Antibiotic prophylaxis of pancreatic infection in patients with necrotizing pancreatitis: rationale, evidence, and recommendations

Antibiosis of Necrotizing Pancreatitis

BACKGROUND

Necrotizing pancreatitis is a life-threatening presentation of acute pancreatitis. The mortality of 20-80% initially depends on the persistence of organ failure and systemic inflammatory response syndrome (SIRS) and, in the later course of the disease, on secondary infection of the necrosis. The questions whether prophylactic antibiotics aiming to prevent this infection should be administered and which antibiotic is the best to use, as well as the problem of fungal infection under antibiotic treatment are still intriguing and insufficiently solved.

METHODS

A search of the literature using PubMed was carried out, supplemented by a review of the programmes of the Digestive Disease Week (DDW) and the United European Gastroenterology Week (UEGW).

RESULTS

Despite the widely practised prophylactic antibiotic administration in severe pancreatitis, no evidence for the benefit of this strategy exists. One of the drawbacks might be a tendency for disastrous fungal infection under prophylactic antibiotics. Bacterial translocation from the gut in the second week after the onset of symptoms is the major source for infection of pancreatic necrosis and provides a clear indication for antibiotic treatment. However, routine fine-needle aspiration for a calculated antibiotic therapy cannot be recommended, and all other tests offer only indirect signs. Important factors such as enteral versus parenteral feeding and the method of necrosectomy are mostly neglected in the trials but seem to be essential for the outcome of the patient.

CONCLUSIONS

Even though most meta-analyses including the newer double-blind, placebo-controlled trials on prophylactic antibiotics showed no beneficial effects in the prevention of infection of necrosis and/or outcome of the patients, this strategy is still widely used in clinical routine. Since nearly all trials published so far show systematic problems (i.e. inaccurate definition of the severity of the disease, poor statistical testing, and neglect of differences in the route of nutrition), there is a need for randomized controlled prospective trials with exact definitions of the disease.

Effects of probiotic supplementation on markers of acute pancreatitis in rats

BACKGROUND

Intestinal barrier disruption followed by bacterial translocation seems to play a role in secondary pancreatic infection in acute pancreatitis. The use of probiotics as a possible adjuvant strategy in the treatment of acute pancreatitis needs to be investigated.

OBJECTIVE

The aim of this study was to determine the effects of dietary supplementation with a prophylactically administered multispecies probiotic mixture on the markers of acute pancreatitis and on the occurrence of bacterial translocation.

METHODS

Thirty adult male Wistar rats were randomly assigned to 1 of 3 groups of 10 rats each: (1) the PS group, in which the rats were given probiotic supplementation prior to induction of acute pancreatitis; (2) the WP group, in which the rats underwent surgery to induce acute pancreatitis without prior probiotic supplementation; and (3) the control group, in which the rats underwent sham surgery. For 14 days before surgery, animals in the PS group received a single daily dose containing ~1.2 × 10(9) colony-forming units of a probiotic mixture administered intragastrically as a bolus. On day 15, the animals underwent surgery to induce acute pancreatitis (PS and WP groups) or simulated surgery (control group). Blood samples were collected to determine leukocyte count, amylase and lipase activities, and glucose and calcium concentrations immediately before and 6 and 12 hours after the beginning of the procedure. Samples of pancreas, spleen, liver, and mesenteric lymph nodes were harvested for microbiologic and histopathologic analysis after the last blood sample collection. The pathologist examining the histopathology was blinded to treatment assignment.

RESULTS

The mean leukocyte count was significantly increased in the PS group compared with the WP group (P = 0.018), whereas the serum amylase and lipase activities and the serum glucose and calcium concentrations were not significantly different between the 2 groups. Comparing the risk for tissue colonization in the PS group with that of the WP group, the odds ratio (OR) for pancreas was 2.91 (95% CI, 0.13-67.10); liver, 66.55 (95% CI, 1.89-2282.66); spleen, 88.58 (95% CI, 3.04-2583.08); and mesenteric lymph nodes, 1.23 (95% CI, 0.06-25.48). When the risks for histopathologic changes were compared between the 2 groups, the OR for acinar necrosis was 1.73 (95% CI, 0.21-12.17); steatonecrosis, 12.08 (95% CI, 1.26-115.54); hemorrhage, 1.38 (95% CI, 0.21-9.53); and leukocyte infiltration, 5.91 (95% CI, 0.64-54.89).

CONCLUSION

Probiotic supplementation before the induction of acute pancreatitis was associated with a greater degree of bacterial translocation and pancreatic tissue damage in this animal model.

Antioxidant therapy in acute pancreatitis: experimental and clinical evidence

SIGNIFICANCE

Oxidative stress plays an important role in the pathogenesis of both acute and chronic pancreatitis. Although its impact is well investigated and has been studied clinically in chronic pancreatitis, it is less well defined for acute pancreatitis.

RECENT ADVANCES

Pathophysiological aspects of oxidative stress in acute pancreatitis have shown that reactive oxidative species (ROS) participate in the inflammatory cascade, and mediate inflammatory cell adhesion and consecutive tissue damage. Furthermore, ROS are involved in the generation of pain as another important clinical feature of patients suffering from acute pancreatitis.

CRITICAL ISSUES

Despite sufficient basic and experimental knowledge and evidence, the step from bench to bedside has not been successfully performed. Only a limited number of clinical studies are available that can give convincing evidence for the use of antioxidants in the clinical setting of acute pancreatitis.

FUTURE DIRECTIONS

Future studies are required to evaluate potential benefits of antioxidative substances to attenuate the severity of acute pancreatitis. Special focus should be put on the aspect of pain generation and the progression from mild to severe acute pancreatitis in the clinical setting.

Acute pancreatitis

PURPOSE OF REVIEW

To review advances over the last year in the prevention, diagnosis and management of acute pancreatitis.

RECENT FINDINGS

Obesity is an independent risk factor for severity in acute pancreatitis, and heavy alcohol consumption for the development of necrosis in severe acute pancreatitis. Biochemical markers have been further tested, including carbohydrate-deficient transferrin for the diagnosis of alcohol-induced acute pancreatitis, urinary trypsinogen-2 as a diagnostic marker for acute pancreatitis, and interleukin-6 and procalcitonin as markers of disease severity. A new, simple stratification system, the 'panc 3 score', has been described. There are conflicting data on the use of antibiotic prophylaxis in acute necrotizing pancreatitis, and on the chemoprevention of postendoscopic retrograde cholangiopancreatography pancreatitis. Enteral feeding is established as standard practice early in the management of acute pancreatitis of all aetiologies; probiotics and other compounds may also play a role.

SUMMARY

Over the last year, there have been further innovations in the risk stratification and management of acute pancreatitis. Unresolved issues include chemoprevention of endoscopic retrograde cholangiopancreatography-induced acute pancreatitis, the indications for antibiotic prophylaxis in severe acute pancreatitis and nutritional supplementation with probiotics and synbiotics.

Pharmacokinetic and pharmacodynamic properties of biapenem, a carbapenem antibiotic, in rat experimental model of severe acute pancreatitis

OBJECTIVES

It is known that prophylaxis with imipenem reduces the risk of infection accompanying severe acute pancreatitis. In this study,we modified a rat experimental model of severe acute pancreatitis for antibiotic evaluation, and the effect of biapenem was compared with that of imipenem to determine the usefulness of biapenem.

METHODS

Severe acute pancreatitis was induced by 5% sodium taurocholate. Antibiotics were subcutaneously administered at 3 and 6 hours and evaluated at 12 hours after the pancreatitis induction. For pharmacokinetic evaluation, antibiotics were subcutaneously administered at 3 hours after the pancreatitis induction.

RESULTS

From 3 hours after the induction, bacteria were detected from the pancreas. The total bacterial count increased in a time-dependent manner for 12 hours. Biapenem administration reduced the total bacterial count in the pancreas, as observed in imipenem administration. The plasma concentration of biapenem was almost equivalent to that of imipenem; however, the pancreatic penetration of biapenem was approximately twice that of imipenem in this model.

CONCLUSIONS

Biapenem was suggested to be effective in prophylactic treatment of infectious complications as much as imipenem because of its superior penetration to the pancreas in severe acute pancreatitis.

Pro/con debate: antifungal prophylaxis is important to prevent fungal infection in patients with acute necrotizing pancreatitis receiving broad-spectrum antibiotics

When critically ill patients with pancreatitis develop infection of the pancreas, the ongoing management of such patients becomes difficult. Sufficient evidence supports the use of broad-spectrum antibiotic prophylaxis to prevent the development of bacterial infection. Since fungal infection is also a relatively common complication of severe pancreatitis--particularly when broad-spectrum antibiotics are used--it seems logical that fungal prophylaxis may be an important component of management. In this issue of Critical Care, two expert groups debate the merits of antifungal prophylaxis in patients with acute necrotizing pancreatitis who are receiving antibiotics.