group 1 patients had uneventful recoveries and few minor complications (wound infections and an incisional hernia). One anastomotic leak occurred in Group 2 after colostomy closure. Although there will continue to be a role for emergent operation for diverticulitis, same admission sigmoid resection with primary anastomosis after antibiotic treatment is safe, uses a shorter course of antibiotics, and has a low complication rate.

Ticarcillin/clavulanate versus imipenem/cilistatin for the treatment of infections associated with gangrenous and perforated appendicitis.

The objective of this study was to compare ticarcillin/clavulanate given at 3.1 g every 6 hours with imipenem/cilistatin given at 500 mg every 6 hours for the treatment of infections associated with gangrenous or perforated appendicitis. One hundred thirty-seven patients were found to have gangrenous or perforated appendicitis and received the study medication for 3 to 5 days in a double-blinded, randomized manner. Clinical success was similar for the two treatment groups, 96.9 and 95.9 per cent in the ticarcillin/clavulanate and imipenem/cilistatin groups, respectively (P=0.99; 95% confidence interval for the difference was -5.6% to 7.6%). Bacteriologic success at the end of therapy was similar in the two groups, 100 and 98.4 per cent in the ticarcillin/clavulanate and imipenem/ cilistatin groups, respectively (P=0.99; 95% confidence interval for the difference was -1.8% to 4.7%). The occurrence of adverse events related to treatment was similar for the two groups (P=0.31) and led to study withdrawal for four patients (one with ticarcillin/clavulanate and three with imipenem/ cilistatin). Ticarcillin/clavulanate given at 3.1 g every 6 hours is as effective and as safe as imipenem/ cilistatin given at 500 mg every 6 hours for treatment of gangrenous or perforated appendicitis.

White blood cell count is a poor predictor of severity of disease in the diagnosis of appendicitis.

The white blood cell (WBC) count is considered to be a useful test in the diagnosis of appendicitis. The purpose of this study was to examine the clinical features of patients with normal WBC appendicitis and also to determine whether a higher WBC count correlates with a more advanced stage of appendicitis. Patients with pathologically confirmed appendicitis from January 1989 to December 1994 were included in the study (n = 1919). The age, gender, temperature, length of hospital stay, and severity of disease (1 = acute appendicitis; 2 = gangrenous appendicitis; 3 = perforated appendicitis with abscess formation; 4 = appendicitis with diffuse peritonitis) were compared for patients with a normal WBC count (range, 3.8-10.9) versus those who had an elevated WBC count. A normal WBC count was seen in 11 per cent of patients (n = 209). There was no difference in age, temperature, gender, or severity of disease in the patients with a normal WBC count compared with those with an elevated WBC count (P > 0.05). The severity of disease of patients with a normal WBC count were: 1 = 58 per cent; 2 = 13 per cent; 3 = 7 per cent; and 4 = 22 per cent. For patients with an elevated WBC count the scores were: 1 = 57 per cent; 2 = 17 per cent; 3 = 13 per cent; and 4 = 14 per cent. The proportion of gangrenous and perforated appendicitis in the patients with a normal WBC count is the same as in the patients with an elevated WBC count.

Emergent ileocecectomy for infection and inflammation.

The role of right colectomy in controlling inflammatory conditions and intra-abdominal sepsis remains controversial. The objective of this study was to define the outcome following emergency ileocecal resection for infectious and inflammatory causes. Retrospective analysis of 83 consecutive patients who underwent such treatment in a university-affiliated public hospital over a 7-year period was performed. Preoperative diagnosis was correct in 54 per cent of patients; CT scan (29 patients) did not improve this rate (59%). Free perforation was noted in 16 per cent of patients, and a defined abscess was found in 39 per cent. Common pathologic diagnoses included appendicitis (39%), diverticulitis (23%), cancer (14%), and Crohn's disease (8%). Primary ileocolic anastomosis was performed in 74 patients (89%); 9 patients (11%) required an ileostomy. Mean postoperative stay was 10 days, and there was no mortality. Complications occurred in 15 patients (18%), and 2 required reoperation (2%). Preoperative presence of an abscess was not associated with an increased complication rate (16%), but free perforation was associated with a 31 per cent complication rate. Definitive emergency treatment of infectious and inflammatory disease of the ileocecum can be safely accomplished by resection with primary anastomosis in the majority of patients, obviating the need for ileostomy and a second operation.

Analysis of risk factors of postappendectomy intra-abdominal abscess.

BACKGROUND: Postappendectomy intra-abdominal abscesses (PAIAA) complicate the recovery of a small but significant fraction of patients with advanced appendicitis. STUDY DESIGN: A retrospective review of 1,184 patients with appendicitis was undertaken to define the clinical characteristics and risk factors associated with PAIAA. RESULTS: Thirty-three patients with 36 PAIAAs were found, an incidence of 2.8 percent. The mean age of patients with PAIAA was less than the overall group (16.9 versus 23.1 years, p = 0.002), and the mean core temperature of the PAIAA group was significantly higher (38.5 versus 38.2 degrees C). The incidence of PAIAA increased as the degree of appendiceal pathology worsened. The incidence of PAIAA was six (3.2 percent) of 190 in patients with gangrenous appendicitis and was 27 (8.7 percent) of 309 among patients with perforated appendicitis. Logistic regression analysis showed that independent predictors for the occurrence of PAIAA were young age and perforation. Although children presented with a higher rate of perforated appendicitis, this did not account for the younger age of the patients with PAIAA. Children (less than ten years of age) with perforation had PAIAA in ten (14 percent) of 69 cases compared with the incidence in the older patients with perforation of 17 (7.1 percent) of 240. CONCLUSIONS: These findings improve the surgeon's ability to identify patients at risk for PAIAA. Alterations in the perioperative management of perforated appendicitis, particularly in the pediatric patient, may reduce the occurrence of PAIAA.

Biliary disease during pregnancy.

BACKGROUND: Biliary disease during pregnancy is rare and the need for surgery in these cases is controversial. We evaluated our experience with biliary disease during pregnancy with regard to outcome and cost containment. PATIENTS AND METHODS: We reviewed the clinical course of pregnant women with biliary disease at the University of California at Los Angeles and Olive View-UCLA Medical Centers from 1988 to 1993. RESULTS: Seventy-two of 46,075 pregnant women presented with biliary disease (incidence 0.16%). Sixteen underwent surgery while pregnant, 5 in the first and 11 in the second trimester. No maternal or fetal deaths occurred secondary to medical or surgical management of biliary disease. Patients who were treated medically at initial presentation had a 69% rate of relapse prior to delivery, compared to no relapses in those treated surgically (P < 0.01). Patients who experienced relapse spent an average of 3.0 additional days in hospital. CONCLUSION: Surgical therapy for biliary disease performed in the second trimester of pregnancy does not increase morbidity and may help reduce relapses and additional days in hospital.

Management of pancreatitis complicating pregnancy.

Pregnancy complicated by pancreatitis may lead to significant fetal and maternal morbidity and mortality. We reviewed the clinical course of 30 women who developed pancreatitis in our institution during pregnancy from 1988 to 1992. Pancreatitis complicated 0.07 per cent of pregnancies (n = 46,075) during this time period. The etiology was gallstones in 22 patients, alcohol in 2 patients, and idiopathic in 6 patients. Average age, multiparity, and symptoms at presentation were similar between patients with gallstone (GSP) or non-gallstone pancreatitis (NGSP). All patients were initially treated medically. GSP patients had significantly lower Ranson criteria than NGSP (0.7 vs. 1.9, P < 0.01), but response to initial therapy, need for emergency surgery, fetal outcome, and fetal and maternal mortality (0 per cent) were the same. Twenty-six of 30 patients were successfully treated with conservative management. A significantly higher relapse rate was seen in GSP than NGSP patients before delivery (72% vs. 0%, P < 0.05). These relapses required hospitalization 90 per cent of the time and resulted in 3.9 additional days per patient. Six patients underwent surgery during pregnancy (two in the first trimester and four in the second trimester) without fetal or maternal mortality and with normal birthweights and Apgar scores. No relapses or additional days in hospital were noted in GSP patients following surgery. We recommend that GSP patients presenting in the first or second trimester should, if possible, undergo cholecystectomy in the second trimester when the risk of anesthesia and premature labor are the lowest. Patients presenting in the third trimester should undergo surgery immediately post-partum.(ABSTRACT TRUNCATED AT 250 WORDS)

Pancreatitis associated with adult choledochal cysts.

We reviewed the records of 32 adult patients with choledochal cysts (CDC) to determine the characteristics of the associated pancreatic disease. Eighteen patients (56%) had 30 documented episodes of pancreatitis with epigastric pain and elevated serum amylase levels. Three patients developed a prolonged course with a pancreatic phlegmon and one patient died secondary to a pancreatic abscess after endoscopic retrograde cholangiopancreatography (ERCP). Pancreatitis occurred in all types of CDC and was not related to the age, gender or race of the patient. There was an association with the size of the CDC: 90% of patients with CDC > or = 5 cm developed pancreatitis compared with only 9% of patients with CDC < 5 cm (p < 0.0004). In addition, ERCP was performed in 14 patients and demonstrated an abnormal pancreaticobiliary duct junction in eight (57%). All eight patients with an abnormal pancreaticobiliary junction developed pancreatitis compared with only 2 out of 6 patients with normal pancreatic duct anatomy (p < 0.006). Patients undergoing surgical bypass rather than resection also tended to have higher rates of pancreatitis (80 vs. 50%). One patient with a Type I CDC and chronic pancreatitis was treated with surgical resection of the CDC and pancreatic head; this combined procedure relieved the pain. Microscopic examination of the CDC and the abnormal "common channel" within the pancreas revealed identical fibrous thickening of the duct walls with focal chronic inflammation and loss of surface epithelium. In conclusion, these data stress the previously unrecognized high incidence of symptomatic pancreatic inflammatory disease that accompanies adult CDC.(ABSTRACT TRUNCATED AT 250 WORDS)

Cecectomy for complicated appendicitis.

BACKGROUND: Cecal leak or disruption after appendectomy for complicated appendicitis is a consequence of severity of disease and is related to residual abscess cavity, inflammation, phlegmon, and nonviable intestine. In an attempt to improve results, we have begun to resect the cecum and other localized infected tissue in instances of complicated appendicitis in which the viability of the appendiceal base and adjacent cecum is questionable. STUDY DESIGN: This is a prospective series of all patients who have undergone resectional therapy for complicated appendicitis in the last four years. Patients with other inflammatory conditions of the right colon have been specifically excluded. RESULTS: Seventeen patients have undergone resectional therapy for complicated appendicitis. Thirteen (76.5 percent) were men; the mean age was 42.4 years. The mean temperature and leukocyte count were 37.8 degrees C and 16.1 x 10(9) per L, respectively. These patients presented with a mean of 6.8 days of abdominal pain. Nine had a palpable abdominal mass, and all had tenderness in the right lower quadrant. In ten patients an abscess was encountered at operation. While the extent of the resection varied, it generally included the cecum, part of the right colon, and 5 to 7 cm of terminal ileum. Fourteen patients had a primary anastomosis, while the other three had the creation of an ileostomy. Complications were encountered in only two patients: one wound infection and one pulmonary embolus. There were no instances of postoperative intra-abdominal abscess, intestinal obstruction, or fecal fistula. All patients had a benign postoperative course and were discharged on the average of 9.9 days postoperatively. The ileostomies in three patients have been closed and no complications have occurred on follow-up examination. CONCLUSIONS: We conclude that aggressive resectional therapy of the cecum during appendectomy in selected patients with complicated appendicitis is effective therapy and can be performed safely.

An analysis of infectious failures in acute cholangitis.

To determine the factors responsible for therapeutic failures in acute cholangitis, a series of 127 patients was analyzed. There were 64 females and 63 males whose mean age was 57.2 years. Ninety-four (74.0%) of these patients were clinically cured with initial measures, whereas 33 patients (26%) failed initial therapy for an infectious reason. No differences were observed between the two groups in regard to age and gender. However, more patients in the group that failed had a malignant cause for their bile duct obstruction (72.7% vs. 42.6%, p < 0.01) and had a pretreatment positive blood culture (45.5% vs. 13.8%, p < 0.01). Patients who failed had a higher mean total bilirubin level (9.7 mg/dl vs. 5.5 mg/dl, p < 0.005) and more of them had a level greater than 2.2 mg/dl (97% vs. 69.9%, p < 0.001). Also, more bile cultures were initially positive (93.9% vs. 76.6%, p < 0.05) and more organisms were isolated per culture (3.88 vs. 2.86, p < 0.03) in the patients who failed. In addition, more patients failed who had two or more organisms in the bile (33% vs. 8.3%, p < 0.02). Patients in whom Candida, or any panresistant organism was isolated also tended to fail. Multivariant analysis showed that malignancy, bacteremia, bilirubin > or = 2.2 mg/dl, > or = 2 organisms in the bile and a panresistant organism were the best predictors of treatment failure with a serum bilirubin level > or = 2.2 mg/dl being the variable that increases a patient's log-odds ratio of failure the greatest.(ABSTRACT TRUNCATED AT 250 WORDS)

Antibiotic update for the surgeon.

All too often, it seems that the utilization of antibiotics by surgeons for either prophylaxis or the treatment of established infections is shrouded in a combination of mysticism and marketing. What should be straight forward, frequently becomes confused by factors such as superstition, habit, recent interaction with an industry representative, and faulty information. The rational use of antibiotics is surprising simply, and is based on the fact that these agents are, quite simply, systemic chemotherapy against bacteria. Once delivered to the patient these agents act not only locally, but, more importantly, sistemically against susceptible microorganisms. This demands that the practitioner make an educated guess as to which bacteria are likely to be present, as well as use an agent that both safe and effective in that specific patient. The types and variety of bacteria present in a surgical infection, or likely to be present, can usually be deduced by the location and / or organ system involved. The safest and most effective agent to be used against those organisms is primarily a function of the specific hospital that the patient in, and whether the infection is hospital-acquired (nosocomial) or community-acquired. The susceptibility patterns for bacteria vary from community to community (as noted by local hospitals), as well as from hospital to hospital dependent on whether it is a community hospital or a tertiary referral center. It is illogical to assume that the same drug or drugs will be just as effective in one setting as in another, regardless of whether they are used for prophylaxis or an established infection.

Cefepime for infections of the biliary tract.

Antibiotic treatment of biliary tract infections is widely accepted. An open, prospective, randomized, multicenter trial comparing cefepime (2 grams every 12 hours) with gentamicin (1.5 milligrams per kilograms every eight hours) plus mezlocillin (3 grams every four hours) for a minimum of five days was undertaken. Of the 149 patients enrolled, 120 were evaluable; 80 were randomized to receive cefepime and 40 were randomized to receive gentamicin plus mezlocillin (two to one randomization schedule). The diagnosis was acute cholecystitis in 101 patients and acute cholangitis in the remainder. There were no differences between the two treatment groups with regard to gender, age, disease, signs and symptoms, admitting temperature or laboratory values. All patients (100 percent) treated with gentamicin and mezlocillin were cured of the infection, as were 78 (97.5 percent) of the patients treated with cefepime (difference not significant). The incidence and spectrum of adverse events and complications were similar between the two groups (8.8 percent for cefepime versus 10 percent for gentamicin and mezlocillin). Our data show that the efficacy and safety of cefepime administered every 12 hours is equivalent to that of gentamicin and mezlocillin combination for treating patients with acute infections of the biliary tract. In addition, twice-daily administration of cefepime may be more cost-effective than the aminoglycoside-based combination.

The role of Yersinia enterocolitica in appendicitis in the southwestern United States.

Infection with Yersinia enterocolitica had been associated with acute appendicitis in approximately six per cent of patients in northern European countries. However, the incidence of Y. enterocolitica in patients with appendicitis in this country is uncertain. Therefore, this study was undertaken to ascertain whether Y. enterocolitica is a possible infectious agent in appendicitis in the southwestern United States. Fifty prospective patients (35 men and 15 women) with an average age of 22.3 years (range 3 to 62 years) underwent appendectomy for presumed appendicitis. Portions of each specimen were cultured for Y. enterocolitica with highly selective media (Cefsulodin-Irgasan-Novobiocin [CIN] agar). Pathologically, 44 of the patients had appendicitis and 6 patients had normal appendices. Four of the 44 patients (9.1%) with appendicitis were found to be culture positive for Y. enterocolitica, while it was recovered from none of the normal appendices. This indicates that Y. enterocolitica may represent the major pathogen in acute appendicitis in a small, but distinct, portion of indigent patients within Los Angeles County as it does elsewhere in the world.

Xanthogranulomatous cholecystitis: a chronic inflammatory pseudotumor of the gallbladder.

Xanthogranulomatous cholecystitis is a benign chronic inflammation of the gallbladder that can morphologically mimic carcinoma. In severe cases, the diagnosis is made intraoperatively using frozen section histology and pathologic consultation. Once the diagnosis of xanthogranulomatous cholecystitis is confirmed, cholecystectomy should be performed. Occasionally, the inflammatory reaction and fibrosis within the gallbladder is so severe that conventional cholecystectomy is unsafe. In these instances, a subtotal cholecystectomy is required.

Cecal diverticulitis: a continuing diagnostic dilemma.

Cecal diverticulitis is a rare entity and remains a difficult diagnostic problem. A retrospective review was undertaken of 16 patients (11 men, 5 women; average age, 33.2 years) with a pathologic diagnosis of cecal or right colon diverticulosis who received treatment from 1979 to the present. Preoperative symptoms were difficult to distinguish from appendicitis. The majority complained of right lower quadrant pain and tenderness. Diagnostic studies were not helpful. Preoperative diagnosis was appendicitis in 88% (14 of 16) and correct in 1 patient (6%). At exploratory celiotomy, the surgeon was able to make the diagnosis of cecal diverticulitis in 9 (60%) of the 15 patients in whom the correct diagnosis had not been made preoperatively. Neoplasm was suspected in 5 patients, and an appendiceal abscess was suspected in 1. Treatment was colectomy in 9 and local excision in 4 patients. In 3 patients, the inflamed diverticulum was left in situ at initial exploration; all underwent later excision, one of these urgently for sepsis. No patient died; however, one anastomotic leak requiring reoperation occurred. On the basis of this experience, we recommend excisional therapy in all cases in which the intraoperative diagnosis is certain. Suspicion of a neoplastic process continues to prompt colectomy in an emergency setting.

Gangrenous and/or perforated appendix: clinical outcome and in vitro susceptibility testing.

The data from this study indicate that cefoxitin was effective and generally well tolerated in the management of gangrenous and/or perforated appendicitis. No strong correlation was identified between in vitro susceptibility testing results and clinical outcome.

Predictive factors for bactibilia in acute cholecystitis.

Acute cholecystitis is well established as one of the high-risk factors bactibilla and wound infection. However, many patients with acute cholecystitis do not have bactibillia. Therefore, we analyzed 20 clinical and laboratory parameters in 49 patients with acute cholecystitis to determine which factor(s) predicted bactibilla. Twenty-one (42.9%) of 49 patients with pathologically proved acute cholecystitis had positive bile and/or gallbladder wall cultures. Univariate analysis suggested that a preoperative temperature greater than 37.3 degrees C, a total serum bilirubin level greater than 8.6 mumol/L, and a white blood cell count greater than 14.1 x 10(9)/L were the best predictors of bactibilia. Multifactorial analysis demonstrated that the 17 patients with zero or one predictive factor had a significantly lower chance of having bactibilia than the 32 patients with two or three predictive factors (6% vs 63%). We concluded that the culture status of patients with acute cholecystitis can be predicted preoperatively. We propose that patients with acute cholecystitis and zero or one of the predictive factors receive a single preoperative antibiotic dose. In patients with two or three predictive factors, antibiotics should be continued until culture data are available.