Behavior of antibiotics during human necrotizing pancreatitis

American College of Gastroenterology Guidelines: Management of Acute Pancreatitis

Acute pancreatitis (AP), defined as acute inflammation of the pancreas, is one of the most common diseases of the gastrointestinal tract leading to hospital admission in the United States. It is important for clinicians to appreciate that AP is heterogenous, progressing differently among patients and is often unpredictable. While most patients experience symptoms lasting a few days, almost one-fifth of patients will go on to experience complications, including pancreatic necrosis and/or organ failure, at times requiring prolonged hospitalization, intensive care, and radiologic, surgical, and/or endoscopic intervention. Early management is essential to identify and treat patients with AP to prevent complications. Patients with biliary pancreatitis typically will require surgery to prevent recurrent disease and may need early endoscopic retrograde cholangiopancreatography if the disease is complicated by cholangitis. Nutrition plays an important role in treating patients with AP. The safety of early refeeding and importance in preventing complications from AP are addressed. This guideline will provide an evidence-based practical approach to the management of patients with AP.

Selective and Concentrative Enteropancreatic Recirculation of Antibiotics by Pigs

Antibiotics that are efficacious for infectious pancreatitis are present in pancreatic exocrine secretion (PES) after intravenous administration and above minimal inhibitory concentrations. We measured concentrations of four antibiotics by tandem liquid chromatography-mass spectroscopy in plasma and PES after enteral administration to juvenile pigs with jugular catheters and re-entrant pancreatic-duodenal catheters. Nystatin, which is not absorbed by the intestine nor used for infectious pancreatitis (negative control), was not detected in plasma or PES. Concentrations of amoxicillin increased in plasma after administration (p = 0.035), but not in PES (p = 0.51). Metronidazole and enrofloxacin that are used for infectious pancreatitis increased in plasma after enteral administration and even more so in PES, with concentrations in PES averaging 3.1 (±0.5)- and 2.3 (±0.6)-fold higher than in plasma, respectively (p's < 0.001). The increase in enrofloxacin in PES relative to plasma was lower after intramuscular administration (1.8 ± 0.5; p = 0.001). The present results demonstrate the presence of a selective and concentrative enteropancreatic pathway of secretion for some antibiotics. Unlike the regulated secretion of bile, the constitutive secretion of PES and intestinal reabsorption may provide a continuous exposure of pancreas tissue and the small intestine to recirculated antibiotics and potentially other therapeutic molecules. There is a need to better understand the enteropancreatic recirculation of antibiotics and the associated mechanisms.

Effect of early antibiotic treatment strategy on prognosis of acute pancreatitis

BACKGROUND

Antibiotic use in the early stages of acute pancreatitis is controversial. The purpose of this study was to investigate the effect of early antibiotic application on the prognosis of acute pancreatitis (AP).

MATERIALS AND METHODS

Clinical data of patients with primary AP admitted to our emergency ward within 72 hours of onset were retrospectively collected from January 2016 to December 2020. We classified patients with acute pancreatitis according to etiology and disease severity, and compared the differences in hospital stay, laparotomy rate, and in-hospital mortality among AP patients who received different antibiotic treatment strategies within 72 hours of onset.

RESULTS

A total of 1134 cases were included, with 681 (60.1%) receiving early antibiotic treatment and 453 (39.9%) not receiving it. There were no significant differences in baseline values and outcomes between the two groups. In subgroup analysis, patients with biliary severe acute pancreatitis (SAP) who received early antibiotics had lower rates of laparotomy and invasive mechanical ventilation, as well as shorter hospital stays compared to those who did not receive antibiotics. In logistic regression analysis, the early administration of carbapenem antibiotics in biliary SAP patients was associated with a lower in-hospital mortality rate. Early antibiotic use in biliary moderate-severe acute pancreatitis (MSAP) reduced hospital stays and in-hospital mortality. Quinolone combined with metronidazole treatment in biliary mild acute pancreatitis (MAP) shortened hospital stays. Early antibiotic use does not benefit patients with non-biliary AP.

CONCLUSION

Strategies for antibiotic use in the early stages of AP need to be stratified according to cause and disease severity.

Overuse and Misuse of Antibiotics and the Clinical Consequence in Necrotizing Pancreatitis: An Observational Multicenter Study

OBJECTIVE

The use and impact of antibiotics and the impact of causative pathogens on clinical outcomes in a large real-world cohort covering the entire clinical spectrum of necrotizing pancreatitis remain unknown.

SUMMARY BACKGROUND DATA

International guidelines recommend broad-spectrum antibiotics in patients with suspected infected necrotizing pancreatitis. This recommendation is not based on high-level evidence and clinical effects are unknown.

MATERIALS AND METHODS

This study is a post-hoc analysis of a nationwide prospective cohort of 401 patients with necrotizing pancreatitis in 15 Dutch centers (2010-2019). Across the patient population from the time of admission to 6 months postadmission, multivariable regression analyses were used to analyze (1) microbiological cultures and (2) antibiotic use.

RESULTS

Antibiotics were started in 321/401 patients (80%) administered at a median of 5 days (P25-P75: 1-13) after admission. The median duration of antibiotics was 27 days (P25-P75: 15-48). In 221/321 patients (69%) infection was not proven by cultures at the time of initiation of antibiotics. Empirical antibiotics for infected necrosis provided insufficient coverage in 64/128 patients (50%) with a pancreatic culture. Prolonged antibiotic therapy was associated with Enterococcus infection (OR 1.08 [95% CI 1.03-1.16], P =0.01). Enterococcus infection was associated with new/persistent organ failure (OR 3.08 [95% CI 1.35-7.29], P <0.01) and mortality (OR 5.78 [95% CI 1.46-38.73], P =0.03). Yeast was found in 30/147 cultures (20%).

DISCUSSION

In this nationwide study of patients with necrotizing pancreatitis, the vast majority received antibiotics, typically administered early in the disease course and without a proven infection. Empirical antibiotics were inappropriate based on pancreatic cultures in half the patients. Future clinical research and practice must consider antibiotic selective pressure due to prolonged therapy and coverage of Enterococcus and yeast. Improved guidelines on antimicrobial diagnostics and therapy could reduce inappropriate antibiotic use and improve clinical outcomes.

Indian College of Radiology and Imaging Consensus Guidelines on Interventions in Pancreatitis

Acute pancreatitis (AP) is one of the common gastrointestinal conditions presenting as medical emergency. Clinically, the severity of AP ranges from mild to severe. Mild AP has a favorable outcome. Patients with moderately severe and severe AP, on the other hand, require hospitalization and considerable utilization of health care resources. These patients require a multidisciplinary management. Pancreatic fluid collections (PFCs) and arterial bleeding are the most important local complications of pancreatitis. PFCs may require drainage when infected or symptomatic. PFCs are drained endoscopically or percutaneously, based on the timing and the location of collection. Both the techniques are complementary, and many patients may undergo dual modality treatment. Percutaneous catheter drainage (PCD) remains the most extensively utilized method for drainage in patients with AP and necrotic PFCs. Besides being effective as a standalone treatment in a significant proportion of these patients, PCD also provides an access for percutaneous endoscopic necrosectomy and minimally invasive necrosectomy. Endovascular embolization is the mainstay of management of arterial complications in patients with AP and chronic pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the percutaneous management of complications of pancreatitis.

Challenges in the diagnosis and management of wound infection

Human epithelia are constantly exposed to microorganisms present in the environment or residing as part of commensal flora. Despite this exposure, infections involving the skin and subcutaneous tissue in healthy individuals are, fortunately, quite rare. Many of the wounds that afflict the human body occur in individuals of ill health and/or where the mechanism of wounding is impeded by host immunological, physiological or regenerative dysfunction. The interplay between microorganisms and host immunity is complex and remains ill defined; however, the interpretation of downstream manifestations of the host response to invading microorganisms is still based largely on the clinical signs and symptoms of an active infectious process. In this review article we will provide a brief overview of the current challenges clinicians face in diagnosing wound infections, how chronic infections caused by biofilms are a major challenge, and how there have been minimal advancements in developing new diagnostics or therapeutics in the identification and management of wound infections.

Antibiotics in Necrotizing Soft Tissue Infections

Necrotizing soft tissue infections (NSTIs) are rare life-threatening bacterial infections characterized by an extensive necrosis of skin and subcutaneous tissues. Initial urgent management of NSTIs relies on broad-spectrum antibiotic therapy, rapid surgical debridement of all infected tissues and, when present, treatment of associated organ failures in the intensive care unit. Antibiotic therapy for NSTI patients faces several challenges and should (1) carry broad-spectrum activity against gram-positive and gram-negative pathogens because of frequent polymicrobial infections, considering extended coverage for multidrug resistance in selected cases. In practice, a broad-spectrum beta-lactam antibiotic (e.g., piperacillin-tazobactam) is the mainstay of empirical therapy; (2) decrease toxin production, typically using a clindamycin combination, mainly in proven or suspected group A streptococcus infections; and (3) achieve the best possible tissue diffusion with regards to impaired regional perfusion, tissue necrosis, and pharmacokinetic and pharmacodynamic alterations. The best duration of antibiotic treatment has not been well established and is generally comprised between 7 and 15 days. This article reviews the currently available knowledge regarding antibiotic use in NSTIs.

Shotgun metagenomics reveals significant gut microbiome features in different grades of acute pancreatitis

BACKGROUND

Acute pancreatitis (AP) has a broad spectrum of severity and is associated with considerable morbidity and mortality. Dysbiosis of gut microbiota may be associated with AP severity.

AIMS

We aimed to evaluate the composition and functional effects of gut microbiota in different grades of AP severity.

METHODS

We carried out shotgun metagenomic sequencing on rectal swab samples from three patients with mild acute pancreatitis (MAP), three with moderately severe acute pancreatitis (MSAP), three with severe acute pancreatitis (SAP) and three normal control persons (NOR). Differences analysis in gut microbiota composition and functional enrichment was performed.

RESULTS

Gut microbiota in AP patients was characterized by decreased species richness. The most representative gut microbiota in mild acute pancreatitis (MAP), moderately severe acute pancreatitis (MSAP), and severe acute pancreatitis (SAP) was Streptococcus, Escherichia-coli, and Enterococcus, respectively. Each of the three AP-associated genera could differentiate AP from healthy control population. Representative pathways associated with the glutathione metabolism, lipopolysaccharide biosynthesis, and amino acid metabolism (valine, leucine and isoleucine degradation) were enriched in MAP, MSAP, and SAP, respectively.

CONCLUSIONS

The study shows a potential association of gut microbiome composition and function to the progression of AP severity.

Rethinking Carbapenems: A Pharmacokinetic Approach for Antimicrobial Selection in Infected Necrotizing Pancreatitis

OBJECTIVE

To provide an overview of pathophysiological changes to the pancreas during infected necrotizing pancreatitis (INP), optimal drug properties needed to penetrate the pancreas, human and animal studies supporting the use of antimicrobials, and carbapenem-sparing strategies in INP.

DATA SOURCES

A literature analysis of PubMed/MEDLINE was performed (from 1960 to September 2020) using the following key terms: infected necrotizing pancreatitis, necrotizing acute pancreatitis, and infected pancreatitis antimicrobial concentration. Individual antimicrobials were investigated with these search terms.

STUDY SELECTION AND DATA EXTRACTION

All relevant studies describing the management of INP, and human and animal pharmacokinetic (PK) data supporting antimicrobial use in the pancreas were reviewed for possible inclusion regardless of sample size or study design.

DATA SYNTHESIS

Piperacillin/tazobactam and cefepime achieve adequate pancreatic tissue concentrations in INP studies. A majority of the literature supporting carbapenem use in INP involves imipenem, and meropenem Monte Carlo simulations suggest that standard dosing regimens of meropenem may not achieve PK targets to eradicate Pseudomonas aeruginosa.

RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE

Carbapenems are often utilized for INP treatment based on guideline recommendations. This review discusses PK data, the history of carbapenem use in INP, and the pathophysiology of pancreatitis to suggest carbapenem-sparing strategies and provides stewardship tactics such as when to start antimicrobials, which empirical antimicrobial to use, and when to discontinue antimicrobials in the INP setting.

CONCLUSIONS

Noncarbapenem antipseudomonals, such as piperacillin/tazobactam and cefepime, are appropriate carbapenem-sparing options in INP, based on PK data, spectrum of activity, and risk of collateral damage.

Impact of prior antibiotics on infected pancreatic necrosis microbiology in ICU patients: a retrospective cohort study

Background

Recent guidelines advise against prophylactic antibiotics in patients with necrotizing pancreatitis, advocating instead a step-up drainage and necrosectomy strategy with antibiotics as dictated by microbiological findings. However, prompt antibiotic therapy is recommended in patients with sepsis or septic shock, a possible presentation of infected pancreatic necrosis (IPN). Consequently, in many critically ill patients with IPN, pancreatic samples are collected only after broad-spectrum antibiotic therapy initiation. Whether this prior antibiotic exposure alters the microbiological findings is unknown. The main objective was to determine whether prior antibiotic exposure sterilized the samples collected during procedures for suspected IPN in patients admitted to the intensive care unit (ICU) for acute pancreatitis with suspected IPN. We retrospectively studied 56 consecutive ICU patients admitted with suspected IPN. We collected details on the microbiological samples and antimicrobials used. A definite diagnosis of IPN was given when bacteria were identified in pancreatic samples.

Results

In all, 137 pancreatic samples were collected, including 91 (66.4%) after antibiotic therapy initiation. IPN was confirmed in 48 (86%) patients. The proportion of positive samples was 74 (81.3%) in antibiotic-exposed patients and 32/46 (69.5%) in unexposed patients (p = 0.58). Of the 74 positive samples from exposed patients, 62 (84%) had organisms susceptible to the antibiotics used. One-third of samples contained more than one organism. Among patients with IPN, 37.5% had positive blood cultures. Multidrug- or extensively drug-resistant bacteria were identified at some point in half the patients. Enterobacter cloacae complex was more frequent in the exposed group (p = 0.02), as were Gram-negative anaerobic bacteria (p = 0.03).

Conclusion

Antibiotic exposure before sampling did not seem to affect culture positivity of pancreatic samples to confirm IPN, but may affect microbiological findings. Our results suggest that, in patients with sepsis and suspected IPN, antibiotics should be started immediately and pancreatic samples obtained as soon as possible thereafter. In other situations, antibiotics can be withheld until the microbiological results of pancreatic samples are available, to ensure accurate targeting of the spectrum to bacterial susceptibility patterns.

ClinicalTrials.gov number NCT03253861

Quantification of metronidazole in human bile fluid and plasma by liquid chromatography-tandem mass spectrometry

This study was conducted to develop a highly selective, sensitive, and validated method for quantifying metronidazole in human plasma and bile fluid. Metronidazole and metronidazole-d4 (internal standard) were extracted from 100 μL of plasma and bile fluid by liquid-liquid extraction. Liquid chromatography with a Hydrosphere C18 column (50 × 2.0 mm) was performed using 10 mM ammonium formate (pH 4.0) and acetonitrile (20:80, v/v) as the mobile phase. Triple quadrupole mass spectrometry was operated with an electrospray ionization interface in multiple reaction monitoring and positive ion modes. The calibration curves were linear for bile and plasma samples over the range of 50-20,000 ng/mL (r² > 0.999). The intra- and inter-day coefficients of variation (CVs) for plasma ranged from 2.50% to 7.85% and 3.11% to 16.9%, respectively; for bile, the intra-and inter-run precision (CVs) ranged from 2.76% to 13.2% and 3.16% to 11.5%, respectively. The mean extraction recovery for metronidazole ranged from 76.5% to 82.1% in plasma and from 78.8% to 87.8% in bile, respectively. Our proposed analytical method was successfully applied to determine metronidazole concentrations in bile as well as in plasma at multiple time points in a patient with acute cholangitis.

Guidelines for Antibiotic Prescription in Intensive Care Unit

How to cite this article: Khilnani GC, Zirpe K, Hadda V, Mehta Y, Madan K, Kulkarni A, Mohan A, Dixit S, Guleria R, Bhattacharya P. Guidelines for Antibiotic Prescription in Intensive Care Unit. Indian Journal of Critical Care Medicine 2019;23 (Suppl 1):1-63.

The microbiology of infected pancreatic necrosis

BACKGROUND

Acute pancreatitis (AP) continues to cause significant morbidity and mortality, especially when it leads to infected pancreatic necrosis (IPN). Modern treatment of IPN frequently involves prolonged courses of antibiotics in combination with minimally invasive therapies. This study aimed to update the existing evidence base by identifying the pathogens causing IPN and therefore aid future selection of empirical antibiotics.

METHODS

Clinical data, including microbiology results, of consecutive patients with IPN undergoing minimally invasive necrosectomy at our institution between January 2009 and July 2016 were retrospectively reviewed.

RESULTS

The results of 40 patients (22 males and 18 females, median age 60 years) with IPN were reviewed. The etiology of AP was gallstones, alcohol, dyslipidemia and unknown in 31, 2, 2 and 5 patients, respectively. The most frequently identified microbes in microbiology cultures were Enterococcus faecalis and faecium (22.5% and 20.0%) and Escherichia coli (20.0%). In 19 cases the cultures grew multiple organisms. The antibiotics with the least resistance amongst the microbiota were teicoplanin (5.0%), linezolid (5.6%), ertapenem (6.5%), and meropenem (7.4%).

CONCLUSION

The carbapenem antibiotics, ertapenem and meropenem provide good antimicrobial cover against the common, mainly enteral, microorganisms causing IPN. Culture and sensitivity results of acquired samples should be regularly reviewed to adjust prescribing and monitor for emergence of resistance.

Evaluation of local instillation of antibiotics in infected walled-off pancreatic necrosis

BACKGROUND

Infected walled-off pancreatic necrosis (WON) is associated with increased morbidity and mortality. Systemic antibiotics are the main treatment, but are associated with adverse reactions and risk of superinfections. This study evaluates the efficacy of local instillation of antibiotics into WON.

METHODS

We performed a retrospective cohort study of all consecutive patients with infected WON, who were treated with endoscopic transmural drainage and necrosectomy (ETDN) at a tertiary referral hospital between 2012 and 2016. A total of 91 patients were included. Patients often received concomitant intravenous and local antibiotics. Local antibiotics were added to the irrigation fluid depending on microbiological findings. A beneficial response was defined as the eradication of a microbe on subsequent culturing. Univariable and multivariable logistic regression analyses were used to evaluate antimicrobial efficacy.

RESULTS

At the first drainage 81 (86%) patients had infected and 10 sterile WON. Among patients with bacterial infections, neither local nor systemic antibiotics were associated with the eradication of microbes between first and second culture. Between the second and third culture, the use of local antibiotics was associated with the eradication of microbes (OR, 2.54; 95% CI, 1.25-5.18; p = 0.01), but not systemic antibiotics (OR, 0.75; 95% CI, 0.38-1.38; p = 0.33). Twelve patients had fungal infections treated with local amphotericin B between first and second culture. The fungus was eradicated in all 12 patients.

CONCLUSION

Local instillation of antibiotics may be a promising supplement to systemic administration.

Vancomycin Concentrations in Necrotic Pancreatic Tissue: A Pilot Study

Purpose:

To determine vancomycin concentrations in necrotic pancreatic tissue of intensive care unit (ICU) patients with acute necrotizing pancreatitis.

Methods:

The prospective, observational pilot study was conducted at a university-based tertiary hospital. The patient population consisted of 11 patients with necrotizing pancreatitis receiving vancomycin and undergoing necrosectomy. Tissue samples taken during surgical debridement were assayed for vancomycin by immunoassay. Patients were divided into steady state and nonsteady-state groups. Two patients were excluded because necrosectomy was not performed, and one tissue sample could not be assayed because of contamination.

Results:

The mean tissue concentration was 5.84 mcg/mL (ranging from 3.1 mcg/mL to 8.94 mcg/mL). Four patients in the nonsteady-state group, who each received a single dose of vancomycin, had a mean tissue concentration of 4.5 ± 1.68 mcg/mL, compared with 7.76 ± 1.05 mcg/mL for the four steady-state patients.

Conclusion:

The data shows that vancomycin is detectable in necrotic pancreas tissue but possibly not in concentrations sufficient to prevent or treat bacterial contamination in patients with pancreatic necrosis.

Antibiotic Prophylaxis in Acute Necrotizing Pancreatitis

Objective:

To review the use of antibiotic prophylaxis in acute necrotizing pancreatitis.

Background:

Acute necrotizing pancreatitis is a complication that occurs in a minority of patients with acute pancreatitis, but has a high incidence of morbidity and mortality. Surgery and supportive care are important in the management of this disease. However, the role of antibiotic prophylaxis has been debated for decades.

Data Sources:

English-language clinical studies and review articles involving human subjects and appropriate in vitro data were located through a literature search (MEDLINE, January 1966-July 1998).

Study Selection and Data Extraction:

Relevant studies describing the use of antibiotic prophylaxis in acute necrotizing pancreatitis were reviewed.

Data Synthesis:

Earlier studies of antibiotic prophylaxis in patients with acute necrotizing pancreatitis did not show any benefit compared with placebo. Newer studies have shown a decrease in mortality and morbidity when antibiotic prophylaxis is given to patients with severe necrotizing pancreatitis. Conflicting results leave many questions unanswered, such as the effect of antibiotic use in resistance patterns, which antibiotic to use, duration of therapy, and cost-effectiveness of this strategy.

Conclusions:

With the available data, it is adequate to recommend that patients with at least 30% necrosis of the pancreas receive antibiotics to prevent infectious complications and to decrease potential mortality. Use of imipenem/cilastatin is supported by the largest prospective trial to date; however, the drug was compared with no treatment. Cefuroxime is the only drug shown to decrease mortality and should be considered an alternative that may be more cost-effective than therapy with imipenem/cilastatin. A comparison trial is needed before further recommendations are given.

Pharmacokinetic Alterations of Antimicrobials in the Critically Ill

Critical illness is accompanied by multiple physiologic alterations that affect the pharmacokinetics of antimicrobials. Although the pharmacokinetics of a number of antimicrobials have been studied in critically ill individuals, an understanding of the physiological alterations in critical illness and general pharmacokinetic principles of antimicrobials is imperative for appropriate selection, dosing, and prediction of toxicity.

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.

Drug elution from high-dose antibiotic-loaded acrylic cement: a comparative, in vitro study

High-dose antibiotic-loaded acrylic cement (ALAC) is used for managing peri-prosthetic joint infections (PJIs). The marked increase in resistant high-virulence bacteria is drawing the attention of physicians toward alternative antimicrobial formulations loaded into acrylic bone cement. The aim of this in vitro study was to determine the elution kinetics of 14 different high-dose ALACs. All ALAC samples showed a burst release of antibiotics in the first hour, progressively decreasing over time, and elution curves strictly adhered to a nonlinear regression analysis formula. Among aminoglycosides, commonly seen as the most appropriate antibiotics to be loaded into the bone cement, the highest elution rate was that of tobramycin. Among the glycopeptides, a class of antibiotics that should be considered to treat PJIs because of the prevalence of aminoglycoside resistance, vancomycin showed better elution than teicoplanin. Clindamycin, which can be associated with aminoglycosides to prepare ALACs and represents a useful option against the most common pathogens responsible for PJIs, showed the highest absolute and relative elutions among all the tested formulations. A noticeable elution was also detected for colistin, an antibiotic of last resort for treating multidrug-resistant bacteria. The current study demonstrates theoretical advantages in the preparation of ALAC for some antibiotics not routinely used in the clinical setting for PJIs. The use of these antibiotics based on the infecting bacteria sensitivity may represent a useful option for physicians to eradicate PJIs. In vivo testing should be considered in the future to confirm the results of this study.

Emphysematous pancreatitis predisposed by Olanzapine

A 32-year-old male presented to our intensive care unit with severe abdominal pain and was diagnosed as acute pancreatitis after 2 months of olanzapine therapy for bipolar disorder. His serum lipase was 900 u/L, serum triglyceride 560 mg/dL, and blood sugar, fasting and postprandial were 230 and 478 mg/dL, respectively on admission. Contrast enhanced computed tomography (CECT) of abdomen was suggestive of acute pancreatitis. Repeat CECT showed gas inside pancreas and collection in peripancreatic area and patient underwent percutaneous drainage and antibiotics irrigation through the drain into pancreas. We describe the rare case of emphysematous pancreatitis due to development of diabetes, hypertriglyceridemia and immunosuppression predisposed by short duration olanzapine therapy.

Clinical pharmacokinetics of meropenem in pancreatic juice and site-specific pharmacodynamic target attainment against Gram-negative bacteria: dosing considerations

BACKGROUND AND OBJECTIVE

Very few studies have revealed the dynamics of meropenem penetration into the pancreas or pancreatic juice in humans. This study of the clinical pharmacokinetics and pharmacodynamics of meropenem in human pancreatic juice was performed to establish a basis for the validation of dosing regimens for pancreatic infections.

METHODS

Ten patients with endoscopic naso-pancreatic drainage received 500 mg meropenem over 0.5 h via intravenous infusion. Venous blood and pancreatic juice samples were collected post-infusion for up to 5.0 h and used to obtain measures of meropenem concentration. The probability of attaining the pharmacodynamic target (40% of the time above the minimum inhibitory concentration [MIC]) in pancreatic juice against MIC distributions for clinical isolates of Gram-negative bacteria was determined using a Monte Carlo simulation.

RESULTS

The mean maximum concentration of meropenem in pancreatic juice was 2.08 ± 0.94 μg/mL at 1.025 ± 0.18 h. The pancreatic juice/plasma ratio was 0.055 ± 0.028. A 0.5-h infusion of 500 mg meropenem every 8 h achieved a 99.4% probability of target attainment against Escherichia coli, 96.4% against Klebsiella species, 94.3% against Enterobacter species and 96.2% against Proteus species, but only 41.3% against Pseudomonas aeruginosa isolates.

CONCLUSION

Intravenous meropenem exhibits low penetrance into pancreatic juice. However, a dosing regimen of 500 mg meropenem (0.5-h infusion) every 8 h provides sufficient drug-exposure time in pancreatic juice against the four common Gram-negative bacteria populations.

Activity of moxifloxacin, imipenem, and ertapenem against Escherichia coli, Enterobacter cloacae, Enterococcus faecalis, and Bacteroides fragilis in monocultures and mixed cultures in an in vitro pharmacokinetic/pharmacodynamic model simulating concentrations in the human pancreas

The activities of moxifloxacin, imipenem, and ertapenem against pathogens causing severe necrotizing pancreatitis were studied in an in vitro pharmacokinetics/pharmacodynamics (PK/PD) model. Escherichia coli, Enterobacter cloacae, Enterococcus faecalis, and Bacteroides fragilis were exposed in monocultures and mixed cultures to concentrations of the three agents comparable to those in the human pancreas. Moxifloxacin was more active than the two carbapenems in monocultures and mixed cultures, reducing the numbers of CFU more drastically and more rapidly.

Physical, mechanical and pharmacological properties of coloured bone cement with and without antibiotics

Coloured bone cements have been introduced to make the removal of cement debris easier at the time of primary and revision joint replacement. We evaluated the physical, mechanical and pharmacological effects of adding methylene blue to bone cement with or without antibiotics (gentamicin, vancomycin or both). The addition of methylene blue to plain cement significantly decreased its mean setting time (570 seconds (sd 4) vs 775 seconds (sd 11), p = 0.01), mean compression strength (95.4 MPa (sd 3) vs 100.1 MPa (sd 6), p = 0.03), and mean bending strength (65.2 MPa (sd 5) vs 76.6 MPa (sd 4), p < 0.001) as well as its mean elastic modulus (2744 MPa (sd 97) vs 3281 MPa (sd 110), p < 0.001). The supplementation of the coloured cement with vancomycin and gentamicin decreased its mean bending resistance (55.7 MPa (sd 4) vs 65.2 MPa (sd 5), p < 0.001).The methylene blue significantly decreased the mean release of gentamicin alone (228.2 µg (sd 24) vs 385.5 µg (sd 26), p < 0.001) or in combination with vancomycin (498.5 µg (sd 70) vs 613 µg (sd 25), p = 0.018) from the bone cement. This study demonstrates several theoretical disadvantages of the antibiotic-loaded bone cement coloured with methylene blue.

Changes in antibiotic distribution due to pancreatitis

This work sought to define how pancreatitis affected antibiotic distribution in a perfused rat pancreas model. The distribution kinetics of four antibiotics were examined in control animals and animals with pancreatitis. Meropenem and piperacillin distributed into the extracellular space, and their distribution kinetics were unaffected by pancreatitis. In contrast, in pancreatic cells from animals with pancreatitis, ciprofloxacin showed a reduced uptake and clindamycin showed a reduced distribution.

Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis

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.

Pharmacotherapy for acute pancreatitis

Our knowledge of acute pancreatitis is still far from complete and there is no unanimous agreement concerning the pathophysiological processes leading to typical alterations during the course of acute pancreatitis. We reviewed the paper published in the last decade on the pathophysiology and treatment of acute pancreatitis. It is difficult to translate the experimental therapeutic results into clinical practice. For example, lexipafant was efficacious in decreasing the severity and mortality of lethal pancreatitis in rats, but seems to have no effect on severe acute pancreatitis in humans. Thus, the main problem in acute pancreatitis, especially in the severe form of the disease, is the difficulty of designing clinical studies capable of giving reliable statistically significant answers regarding the benefits of the various proposed therapeutic agents previously tested in experimental settings. Thus, analgesia, supportive care, and treatment of the pulmonary and renal complications remain the cornerstones of the treatment of acute pancreatitis, especially in the severe form of the disease.

Acute pancreatitis and critical illness: a pancreatic tale of hypoperfusion and inflammation

Since it was first widely recognized at the end of the 19th century, acute pancreatitis has proven a formidable clinical challenge, frequently resulting in management within critical care settings. Because the early assessment of severity is difficult, the recognition of severe acute pancreatitis (SAP) and the implementation of critical care treatment precepts often are delayed. Although different management strategies for life-threatening features of SAP have been debated for decades, there has been little recent reduction in mortality rates, which can be as high as 30%. This article discusses severity designation at the time of diagnosis, reviews the pathophysiologic mechanisms so well characterized by the noxious combination of severe systemic inflammation and hypoperfusion, and provides a management algorithm that parallels current critical care strategies.

[Antibiotic therapy in acute pancreatitis]

Infected pancreatic necrosis (IPN) is one of the main causes of mortality in patients with acute pancreatitis (AP). The choice of antibiotic therapy in AP should be based on penetration of the drug in the pancreas and the degree of coverage provided against the typical bacterial flora produced in IPN. Drugs such as imipenem, ciprofloxacin and metronidazole have been widely studied and seem to be ideal in the treatment of INP. Clinical practice guidelines recommend a carbapenem agent as the initial empirical treatment. When Gram-positive pathogens are isolated in pancreatic samples, vancomycin can be used alone or associated with a carbapenem. Currently, prophylactic antibiotic therapy for IPN is not supported by the scientific evidence, since both the best quality studies (double-blind) and the latest meta-analysis published have found no benefit of the use of this strategy.

A double-blind, placebo-controlled trial of ciprofloxacin prophylaxis in patients with acute necrotizing pancreatitis

BACKGROUND

The use of prophylactic antibiotics in acute severe necrotizing pancreatitis is controversial.

METHODS

Prospective, randomized, placebo-controlled, double-blind study was carried out at Bellvitge Hospital, in Barcelona, Spain. Among 229 diagnosed with severe acute pancreatitis, 80 had evidence of necrotizing pancreatitis (34/80 patients were excluded of the protocol). Forty-six patients without previous antibiotic treatment with pancreatic necrosis in a contrast-enhanced CT scan were randomly assigned to receive either intravenous ciprofloxacin or placebo. Five patients were secondarily excluded, and the remaining 41 patients were finally included in the study (22 patients received intravenous ciprofloxacin and 19 patients placebo).

RESULTS

Comparing the 22 with intravenous ciprofloxacin and 19 with placebo, infected pancreatic necrosis was detected in 36% and 42% respectively (p = 0.7). The mortality rate was 18% and 11%, respectively (p = 0.6). No significant differences between both treatment groups were observed with respect to variables such as: non-pancreatic infections, surgical treatment, timing and the re-operation rate, organ failure, length of hospital and ICU stays.

CONCLUSION

The prophylactic use of ciprofloxacin in patients with severe necrotizing pancreatitis did not significantly reduce the risk of developing pancreatic infection or decrease the mortality rate. The small number of patients included in this study should be considered.

Prophylactic antibiotic treatment in acute necrotizing pancreatitis: results from a meta-analysis

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.

Piperacillin-tazobactam penetration into human pancreatic juice

Piperacillin-tazobactam was administered as a single dose (4.5 g intravenous) to five patients with stabilized external pancreatic fistula. The penetration into pancreatic juice was prompt, and inhibitory concentrations were achieved and maintained for different periods (0.5 to 6 h) according to bacterial susceptibility and patients' characteristics. Piperacillin and tazobactam showed superimposable pharmacokinetics in both serum and pancreatic juice.

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.

Prevention of infection following severe acute pancreatitis

PURPOSE OF REVIEW

This review highlights recently reported strategies aimed at quantifying severity of illness earlier in the course of acute pancreatitis and at preventing secondary infection in pancreatic necrosis.

RECENT FINDINGS

New and improved scoring models appear to suggest that the optimal interventional window is between 24 and 72 h of the onset of severe acute pancreatitis. Prospective randomized clinical trials in which patients with severe acute pancreatitis were treated with broad-spectrum antimicrobial regimens as prophylaxis, however, have demonstrated no benefit in terms of preventing late infection in pancreatic necrosis. In contrast, early enteral nutrition with various formulas and supplements, including probiotics, may confer a clinical advantage in terms of morbidity and mortality.

SUMMARY

Continuing to advocate antimicrobial prophylaxis in severe acute pancreatitis is not reasonable, in view of the evidence now available from two large clinical trials. Current guidelines should be revised because of the potential harm to gastrointestinal ecology associated with long-term antibiotic treatment. A suitable alternative way to prevent bacterial overgrowth and secondary infection is lacking, however.

Randomized controlled trials of antibiotic prophylaxis in severe acute pancreatitis: relationship between methodological quality and outcome

AIM

To evaluate the methodological quality of randomized controlled trials (RCTs) of systemic antibiotic prophylaxis in severe acute pancreatitis in relation to outcome.

METHODS

The MEDLINE, EMBASE and Cochrane databases were searched for RCTs that studied the effectiveness of systemic antibiotic prophylaxis in severe acute pancreatitis. A meta-analysis was performed with a random effects model. Methodological quality was quantified by a previously published scoring system (range 0-17 points).

RESULTS

Six studies, with a total of 397 participants, obtained a methodological score of at least 5 points and were included. Systemic antibiotic prophylaxis had no significant effect on infection of pancreatic necrosis (absolute risk reduction (ARR) 0.055; 95% CI -0.084 to 0.194) and mortality (ARR 0.058, 95% CI -0.017 to 0.134). Spearman correlation showed an inverse association between methodological quality and ARR for mortality (correlation coefficient -0.841, p = 0.036).

CONCLUSIONS

The inverse relationship between methodological quality and impact of antibiotic prophylaxis on mortality emphasizes the importance of high-quality RCTs. At present, adequate evidence for the routine use of antibiotic prophylaxis in severe acute pancreatitis is lacking.

Early antibiotic treatment for severe acute necrotizing pancreatitis: a randomized, double-blind, placebo-controlled study

BACKGROUND & AIMS

In patients with severe, necrotizing pancreatitis, it is common to administer early, broad-spectrum antibiotics, often a carbapenem, in the hope of reducing the incidence of pancreatic and peripancreatic infections, although the benefits of doing so have not been proved.

METHODS

A multicenter, prospective, double-blind, placebo-controlled randomized study set in 32 centers within North America and Europe.

PARTICIPANTS

One hundred patients with clinically severe, confirmed necrotizing pancreatitis: 50 received meropenem and 50 received placebo.

INTERVENTIONS

Meropenem (1 g intravenously every 8 hours) or placebo within 5 days of the onset of symptoms for 7 to 21 days.

MAIN OUTCOME MEASURES

Primary endpoint: development of pancreatic or peripancreatic infection within 42 days following randomization. Other endpoints: time between onset of pancreatitis and the development of pancreatic or peripancreatic infection; all-cause mortality; requirement for surgical intervention; development of nonpancreatic infections within 42 days following randomization.

RESULTS

Pancreatic or peripancreatic infections developed in 18% (9 of 50) of patients in the meropenem group compared with 12% (6 of 50) in the placebo group (P = 0.401). Overall mortality rate was 20% (10 of 50) in the meropenem group and 18% (9 of 50) in the placebo group (P = 0.799). Surgical intervention was required in 26% (13 of 50) and 20% (10 of 50) of the meropenem and placebo groups, respectively (P = 0.476).

CONCLUSIONS

This study demonstrated no statistically significant difference between the treatment groups for pancreatic or peripancreatic infection, mortality, or requirement for surgical intervention, and did not support early prophylactic antimicrobial use in patients with severe acute necrotizing pancreatitis.

Early treatment of severe pancreatitis with imipenem: a prospective randomized clinical trial

OBJECTIVE

The main causes of death in severe pancreatitis are multiorgan failure and septic complications. Prophylactic treatment with effective antibiotics is therefore a tempting therapeutic option. However, there could be side effects such as selection of resistant microbes and fungi. The aim of the present study was to compare the rate of infectious complications, interventions, days in the intensive care unit (ICU), morbidity and mortality in patients with severe pancreatitis randomized to prophylactic therapy with imipenem compared with those receiving no treatment at all.

MATERIAL AND METHODS

Seventy-three patients with severe pancreatitis were included in a prospective, randomized, clinical study in seven Norwegian hospitals. The number of patients was limited to 73 because of slow patient accrual. Severe pancreatitis was defined as a C-reactive protein (CRP) level of >120 mg/l after 24 h or CRP >200 48 h after the start of symptoms. The patients were randomized to either early antibiotic treatment (imipenem 0.5 g x 3 for 5-7 days) (imipenem group) (n=36) or no antibiotics (control group) (n=37).

RESULTS

The groups were similar in age, cause of pancreatitis, duration of symptoms and APACHE II score. Patients in the imipenem group experienced lower rates of complications (12 versus 22 patients) (p=0.035) and infections (5 versus 16 patients) (p=0.009) than those in the control group. There was no difference in length of hospital stay (18 versus 22 days), need of intensive care (8 versus 7 patients), need of acute interventions (10 versus 13), nor for surgery (3 versus 3) or 30-day mortality rates (3 versus 4).

CONCLUSIONS

The study, although underpowered, supports the use of early prophylactic treatment with imipenem in order to reduce the rate of septic complications in patients with severe pancreatitis.

Factors influencing caspofungin plasma concentrations in patients of a surgical intensive care unit

BACKGROUND

Co-morbidity, medical and surgical interventions often cause alterations to drug plasma concentrations and pharmacokinetic parameters in critically ill patients. In the present study, we investigated parameters influencing plasma caspofungin concentrations in patients of a surgical intensive care unit (SICU).

METHODS

In a monocentre open study, caspofungin trough concentrations (C(24)) were determined for a group of SICU patients. A linear-mixed model was then used to assess factors influencing caspofungin plasma concentrations.

RESULTS

A total of 40 SICU patients were enrolled. Age and body weight ranged from 22 to 76 years and 47 to 108 kg, respectively. All participants received a caspofungin loading dose of 70 mg and a maintenance dose of 50 mg/day. The median duration of therapy was 10 days. Caspofungin C(24) in SICU patients varied more than those determined for healthy subjects reported in previous studies (0.52-4.08 microg/mL versus 1.12-1.78 microg/mL). According to our model, caspofungin C(24) were predicted to be significantly higher in patients with body weight <75 kg (P=0.019) and patients with albumin concentration >23.6 g/L (P=0.030).

CONCLUSIONS

Our results show that body weight and albumin concentration influence caspofungin C(24) in SICU patients and should therefore be considered prognostic factors.

Prevention of infectious complications in severe acute pancreatitis with systemic antibiotics: where are we now?

Infectious complications are the leading cause of death in patients with severe acute pancreatitis. Currently, there is controversy concerning the therapeutic possibilities to reduce the incidence of bacterial infection in this disease. Numerous studies are available which apparently support the prophylactic use of antibiotics in patients with necrotizing pancreatitis. The results, however, are contradicting and interpretation is difficult as these studies have used various antibiotic drugs with different application schemes and heterogeneous study end points. This article gives a critical overview of the background of antibiotic treatment in severe acute pancreatitis, the published data on antibiotic treatment and an outlook on the topics that need to be addressed by future research.

Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis

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.

Meta-analysis of prophylactic antibiotic use in acute necrotizing pancreatitis

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.

The management of suspected pancreatic sepsis

The management of infected pancreatic necrosis is centered on image-guided fine needle aspiration followed by antibiotic therapy that is based on microbiologic culture results. The authors favor targeted antibiotic therapy rather than routine prophylactic antibiotic coverage. Prompt surgical debridement is recommended for patients who have infected necrosis who are suitable operative candidates. Newer surgical, percutaneous, and endoscopic techniques, as well as prolonged antibiotic therapy without intervention, are being evaluated as alternatives to operative debridement. Well-designed prospective trials will help to determine optimal treatment for patients who have infected pancreatic necrosis.

The role of antibiotic prophylaxis in the treatment of acute pancreatitis

Acute pancreatitis is an inflammatory disorder, but it is not generally caused by infectious agents. Yet, in tertiary referral hospitals, the majority of patients who die of necrotizing pancreatitis do so as a consequence of infectious complications. These generally develop late (2-4 weeks) in the disease process. This finding prompted the hypothesis that infectious pancreatitis complications, such as an abscess or an infected necrosis which can lead to death, can be reduced by treating patients who suffer, at least initially, from a sterile inflammatory disorder, with broad-spectrum antibiotics. Here we review the experimental foundations of this hypothesis, as well as the difficulties that were encountered when clinical trials were undertaken to confirm it. At present, there is still a case for treating necrotizing pancreatitis patients with broad-spectrum antibiotics (specifically carbapenems), but the extent of the beneficial effect and the number of patients expected to profit from this approach should not be overestimated.

Efficacy of antibiotic penetration into pancreatic necrosis

BACKGROUND

Infection of pancreatic necrosis is the most dangerous complication of acute necrotizing pancreatitis. Infection is undoubtedly caused by the endogenous flora of the host. This is why prophylaxis with a broad-spectrum antibiotic is considered an effective procedure. However, two aspects should be taken into consideration when choosing the antibiotic; it should have the spectrum of action consistent with the pathogens and it should penetrate effectively to the necrotic tissue of the pancreas. The aim of the study was to estimate the efficacy of piperacillin/tazobactam penetration into pancreatic necrosis in patients who received intravenous infusion of piperacillin/tazobactam at a dose of 4.5 g every 8 h for 14-21 days, as the prophylaxis in the treatment of acute necrotizing pancreatitis.

PATIENTS AND METHODS

Necrotic tissue of the pancreas and the inflammatory ascites surrounding the pancreas were derived from 15 patients (male, 10; female, 5; mean age 46 years), who underwent laparatomy due to pancreatic necrosis after treatment for 14-21 days. Tissue/fluid samples were investigated for the concentration of the antibiotic by fluoroscopic/spectroscopic methods of registration in an HPLC system.

RESULTS

The mean concentration of piperacillin/tazobactam was established as 120 mg/kg (SD+/-34) in the necrotic pancreatic tissue and as 183 mg/kg (SD+/-37) in the inflammatory pancreatic ascites.

CONCLUSIONS

In patients with acute necrotizing pancreatitis, the study indicates effective penetration of piperacillin/tazobactam to the necrotic pancreatic tissue and to the inflammatory ascites surrounding the pancreas.

Pharmacological prevention and treatment of acute pancreatitis: where are we now?

Acute pancreatitis is a disease of increasing prevalence, unchanged mortality over many decades, and limited treatment strategies. Progress has been made in developing therapies that reduce the rate of endoscopic retrograde cholangiopancreatography (ERCP)-associated pancreatitis and in preventing infected pancreatic necrosis with intravenous carbapenems. Attempts at reducing pancreatic enzyme output or inhibiting the activity of digestive enzyme proteases have not yielded encouraging results - nor have anti-inflammatory strategies for the treatment of acute pancreatitis been found to be effective so far. Future therapeutic options that are presently being developed or under investigation attempt to restore pancreatic secretory function, interfere with inflammatory pathways in a more effective manner, or inhibit digestive enzyme proteases more selectively.

Pathologic alterations detected in acute pancreatitis induced by sodium taurocholate in rats and therapeutic effects of curcumin, ciprofloxacin and metronidazole combination

BACKGROUND AND AIMS

Secondary bacterial infections and free radical injury have been known to play an important role in the pathogenesis and clinical outcome of acute pancreatitis. Despite the therapy models developed in recent years, the mortality rate is still reported to be higher than expected. The objective of this study therefore was to investigate the effectiveness of ciprofloxacin and metronidazole combination and curcumin together in the treatment of acute pancreatitis.

METHODS

Acute pancreatitis was induced in rats by sodium taurocholate (n = 60). Starting 6 h after the induction of acute pancreatitis, groups I and II were injected 200 mg/kg ciprofloxacin and 500 mg/kg metronidazole intraperitoneally every 12 h for 6 days. Groups II and III received 100 mg/kg curcumin since day 20 prior to the initiation of acute pancreatitis. On day 6, animals of all groups were killed. Blood and tissue samples were taken for biochemical, pathologic and bacteriologic examination.

RESULTS

No statistical difference in the treatment groups versus the non-treatment group has been detected in the pancreatic tissue on the basis of histopathological scoring results. Prevalences of bacterial translocation were significantly lower in the treatment groups (groups I-III) than in the non-treatment group (group IV) (p < 0.001, p < 0.001, p < 0.05, respectively). Serum amylase, lipase, malon dialdehyde and nitric oxide (except for nitric oxide level in group I), levels of groups I, II and III were significantly lower than those of group IV (p < 0.05).

CONCLUSIONS

The administration of ciprofloxacin and metronidazole in combination and curcumin in acute pancreatitis failed to provide a preventive effect on the occurrence of tissue injury, whereas free radical injury and prevalence of bacterial translocation were reduced significantly.

Chinese medicinal herbs for acute pancreatitis

BACKGROUND

Acute pancreatitis is a relatively common acute abdominal emergency but there is no specific therapy for it. Traditional Chinese medicinal herbs have been used widely for many years in China to treat acute pancreatitis, and several controlled trials have been carried out to investigate their efficacy.

OBJECTIVES

To assess the efficacy and safety of traditional Chinese medicinal herbs for acute pancreatitis.

SEARCH STRATEGY

The following electronic databases were searched, in September 2002: the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library Issue 3, 2002, MEDLINE, EMBASE, AHMED (Allied and Complementary Medicine Database) and SIGLE (System for Information on Grey Literature). Four Chinese journals and conference proceedings were handsearched. No language restriction was used. The searches were updated in October 2003 (The Cochrane Library Issue 3, 2003).

SELECTION CRITERIA

All randomized controlled trials involving traditional Chinese medicinal herbs in the treatment of acute pancreatitis and published in any language, regardless of whether they were single-blinded, double-blinded, or not blinded.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers. The methodological quality of trials was evaluated using the Jadad scale plus allocation concealment.

MAIN RESULTS

Eleven randomized clinical trials (including a total of 658 participants) were identified in which Chinese medicinal herbs or Chinese medicinal herbs plus routine treatment were compared with routine treatment. All of these trials were published in Chinese and all included inpatients. None of the articles described the method of randomisation. The large heterogeneity of the intervention prevented us from doing a meaningful subgroup analysis. There appeared to be some benefit from Chinese medicinal herbs over control for mortality rates, length of hospital stay and operative intervention but the trials were of low quality and this benefit did not reach statistical significance.

AUTHORS' CONCLUSIONS

Some Chinese medicinal herbs may work in acute pancreatitis. However, the evidence is too weak to recommend any single herb. Rigorously designed, randomized, double-blind, placebo-controlled trials are required.