Karın Ağrısında Antibiyotik Tedavisi
Özet
Karın ağrısı, acil servislere başvurunun en sık nedenlerinden biri olup, akut karın ağrısı yaşamı tehdit edebilen ve hızlı tanı ile uygun tedavi gerektiren klinik bir tablodur. Tanısal belirsizlik ve zaman baskısı nedeniyle acil servislerde karın ağrısı ile başvuran hastalara antibiyotiklerin sıklıkla koruyucu amaçla başlandığı görülmektedir. Ancak karın ağrısı etiyolojilerinin önemli bir kısmı enfeksiyöz olmayıp, gereksiz antibiyotik kullanımı hem bireysel hem de toplumsal düzeyde ciddi riskler taşımaktadır. Acil serviste antibiyotik gerektiren başlıca nedenler arasında akut apandisit, komplike divertikülit, akut kolesistit ve kolanjit, intraabdominal perforasyon ve peritonit, pelvik inflamatuar hastalık ve komplike üriner sistem enfeksiyonları yer almaktadır. Bu klinik tablolarda antibiyotik tedavisi, hastalık şiddeti, sepsis bulguları ve hasta özellikleri doğrultusunda zamanında ve uygun spektrumda uygulanmalıdır. Buna karşılık akut pankreatit, ileus, mezenter iskemi, over torsiyonu ve fonksiyonel karın ağrılarında rutin antibiyotik kullanımının yeri yoktur. Gereksiz antibiyotik kullanımı tanının gecikmesine, antimikrobiyal direnç gelişimine, Clostridioides difficile enfeksiyonuna ve ilaç ilişkili toksisitelerin artmasına yol açabilmektedir. Bu nedenle acil serviste karın ağrısı yönetiminde antibiyotik uygulama kararı, klinik, laboratuvar ve görüntüleme bulgularına dayalı, kanıta dayalı ve bireyselleştirilmiş bir yaklaşımla verilmelidir.
Abdominal pain is one of the most common reasons for emergency department visits, and acute abdominal pain represents a potentially life threatening clinical condition that requires rapid diagnosis and appropriate treatment. Diagnostic uncertainty and time pressure in the emergency setting often lead to the frequent initiation of antibiotics for abdominal pain as a precautionary measure. However, a significant proportion of abdominal pain etiologies are non-infectious, and unnecessary antibiotic use poses serious risks at both the individual and societal levels. The main causes of abdominal pain requiring antibiotic therapy in the emergency department include acute appendicitis, complicated diverticulitis, acute cholecystitis and cholangitis, intra-abdominal perforation and peritonitis, pelvic inflammatory disease, and complicated urinary tract infections. In these clinical conditions, antibiotic therapy should be initiated in a timely manner and with an appropriate spectrum, guided by disease severity, the presence of sepsis, and patient-specific factors. In contrast, routine antibiotic use is not indicated in conditions such as acute pancreatitis, ileus, mesenteric ischemia, ovarian torsion, and functional abdominal pain. Unnecessary antibiotic use may lead to delayed diagnosis, the development of antimicrobial resistance, Clostridioides difficile infection, and an increased risk of drug-related toxicities. Therefore, antibiotic decision-making in the management of abdominal pain in the emergency department should be based on clinical assessment supported by laboratory and imaging findings, following an evidence based and individualized approach.
Referanslar
Börner N, Kappenberger AS, Weber S, et al. The Acute Abdomen: Structured Diagnosis and Treatment. Deutsches Ärzteblatt International 2025 Mar 7;122(5):137-144. doi: 10.3238/arztebl.m2025.0019.
Long B, Gottlieb M. Emergency medicine updates: Acute appendicitis in the adult patient. American Journal of Emergency Medicine 2025 Dec;98:262-268. doi: 10.1016/j.ajem.2025.09.007
Salminen P, Haijanen J, Minneci PC, et al. Appendicitis. Nature Reviews Disease Primers. 2025 Nov 13;11(1):79. doi: 10.1038/s41572-025-00659-6.
DiSaverio S, Podda M, De Simone B, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World Journal of Emergency Surgery. 2020 Apr 15;15(1):27. doi: 10.1186/s13017-020-00306-3.
Mayl J, Marchenko M, Frierson E. Management of Acute Uncomplicated Diverticulitis May Exclude Antibiotic Therapy. Cureus. 2017 May 15;9(5):e1250. doi: 10.7759/cureus.1250.
Garfinkle R, Salama E, Amar-Zifkin A, et al. Observational versus antibiotic therapy for acute uncomplicated diverticulitis: A non-inferiority meta-analysis based on a Delphi consensus. Surgery. 2022 Feb;171(2):328-335. doi: 10.1016/j.surg.2021.07.012.
Long B, Werner J, Gottlieb M. Emergency medicine updates: Acute diverticulitis. American Journal of Emergency Medicine 2024 Feb;76:1-6. doi: 10.1016/j.ajem.2023.10.051.
Fico V, La Greca A, Tropeano G, et al. Updates on Antibiotic Regimens in Acute Cholecystitis. Medicina (Kaunas). 2024 Jun 25;60(7):1040. doi: 10.3390/medicina60071040.
Gomi H, Solomkin JS, Schlossberg D, et al. Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis. Journal of Hepato-Biliary-Pancreatic Sciences 2018 Jan;25(1):3-16. doi: 10.1002/jhbp.518.
Thompson,J.E.,Jr., Bennion, R.S., Doty, J.E. et al. Predictive factors for bactibilia in acute cholecystitis. Archives of Surgery 1990, 125, 261–264.
La Regina D, DiGiuseppe M, Cafarotti S, et al. A. Antibiotic administration after cholecystectomy for acute mild-moderate cholecystitis: a PRISMA-compliant meta-analysis. Surgical Endoscopy 2019 Feb;33(2):377-383. doi: 10.1007/s00464-018-6498-0.
Tarasconi A, Coccolini F, Biffl WL, et al. Perforated and bleeding peptic ulcer: WSES guidelines. World Journal of Emergency Surgery 2020 Jan 7;15:3. doi: 10.1186/s13017-019-0283-9.
Li PK, Chow KM, Cho Y, et al. ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Peritoneal Dialysis International 2024 May;44(3):223. doi: 10.1177/08968608241251453.
Szatmary P, Grammatikopoulos T, Cai W, et al. Acute Pancreatitis: Diagnosis and Treatment. Drugs. 2022 Aug;82(12):1251-1276. doi: 10.1007/s40265-022-01766-4.
Vilz TO, Stoffels B, Strassburg C, et al. Ileus in Adults. Deutsches Ärzteblatt International 2017 Jul 24;114(29-30):508-518. doi: 10.3238/arztebl.2017.0508.
Bala M, Kashuk J, Moore EE, et al. Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery. World Journal of Emergency Surgery 2017 Aug7;12:38. doi: 10.1186/s13017-017-0150-5.
Berland T, Oldenburg WA. Acute mesenteric ischemia. Current Gastroenterology Reports 2008 Jun;10(3):341-6. doi: 10.1007/s11894-008-0065-0.
Campbell BT, Austin DM, Kahn O, et al. Current trends in the surgical treatment of pediatric ovarian torsion: we can do better. Journal of Pediatric Surgery 2015 Aug;50(8):1374-7. doi: 10.1016/j.jpedsurg.2015.04.018.
Thanasa E, Thanasa A, Xydias EM, et al. Adnexal Torsion of a Mature Cystic Ovarian Teratoma With Hemorrhagic Infarction Misdiagnosed As Pelvic Inflammatory Disease in a Perimenopausal Patient: A Case Report. Cureus. 2023 May 7;15(5):e38680. doi: 10.7759/cureus.38680.
Frock-Welnak DN, Tam J. Identification and Treatment of Acute Pelvic Inflammatory Disease and Associated Sequelae. Obstetrics and Gynecology Clinics of North America 2022 Sep;49(3):551-579. doi: 10.1016/j.ogc.2022.02.019.
Schmiemann G, Kranz J, Mandraka F, et al. The Diagnosis, Treatment, and Prevention of Recurrent Urinary Tract Infection. Deutsches Ärzteblatt International 2024 May 31;121(11):373-382. doi: 10.3238/arztebl.m2024.0068.
Tan CW, Chlebicki MP. Urinary tract infections in adults. Singapore Medical Journal 2016 Sep;57(9):485-90. doi: 10.11622/smedj.2016153.
Fleckenstein JM, Matthew Kuhlmann F, Sheikh A. Acute Bacterial Gastroenteritis. Gastroenterology Clinics of North America 2021 Jun;50(2):283-304. doi: 10.1016/j.gtc.2021.02.002.
Riddle MS, DuPont HL, Connor BA. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. American Journal of Gastroenterology 2016 May;111(5):602-22. doi: 10.1038/ajg.2016.126.
Tang KWK, Millar BC, Moore JE. Antimicrobial Resistance (AMR). British Journal of Biomedical Science 2023 Jun28;80:11387. doi: 10.3389/bjbs.2023.11387.
Reyman M, vanHouten MA, Watson RL, et al. Effects of early-life antibiotics on the developing infant gut microbiome and resistome: a randomized trial. Nature Communications 2022 Feb 16;13(1):893. doi: 10.1038/s41467-022-28525-z.
Abad CLR, Safdar N. A Review of Clostridioides difficile Infection and Antibiotic Associated Diarrhea. Gastroenterology Clinics of North America 2021 Jun;50(2):323-340. doi: 10.1016/j.gtc.2021.02.010.
Referanslar
Börner N, Kappenberger AS, Weber S, et al. The Acute Abdomen: Structured Diagnosis and Treatment. Deutsches Ärzteblatt International 2025 Mar 7;122(5):137-144. doi: 10.3238/arztebl.m2025.0019.
Long B, Gottlieb M. Emergency medicine updates: Acute appendicitis in the adult patient. American Journal of Emergency Medicine 2025 Dec;98:262-268. doi: 10.1016/j.ajem.2025.09.007
Salminen P, Haijanen J, Minneci PC, et al. Appendicitis. Nature Reviews Disease Primers. 2025 Nov 13;11(1):79. doi: 10.1038/s41572-025-00659-6.
DiSaverio S, Podda M, De Simone B, et al. Diagnosis and treatment of acute appendicitis: 2020 update of the WSES Jerusalem guidelines. World Journal of Emergency Surgery. 2020 Apr 15;15(1):27. doi: 10.1186/s13017-020-00306-3.
Mayl J, Marchenko M, Frierson E. Management of Acute Uncomplicated Diverticulitis May Exclude Antibiotic Therapy. Cureus. 2017 May 15;9(5):e1250. doi: 10.7759/cureus.1250.
Garfinkle R, Salama E, Amar-Zifkin A, et al. Observational versus antibiotic therapy for acute uncomplicated diverticulitis: A non-inferiority meta-analysis based on a Delphi consensus. Surgery. 2022 Feb;171(2):328-335. doi: 10.1016/j.surg.2021.07.012.
Long B, Werner J, Gottlieb M. Emergency medicine updates: Acute diverticulitis. American Journal of Emergency Medicine 2024 Feb;76:1-6. doi: 10.1016/j.ajem.2023.10.051.
Fico V, La Greca A, Tropeano G, et al. Updates on Antibiotic Regimens in Acute Cholecystitis. Medicina (Kaunas). 2024 Jun 25;60(7):1040. doi: 10.3390/medicina60071040.
Gomi H, Solomkin JS, Schlossberg D, et al. Tokyo Guidelines 2018: antimicrobial therapy for acute cholangitis and cholecystitis. Journal of Hepato-Biliary-Pancreatic Sciences 2018 Jan;25(1):3-16. doi: 10.1002/jhbp.518.
Thompson,J.E.,Jr., Bennion, R.S., Doty, J.E. et al. Predictive factors for bactibilia in acute cholecystitis. Archives of Surgery 1990, 125, 261–264.
La Regina D, DiGiuseppe M, Cafarotti S, et al. A. Antibiotic administration after cholecystectomy for acute mild-moderate cholecystitis: a PRISMA-compliant meta-analysis. Surgical Endoscopy 2019 Feb;33(2):377-383. doi: 10.1007/s00464-018-6498-0.
Tarasconi A, Coccolini F, Biffl WL, et al. Perforated and bleeding peptic ulcer: WSES guidelines. World Journal of Emergency Surgery 2020 Jan 7;15:3. doi: 10.1186/s13017-019-0283-9.
Li PK, Chow KM, Cho Y, et al. ISPD peritonitis guideline recommendations: 2022 update on prevention and treatment. Peritoneal Dialysis International 2024 May;44(3):223. doi: 10.1177/08968608241251453.
Szatmary P, Grammatikopoulos T, Cai W, et al. Acute Pancreatitis: Diagnosis and Treatment. Drugs. 2022 Aug;82(12):1251-1276. doi: 10.1007/s40265-022-01766-4.
Vilz TO, Stoffels B, Strassburg C, et al. Ileus in Adults. Deutsches Ärzteblatt International 2017 Jul 24;114(29-30):508-518. doi: 10.3238/arztebl.2017.0508.
Bala M, Kashuk J, Moore EE, et al. Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery. World Journal of Emergency Surgery 2017 Aug7;12:38. doi: 10.1186/s13017-017-0150-5.
Berland T, Oldenburg WA. Acute mesenteric ischemia. Current Gastroenterology Reports 2008 Jun;10(3):341-6. doi: 10.1007/s11894-008-0065-0.
Campbell BT, Austin DM, Kahn O, et al. Current trends in the surgical treatment of pediatric ovarian torsion: we can do better. Journal of Pediatric Surgery 2015 Aug;50(8):1374-7. doi: 10.1016/j.jpedsurg.2015.04.018.
Thanasa E, Thanasa A, Xydias EM, et al. Adnexal Torsion of a Mature Cystic Ovarian Teratoma With Hemorrhagic Infarction Misdiagnosed As Pelvic Inflammatory Disease in a Perimenopausal Patient: A Case Report. Cureus. 2023 May 7;15(5):e38680. doi: 10.7759/cureus.38680.
Frock-Welnak DN, Tam J. Identification and Treatment of Acute Pelvic Inflammatory Disease and Associated Sequelae. Obstetrics and Gynecology Clinics of North America 2022 Sep;49(3):551-579. doi: 10.1016/j.ogc.2022.02.019.
Schmiemann G, Kranz J, Mandraka F, et al. The Diagnosis, Treatment, and Prevention of Recurrent Urinary Tract Infection. Deutsches Ärzteblatt International 2024 May 31;121(11):373-382. doi: 10.3238/arztebl.m2024.0068.
Tan CW, Chlebicki MP. Urinary tract infections in adults. Singapore Medical Journal 2016 Sep;57(9):485-90. doi: 10.11622/smedj.2016153.
Fleckenstein JM, Matthew Kuhlmann F, Sheikh A. Acute Bacterial Gastroenteritis. Gastroenterology Clinics of North America 2021 Jun;50(2):283-304. doi: 10.1016/j.gtc.2021.02.002.
Riddle MS, DuPont HL, Connor BA. ACG Clinical Guideline: Diagnosis, Treatment, and Prevention of Acute Diarrheal Infections in Adults. American Journal of Gastroenterology 2016 May;111(5):602-22. doi: 10.1038/ajg.2016.126.
Tang KWK, Millar BC, Moore JE. Antimicrobial Resistance (AMR). British Journal of Biomedical Science 2023 Jun28;80:11387. doi: 10.3389/bjbs.2023.11387.
Reyman M, vanHouten MA, Watson RL, et al. Effects of early-life antibiotics on the developing infant gut microbiome and resistome: a randomized trial. Nature Communications 2022 Feb 16;13(1):893. doi: 10.1038/s41467-022-28525-z.
Abad CLR, Safdar N. A Review of Clostridioides difficile Infection and Antibiotic Associated Diarrhea. Gastroenterology Clinics of North America 2021 Jun;50(2):323-340. doi: 10.1016/j.gtc.2021.02.010.
