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Kovacic S, Roginic S, Nemrava J, Gospocic K, Seferovic Saric M, Luetic K. Acute pancreatitis in two patients with Parkinson’s disease. COGENT MEDICINE 2017. [DOI: 10.1080/2331205x.2017.1312802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Sanja Kovacic
- Department of Neurology, General Hospital Zabok and Hospital of Croatian Veterans, Bracak 8, 49210 Zabok, Croatia
- Faculty of Medicine, University of Osijek, Josip Juraj Strosmayer, 31000 Osijek, Croatia
| | - Sinisa Roginic
- Department of Internal Medicine, General Hospital Zabok and Hospital of Croatian, Veterans, Bracak 8, 49210 Zabok, Croatia
| | - Johann Nemrava
- Department of Surgery, General Hospital Zabok and Hospital of Croatian Veterans, Bracak 8, 49210 Zabok, Croatia
| | - Ksenija Gospocic
- Department of Radiology, General Hospital Zabok and Hospital of Croatian Veterans, Bracak 8, 49210 Zabok, Croatia
| | - Maida Seferovic Saric
- Department of Neurology, General Hospital Zabok and Hospital of Croatian Veterans, Bracak 8, 49210 Zabok, Croatia
| | - Kresimir Luetic
- Clinic for Internal Medicine, University Hospital Sv. Duh, Sv. Duh 64, 10000 Zagreb, Croatia
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Villatoro E, Mulla M, Larvin M. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane Database Syst Rev 2010; 2010:CD002941. [PMID: 20464721 PMCID: PMC7138080 DOI: 10.1002/14651858.cd002941.pub3] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pancreatic necrosis may complicate severe acute pancreatitis, and is detectable by computed tomography (CT). If it becomes infected mortality increases, but the use of prophylactic antibiotics raises concerns about antibiotic resistance and fungal infection. OBJECTIVES To determine the efficacy and safety of prophylactic antibiotics in acute pancreatitis complicated by CT proven pancreatic necrosis. SEARCH STRATEGY Searches were updated in November 2008, in The Cochrane Library (Issue 2, 2008), MEDLINE, EMBASE, and CINAHL. Conference proceedings and references from found articles were also searched. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing antibiotics versus placebo in acute pancreatitis with CT proven necrosis. DATA COLLECTION AND ANALYSIS Primary outcomes were mortality and pancreatic infection rates. Secondary end-points included non pancreatic infection, all sites infection, operative rates, fungal infections, and antibiotic resistance. Subgroup analyses were performed for antibiotic regimen (beta-lactam, quinolone, and imipenem). MAIN RESULTS Seven evaluable studies randomised 404 patients. There was no statistically significant effect on reduction of mortality with therapy: 8.4% versus controls 14.4%, and infected pancreatic necrosis rates: 19.7% versus controls 24.4%. Non-pancreatic infection rates and the incidence of overall infections were not significantly reduced with antibiotics: 23.7% versus 36%; 37.5% versus 51.9% respectively. Operative treatment and fungal infections were not significantly different. Insufficient data were provided concerning antibiotic resistance.With beta-lactam antibiotic prophylaxis there was less mortality (9.4% treatment, 15% controls), and less infected pancreatic necrosis (16.8% treatment group, 24.2% controls) but this was not statistically significant. The incidence of non-pancreatic infections was non-significantly different (21% versus 32.5%), as was the incidence of overall infections (34.4% versus 52.8%), and operative treatment rates. No significant differences were seen with quinolone plus imidazole in any of the end points measured. Imipenem on its own showed no difference in the incidence of mortality, but there was a significant reduction in the rate of pancreatic infection (p=0.02; RR 0.34, 95% CI 0.13 to 0.84). AUTHORS' CONCLUSIONS No benefit of antibiotics in preventing infection of pancreatic necrosis or mortality was found, except for when imipenem (a beta-lactam) was considered on its own, where a significantly decrease in pancreatic infection was found. None of the studies included in this review were adequately powered. Further better designed studies are needed if the use of antibiotic prophylaxis is to be recommended.
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Affiliation(s)
- Eduardo Villatoro
- University of NottinghamAcademic Division of Surgery, School of Graduate Entry MedicineDerby City General HospitalUttoxeter RoadDerbyDerbyshireUKDE22 3DT
| | - Mubashir Mulla
- University of NottinghamAcademic Division of Surgery, School of Graduate Entry MedicineDerby City General HospitalUttoxeter RoadDerbyDerbyshireUKDE22 3DT
| | - Mike Larvin
- University of NottinghamAcademic Division of Surgery, School of Graduate Entry MedicineDerby City General HospitalUttoxeter RoadDerbyDerbyshireUKDE22 3DT
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Xu T, Cai Q. Prophylactic antibiotic treatment in acute necrotizing pancreatitis: results from a meta-analysis. Scand J Gastroenterol 2009; 43:1249-58. [PMID: 18609129 DOI: 10.1080/00365520802130175] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The effect of prophylactic antibiotic treatment on infection and survival of acute necrotizing pancreatitis (ANP) remains uncertain. The aim of this study was to assess the long-term efficacy of prophylactic antibiotic treatment for ANP. MATERIAL AND METHODS Searches were carried out of electronic databases including Medline, EMBASE, the Cochrane Controlled Trials Register, the Science Citation Index, and PubMed (updated to December 2007), and manual bibliographical searches were also conducted. A meta-analysis of all randomized controlled trials (RCTs) comparing prophylactic antibiotic treatment with placebo or no treatment was performed. RESULTS Eight RCTs including 540 patients were assessed. The outcomes included infected necrosis, death, non-pancreatic infection, surgical intervention, and length of hospital stay. Prophylactic antibiotic use leads to a significant reduction of infected necrosis (relative risk (RR) 0.69, 95% CI, 0.50-0.95; p=0.02), non-pancreatic infections (RR 0.66 95% CI, 0.48-0.91; p=0.01), and length of hospital stay (p=0.004) but was not associated with a statistically significant reduction in mortality (RR 0.76 95% CI, 0.50-1.18; p=0.22) and surgical intervention (RR 0.90 95% CI, 0.66-1.23; p=0.52). In a subgroup analysis, carbapenem was associated with a significant reduction in infected necrosis (p=0.009) and non-pancreatic infections (p=0.006), whereas other antibiotics were not. CONCLUSIONS Prophylactic antibiotic treatment is associated with a significant reduction of pancreatic or peripancreatic infection, non-pancreatic infection, and length of hospital stay, but cannot prevent death and surgical intervention in acute necrotizing pancreatitis.
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Affiliation(s)
- Tao Xu
- Department of General Surgery, Changzheng Hospital, Second Military Medical University, Shanghai, China
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Rojas-Serrano J, Pedroza J, Regalado J, Robledo J, Reyes E, Sifuentes-Osornio J, Flores-Suárez LF. High prevalence of infections in patients with systemic lupus erythematosus and pulmonary haemorrhage. Lupus 2008; 17:295-9. [DOI: 10.1177/0961203307086930] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The main objective of this study is to describe the presence of infections in patients with pulmonary haemorrhage and systemic lupus erythematosus. Patients with systemic lupus erythematosus and pulmonary haemorrhage were thoroughly evaluated in the first 48 hours with imaging plus bronchoscopy and bronchoalveolar fluid analysis. If needed, videoassisted thoracoscopy and lung biopsy were performed too. In all, search for bacterial, mycobacterial and fungal infections proceeded. Appropriate blood, bronchoalveolar fluid and tissue cultures were taken. Patients were treated with antibiotics and corticosteroids in case of infection. Otherwise, they received initial intravenous methylprednsiolone pulses for 3 days as standard therapy for pulmonary haemorrhage in systemic lupus erythematosus. Additional treatment with immunosuppressives was further decided by the treating physicians. Fourteen events in 13 patients were evaluated. In eight events (57%), an infection was demonstrated. Aetiological agents included Pseudomonas sp. and Aspergillus fumigatus. Four patients died, three of them because of the pulmonary infection and one because of cerebral haemorrhage secondary to severe systemic hypertension, 48 hours after methylprednisolone treatment. Patients with systemic lupus erythematosus and pulmonary haemorrhage have a high prevalence of infections. The influence of pulmonary haemorrhage in the setting of systemic lupus erythematosus needs further study to establish adequate treatment and to reduce the high mortality of this complication.
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Affiliation(s)
- J Rojas-Serrano
- Instituto Nacional de Enfermedades Respiratorias, Ismael Cosío Villegas, Mexico City, Mexico
| | - J Pedroza
- Critical Care Medicine Division, Instituto Nacional de Ciencias Médicas y Nutrición, Mexico City, Mexico
| | - J Regalado
- Instituto Nacional de Enfermedades Respiratorias, Ismael Cosío Villegas, Mexico City, Mexico
| | - J Robledo
- Instituto Nacional de Enfermedades Respiratorias, Ismael Cosío Villegas, Mexico City, Mexico
| | - E Reyes
- Department of Pathology, Instituto Nacional de Ciencias Médicas y Nutrición, Mexico City, Mexico
| | - J Sifuentes-Osornio
- Department of Infectious Diseases, Instituto Nacional de Ciencias Médicas y Nutrición, Mexico City, Mexico
| | - LF Flores-Suárez
- Department of Immunology and Rheumatology, Instituto Nacional de Ciencias Médicas y Nutrición, Mexico City, Mexico
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Villatoro E, Bassi C, Larvin M. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane Database Syst Rev 2006:CD002941. [PMID: 17054156 DOI: 10.1002/14651858.cd002941.pub2] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Acute pancreatitis is a common abdominal emergency with no specific treatment. Pancreatic necrosis may complicate severe attacks, detectable by computed tomography (CT). Necrosis can become infected, making surgical intervention necessary and increasing mortality to more than 40%. Experimental studies suggest that antibiotic therapy may prevent infection, but could promote resistance and fungal infection. OBJECTIVES To determine the effectiveness and safety of prophylactic antibiotics in acute pancreatitis complicated by pancreatic necrosis. SEARCH STRATEGY The Cochrane Library (Issue 1, 2006), MEDLINE (January 1966-December 2005), EMBASE (January 1980-December 2005) and CINAHL (January 1982-December 2005) were searched. We also examined Conference proceedings. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing antibiotics versus placebo in acute pancreatitis with CT proven necrosis were sought using a detailed search strategy without linguistic limitation. RCTs. Initial searching was undertaken in November 2001. Latest update: December 2005. DATA COLLECTION AND ANALYSIS Two reviewers extracted data independently for rates of primary end-points: mortality and pancreatic infection rates. Secondary end-points included: non pancreatic infection and operative rates. Adverse events: antibiotic resistance and fungal infections. Subgroup analyses: antibiotic regimen. MAIN RESULTS Five evaluable studies randomised 294 patients. Analysis suggested significantly less mortality with therapy (6%) versus controls (15.3%), odds ratio 0.37 (95% CI 0.17, 0.83). Infected pancreatic necrosis rates were not significantly different (therapy 20%, controls 27.8%), odds ratio 0.62 (95% CI 0.35, 1.09), and neither were operative treatment rates or non-pancreatic infection rates. Fungal infections were not significantly different at 4% with therapy versus 4.9% in controls, odds ratio 0.83 (95% CI 0.30, 2.27). There were no evaluable data on antibiotic resistance. Sub-group analysis was performed for antibiotic regimen: beta lactam (192 patients), and quinolone plus imidazole (102 patients). With beta lactam prophylaxis there was significantly less mortality (6.3%) versus controls (16.7%), odds ratio 0.34 (95% CI 0.13, 0.91), and infected pancreatic necrosis (15.6%) versus (29.2%) in controls, odds ratio 0.41 (95% CI 0.20, 0.85), but there were no significant differences in operative treatment rates or non-pancreatic infections. No significant differences were seen with quinolone plus imidazole. AUTHORS' CONCLUSIONS Antibiotic prophylaxis appeared to be associated with significantly decreased mortality but not infected pancreatic necrosis. Beta lactams were associated with significantly decreased mortality and infected pancreatic necrosis, but quinolone plus imidazole regimens were not. There were variations in methodological quality, treatment regimens, and a lack of data on adverse effects. Further better designed studies are needed to support antibiotic prophylaxis and, should these prove beneficial, to compare beta-lactams with quinolones directly.
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Affiliation(s)
- E Villatoro
- University of Nottingham, Division of GI Surgery, University of Nottingham School of Medicine, Clinical Science Buildings, Derby City General Hospital, Uttoxeter Road, Derby, Derbyshire, UK
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Chang YC, Tsai HM, Lin XZ, Chang CH, Chuang JP. No debridement is necessary for symptomatic or infected acute necrotizing pancreatitis: delayed, mini-retroperitoneal drainage for acute necrotizing pancreatitis without debridement and irrigation. Dig Dis Sci 2006; 51:1388-95. [PMID: 16855881 DOI: 10.1007/s10620-006-9112-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2005] [Accepted: 11/01/2005] [Indexed: 12/19/2022]
Abstract
We sought to determine if necrosectomy can be omitted for complicated acute necrotizing pancreatitis (ANP). Since 1996, we prospectively performed retroperitoneal drainage by introducing a sump drain to the pancreatic head area via a small left flank incision without debridement and irrigation on 19 consecutive complicated ANP patients. We purposely delayed surgery until liquefaction of retroperitoneal tissue reached the left flank. Our patients had a mean Ranson's and APACHE II score of 5.9 (range, 4-8) and 20.1(range, 4-45), respectively. Sixteen available CT showed retroperitoneal liquefaction after 21.3 days (range, 14-26). Operations were delayed for 4.7 weeks (range, 1.3-9.0). No patient succumbed during this period. The indications were infected necrosis in 16 and severe abdominal pain/food intolerance in 3 patients. Average skin incision was 4.0 cm (range, 3-9). Fungi or bacteria were cultured in 15 patients (80.0%). The recovery courses were surprisingly uneventful. Oral intake began within 2.4 days (range, 1-5) and mean hospital stay (16 survivals) was 23.2 days (range, 4-120) after operation. Drains were completely removed 120.6 days (range, 60-250) later from these outpatients. One gastric perforation and one minor duodenal leak were the only procedure-related complications (10.5%). Three patients died (15.8%), although one had a healed ANP. In conclusion, this delay-until-liquefaction strategy without necrosectomy is an easy and effective treatment method.
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Affiliation(s)
- Yu-Chung Chang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138, Sheng Li Road, Tainan, 70428, Taiwan.
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Mazaki T, Ishii Y, Takayama T. Meta-analysis of prophylactic antibiotic use in acute necrotizing pancreatitis. Br J Surg 2006; 93:674-84. [PMID: 16703633 DOI: 10.1002/bjs.5389] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Death from infected necrosis in acute pancreatitis is common and prevention has focused on prophylactic antibiotics. This study assesses whether intravenous prophylactic antibiotic use reduces infected necrosis and death in acute necrotizing pancreatitis. METHODS A meta-analysis of randomized controlled trials was carried out. Medline, Web of Science, the Cochrane controlled trials register and international conference proceedings were searched, with a citation review of relevant primary and review articles. RESULTS Six of 328 studies assessed were included in data extraction. Primary outcome measures were infected necrosis and death. Secondary outcome measures were non-pancreatic infections, surgical intervention and length of hospital stay. Prophylactic antibiotic use was not associated with a statistically significant reduction in infected necrosis (relative risk (RR) 0.77 (95 per cent confidence interval (c.i.) 0.54 to 1.12); P = 0.173), mortality (RR 0.78 (95 per cent c.i. 0.44 to 1.39); P = 0.404), non-pancreatic infections (RR 0.71 (95 per cent c.i. 0.32 to 1.58); P = 0.402) and surgical intervention (RR 0.78 (95 per cent c.i. 0.55 to 1.11); P = 0.167). It was, however, associated with a statistically significant reduction in hospital stay (P = 0.040). CONCLUSION Prophylactic antibiotics do not prevent infected necrosis or death in acute necrotizing pancreatitis.
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Affiliation(s)
- T Mazaki
- Division of Digestive Surgery, Department of Surgery, Nihon University School of Medicine, Tokyo, Japan.
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Amico EC, Canedo LF, Machado CC, Faria SG, Vivas DV. Conservative treatment of pancreatic necrosis with suggestive signs of infection. Clinics (Sao Paulo) 2005; 60:429-32. [PMID: 16254680 DOI: 10.1590/s1807-59322005000500012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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N/A, 孙 备. N/A. Shijie Huaren Xiaohua Zazhi 2005; 13:1574-1576. [DOI: 10.11569/wcjd.v13.i13.1574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023] Open
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Abstract
The aging process influences and modifies the clinical picture and treatment modalities of inflammatory pancreatic diseases in elderly patients. The two major categories of inflammatory exocrine pancreatic diseases seen in the elderly are acute pancreatitis (AP) and chronic pancreatitis (CP). In elderly patients with AP, the presence of concomitant diseases affecting renal, hepatic and cardiopulmonary function make the early clinical assessment of the severity of AP inaccurate at the time of admission to hospital. In addition, the classical multifactorial scoring system routinely utilised in clinical practice to determine the severity of AP may overscore elderly patients because increasing age is associated with more points. Contrast-enhanced computed tomography is particularly useful in assessing the severity of AP and is required in all patients suspected with severe AP. It should be repeated after a certain time period to monitor the disease. The most important aspect of the management of elderly patients with severe AP is the prevention and treatment of systemic and local complications. Treatment of AP should address the removal of aetiological factor(s) and support of organ systems and hydroelectrolytic/caloric balance; specific treatments (antiproteases, antibacterials) should also be administered to patients with severe AP. Surgery is indicated mainly when infection occurs following pancreatic necrosis and/or fluid collection. However, in selected patients with a high anaesthetic risk, alternative, less invasive drainage options (percutaneous, endoscopic) should be considered. CP rarely occurs in older age, and it should be suspected based on clinical findings. The greatest challenge is the differentiation between CP and pancreatic cancer. Treatment of CP in the elderly should be directed at controlling the symptoms, by management of diabetes and exocrine insufficiency because pain and complications are rare in elderly patients with CP. Compliance with treatment should be periodically assessed if insulin and/or oral enzyme supplementation is required. Careful evaluation of nutritional status and its prompt correction is also important.
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Affiliation(s)
- Generoso Uomo
- Department of Internal Medicine, 3rd Division, Cardarelli Hospital, Naples, Italy.
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Papagoras D, Giamarellos-Bourboulis EJ, Kanara M, Douridas G, Paraskevopoulos I, Antzaklis G, Karayannacos P, Giamarellou H. Pancreatic concentrations of cefepime in experimental necrotizing pancreatitis. J Chemother 2003; 15:43-6. [PMID: 12678413 DOI: 10.1179/joc.2003.15.1.43] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
To evaluate the penetration of cefepime in the inflamed pancreas, three doses of 50 mg/kg were administered intramuscularly at 8-h intervals after induction of acute necrotizing pancreatitis using intraperitoneal injection of DL-ethionine in 35 rabbits and in 33 controls. Animals were sacrificed and concentrations of cefepime were determined by a microbiological assay. Cefepime reached its peak concentrations 60 min after the last drug dose when mean values of 46.05 microg/ml, 22.34 microg/g and 34.74 microg/ml were found in serum, pancreas and bile, respectively, in rabbits with acute necrotizing pancreatitis and 45.19 microg/ml, 12.68 microg/g and 20.77 microg/ml respectively in controls. Tissue/serum ratios of cefepime were 0.48, 0.23, 0.15 and 0.09 at 60, 90, 120 and 180 min, respectively, after the last dose of cefepime in rabbits with acute necrotizing pancreatitis and 0.28, 0.18, 0.16 and 0.16, respectively at 60, 90, 120 and 180 min in controls. It is concluded that the administration of cefepime in rabbits with acute necrotizing pancreatitis resulted in pancreatic tissue levels well above the MIC90s of the common pathogens involved in pancreatic superinfection, so that its administration might be proposed for the therapy of superinfection following acute necrotizing pancreatitis in humans.
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Affiliation(s)
- D Papagoras
- Department of Surgery, Sismanoglion General Hospital, Maroussi Attikis, Greece
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Adler DG, Chari ST, Dahl TJ, Farnell MB, Pearson RK. Conservative management of infected necrosis complicating severe acute pancreatitis. Am J Gastroenterol 2003; 98:98-103. [PMID: 12526943 DOI: 10.1111/j.1572-0241.2003.07162.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Patients with severe necrotizing pancreatitis are at risk for infection, a major cause of morbidity and mortality. Most patients with infected pancreatic tissue require surgical intervention (necrosectomy), which is associated with high morbidity and mortality. A subset of these patients can be managed successfully with conservative management combined with prolonged courses of antibiotics. METHODS Three cases of severe acute pancreatitis seen at our institution are described, in which the patients developed aspirate-proven pancreatic infections. The patients were nonetheless stable from a clinical standpoint and were treated with long courses of antibiotics known to penetrate the pancreas; emergent surgery was deferred. RESULTS In two patients, surgery was completely avoided, with good clinical outcome. In the third patient, elective surgery was undertaken 12 wk after the episode of acute pancreatitis, to perform necrosectomy on organized pancreatic necrosis and to evaluate the patient's biliary tree. There were no postoperative complications. CONCLUSIONS A subset of patients with severe acute pancreatitis complicated by infection can be successfully managed with long term antibiotics and other supportive measures. High risk necrosectomy can, in some instances, be delayed or avoided entirely.
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Affiliation(s)
- Douglas G Adler
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota 55901, USA
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Bassi C, Larvin M, Villatoro E. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane Database Syst Rev 2003:CD002941. [PMID: 14583957 DOI: 10.1002/14651858.cd002941] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Acute pancreatitis is a common acute abdominal emergency which lacks specific therapy. In severe attacks, areas of the pancreas may become necrotic. The mortality risk rises to >40% if sterile necrosis becomes superinfected, usually with gut derived aerobic organisms. Experimental and clinical studies indicate a window of opportunity of 1-2 weeks, when superinfection, and thus high-risk surgical debridement, may be prevented by administering systemic antibiotics to 'sterilise' tissues adjacent to necrotic areas. There are theoretical risks of encouraging antibacterial resistance and opportunistic fungal infections. OBJECTIVES To determine the effectiveness and safety of prophylactic antibiotic therapy in patients with severe acute pancreatitis who have developed pancreatic necrosis. SEARCH STRATEGY MEDLINE, EMBASE, and the Cochrane Library were searched. We also examined other sources including Conference Abstracts (published and unpublished data). SELECTION CRITERIA Randomised controlled trials (RCT) were sought using the search strategy detailed below. No linguistic limitations were applied. RCTs were selected in which antibacterial therapy was evaluated in patients with severe acute pancreatitis associated with pancreatic necrosis proven by intravenous contrast-enhanced computed tomography (CT). No linguistic limitations were applied. Searching was undertaken initially in November 2001 and updated in March 2003. DATA COLLECTION AND ANALYSIS Two reviewers extracted data from trial publications independently, concerning rates for the primary end-points: with respect to: all cause mortality and rates of infection of pancreatic necrosis (proven by microbiological examination of fine needle aspirate or operative specimens). In addition, secondary end-points included peri-pancreatic sepsis, remote sepsis (respiratory, urinary, central venous line sources), operative rates, length of hospital stay, adverse events including the incidence of drug resistant microorganisms and opportunistic fungal infection. MAIN RESULTS It was possible to evaluate mortality in all four included studies, and it demonstrated a survival advantage for antibiotic therapy (Odds ratio 0.32, p=0.02). Pancreatic sepsis (infected necrosis) was also measurable in all four studies and showed an advantage for therapy (Odds ratio 0.51, p=0.04). Extra-pancreatic infection could be evaluated in three studies, but showed no significant advantage for therapy (Odds ratio 0.47, p=0.05).Operative treatment data was available in three studies, but surgery rates were not significantly reduced (Odds ratio 0.55, p=0.08). Fungal infections showed no strongly increased preponderance with therapy (Odds ratio 0.83, p=0.7), but there were no data on infection with resistant organisms. Length of hospital stay could only be evaluated in two studies and was not significantly different. Sub-group analyses planned for the influence on outcome measures of the antibiotic regimen, the time of commencement of therapy in relation to symptom onset and/or hospitalisation, duration of therapy, and aetiology could not be performed as no data were available. REVIEWER'S CONCLUSIONS Despite variations in drug agent, case mix, duration of treatment and methodological quality (especially the lack of double blinded studies), there was strong evidence that intravenous antibiotic prophylactic therapy for 10 to 14 days decreased the risk of superinfection of necrotic tissue and mortality in patients with severe acute pancreatitis with proven pancreatic necrosis at CT. Further studies are required to confirm all of the benefits suggested (in particular the need for operative debridement), to provide more adequate data on adverse effects, to address the choice of antibacterial agents and effects of varying duration of therapy, and whether outcome is related to aetiology.
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Affiliation(s)
- Eduardo B V da Silveira
- Division of Gastroenterology, University of Miami, School of Medicine/Mt Sinai Medical Center, Florida, USA
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Abstract
Acute severe pancreatitis is an aggressive disease with a mortality rate of up to 30 percent. In recent years therapy has shifted away from early surgery to intensive medical care. This article focuses on several issues of the management of acute severe pancreatitis emphasising evidence from recent clinical trials and recommendations from recent consensus conferences. Since a correct assessment of the severity of the disease is mandatory as early as possible in the treatment, several multiple scoring factor systems and individual risk factors are explained. The indications and the optimal timing of ERCP are discussed. Prophylactic administration of antibiotics, intravenously or by means of a selective digestive decontamination scheme, seems to be beneficial in decreasing morbidity but not mortality. Adequate nutritional support, preferably achieved by enteral feeding, is an important component in the supportive therapy. Protease inhibitors and anti-secretory drugs have not proven to be of benefit in improving outcome. Immunomodulating substances like platelet activating antagonists are promising but further studies are necessary to confirm the results of the early studies. Finally, indications for surgery are discussed.
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Affiliation(s)
- J Ponette
- Division of Internal Medicine, Department of General Internal Medicine, Medical Intensive Care Unit, Gasthuisberg University Hospital, K.U. Leuven, 3000 Leuven, Belgium
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