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Проблемы использования антибактериальных и антифунгальных препаратов у больных острым панкреатитом с высоким риском развития панкреатогенного сепсиса (обзор)

Проблемы использования антибактериальных и антифунгальных препаратов у больных острым панкреатитом с высоким риском развития панкреатогенного сепсиса (обзор)

В.Г. Фирсова, В.В. Паршиков, М.В. Кукош, А.С. Мухин
Ключевые слова: острый панкреатит; сепсис; антибиотикотерапия; антибиотикопрофилактика; антифунгальная терапия.
2020, том 12, номер 1, стр. 126.
DOI: https://doi.org/10.17691/stm2020.12.1.15

Полный текст статьи

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Контроль за инфекцией имеет ключевое значение в лечении больных острым панкреатитом (ОП). Течение инфекционного процесса при ОП характеризуется особенностями, предрасполагающими к развитию сепсиса: значительный объем поражения не только поджелудочной железы, но и забрюшинной клетчатки; быстро развивающиеся нарушения в иммунной системе; плохое проникновение антимикробных препаратов в некротизированную ткань; невозможность одномоментной хирургической санации очагов. Антибактериальная и противогрибковая терапия больных с инфицированным некрозом, а также с внепанкреатическими инфекциями, ассоциированными с ОП, остается сложной и во многом нерешенной проблемой, в том числе из-за высокой частоты инфицирования полирезистентными микроорганизмами. Использование антимикробных препаратов с целью профилактики инфицирования является предметом многочисленных исследований, результаты которых неоднозначны, что затрудняет выработку единой стратегии в клинике. Данные метаанализов последних лет не демонстрируют убедительных доказательств эффективности профилактического использования антибактериальных средств в снижении летальности, частоты инфицирования, потребности в хирургическом лечении у больных некротическим ОП. Только два исследования свидетельствуют о преимуществах применения карбапенемов с профилактической целью и один метаанализ содержит доказательства возможного снижения летальности при назначении антибиотиков не позднее 72 ч от начала приступа. Селективная деконтаминация кишечника рассматривается как один из методов профилактики инфицирования, хотя имеющиеся данные не являются строго достоверными.

Основными показаниями к назначению антибактериальных препаратов при ОП считают подтвержденный инфицированный некроз или инфекцию внепанкреатической локализации, а также клиническое подозрение на развитие инфицирования. Внутриартериальная инфузия и местное применение антибиотиков могут увеличить эффективность антибактериальной терапии. Рандомизированные исследования антифунгальной профилактики при ОП отсутствуют, в ряде работ обосновано ее проведение при высоком риске инвазивного кандидоза, который может быть оценен при помощи специальных индексов.

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