Use of antibiotics in severe acute pancreatitis

Use of antibiotics in acute pancreatitis: ten major concerns

Acute pancreatitis is one of the most common gastrointestinal causes for hospitalization. In 15-20% it evolves into severe necrotizing pancreatitis. Recent studies have shown no association between the initiation of antibiotic therapy in acute pancreatitis and severe outcomes such as organ failure, infection of pancreatic necrosis, extrapancreatic infections or mortality. Specific subgroups with predicted severe acute pancreatitis or both extensive sterile necrosis and persistent organ failure may benefit from prophylactic antibiotics. Local infection develops in 30% of patients with pancreatic necrosis and results in morbidity and mortality. Contrast enhanced computed tomography should be performed in all patients with acute pancreatitis who develop sepsis, organ failure or fail to improve. C-reactive protein is an independent predictor of severe acute pancreatitis. Procalcitonin is the most sensitive laboratory test for detection of pancreatic infection. Antibiotics do however play a large role in patients with suspected or confirmed infected pancreatic necrosis and extrapancreatic infections. In clinical practice most clinicians prescribe antibiotics in the first 3 days of acute pancreatitis which in turns lead to excessive, unjustified use of antibiotics. Deep knowledge of the recent guidelines combined with an individualized management based on right clinical judgment is a rationale approach of patients with acute pancreatitis.

Prevention of Infectious Complications in Acute Pancreatitis: Results of a Single-Center, Randomized, Controlled Trial

OBJECTIVES

This study aimed to investigate the efficiency of imipenem to prevent infectious complications in predicted severe acute pancreatitis (AP).

METHODS

Consecutive AP patients were randomized to imipenem 3 × 500 mg intravenously daily or an identical placebo. Exclusion criteria were prior AP, chronic pancreatitis, active malignancy, immune deficiency, active infection, concomitant antibiotic treatment, pregnancy, and patients younger than 18 years. Infectious complications including infected pancreatic necrosis, pneumonia, urinary tract infection, positive blood cultures, sepsis, and other infections were assessed as the primary outcome. Secondary outcomes included mortality, persistent organ failure, systemic inflammatory response syndrome, local complications, serious adverse events, and need for surgical intervention.

RESULTS

Forty-nine patients were randomized to each group. Infectious complications were present in 10 versus 12 of 49 patients (relative risk [RR], 0.833; 95% confidence interval [CI], 0.398-1.747). There were no significant differences in infected pancreatic necrosis (RR, 1.5; 95% CI, 0.262-8.588), pneumonia (RR, 1.5; 95% CI, 0.262-8.588), urinary tract infection (RR, 0.6; 95% CI, 0.152-2.374), positive blood cultures (RR, 0.5; 95% CI, 0.047-5.336), sepsis (RR, 0.333; 95% CI, 0.036-3.095), and other (RR, 1.333; 95% CI, 0.315-5.648). We found no significant differences in secondary outcomes.

CONCLUSIONS

Concordantly to available evidence, there is currently no ground to support prophylactic use of antibiotics in predicted severe AP.

Application of semi-automated ultrasonography on nutritional support for severe acute pancreatitis

OBJECTIVE

To evaluate the application value of semi-automated ultrasound on the guidance of nasogastrojejunal tube replacement for patients with acute severe pancreatitis (ASP), as well as the value of the nutritional support for standardized treatment in clinical practice.

METHODS

The retrospective research was performed in our hospital, and 34 patients suffering from ASP were enrolled into this study. All these identified participants ever received CT scans in order to make definitive diagnoses. Following, these patients received semi-automated ultrasound examinations within 1 days after their onset, in order to provide enteral nutrititon treatment via nasogastrojejunal tube, or freehand nasogastrojejunal tube replacement. In terms of statistical analysis, the application value of semi-automated ultrasound guidance on nasogastrojejunal tube replacement was evaluated, and was compared with tube replacement of no guidance. After cathetering, the additional enteral nutrition was provided, and its therapeutic effect on SAP was analyzed in further.

RESULTS

A total of 34 patients with pancreatitis were identified in this research, 29 cases with necrosis of pancreas parenchyma. After further examinations, 32 cases were SAP, 2 cases were mild acute pancreatitis. When the firm diagnosis was made, additional enteral nutrition (EN) was given, all the patient conditions appeared good, and they all were satisfied with this kind of nutritional support. According to our clinical experience, when there was 200-250 ml liquid in the stomach, the successful rate of intubation appeared higher. Additionally, the comparison between ultrasound-guided and freehand nasogastrojejunal tube replacement was made. According to the statistical results, in terms of the utilization ratio of nutritional support, it was better in ultrasound-guided group, when compared with it in freehand group, within 1 day, after 3 days and after 7 days (7/20 versus 2/14; P < 0.05; 14/20 versus 6/14; P < 0.05; 20/20 versus 12/14; P < 0.05). Besides, the complications caused by cathetering between two groups was not statistically different (P > 0.05).

CONCLUSIONS

It can be indicated that semi-automated ultrasound guidance is a reliable method for nasogastrojejunal tube replacement, and should be substituted for no guidance of cathetering. In terms of therapeutic effect of EN, additional nutritional support contributed to significantly improve the prognosis of SAP patients, and should be widely recommended in clinical practice. Surely, this conclusion should be evaluated in further, by means of randomized controlled trials and economic evaluation.

Acute pancreatitis

PURPOSE OF REVIEW

To review the changing insights in the pathophysiology and management of acute pancreatitis.

RECENT FINDINGS

The outdated 1992 Atlanta classification has been replaced by two new classifications, both of which acknowledge the role of organ dysfunction in determining the outcome of acute pancreatitis, and both of which have introduced a new category of 'moderate' pancreatitis. The new classifications will allow fewer patients to be classified as severe, which better reflects the risk of dying of the disease. Intra-abdominal hypertension has emerged as a relevant issue, and strategies to lower intra-abdominal pressure may often be required. Antibiotic prophylaxis has been discontinued for some time, but aggressive fluid resuscitation is also being questioned, and the role of surgery is further reduced as percutaneous drainage of collections has shown to reduce the need for more surgical interventions. If needed, surgery should be as conservative as possible, with minimally invasive strategies preferable. Newer techniques such as endoscopic transgastric drainage are being developed, but their exact role has yet to be defined.

SUMMARY

Management of severe acute pancreatitis is changing fundamentally. 'Less is more' is the new paradigm in acute pancreatitis - less antibiotics, less fluids, less surgery, which should eventually lead to less morbidity and mortality.

Infections and use of antibiotics in patients admitted for severe acute pancreatitis: data from the EPIC II study

BACKGROUND

Infectious complications are frequent in severe acute pancreatitis (SAP) but multinational epidemiologic data are lacking. The aim of the study was to analyze the characteristics of the infectious complications and antimicrobial use in this setting.

METHODS

One-day point prevalence study of infection in critically ill patients (Extended Prevalence of Infection in the ICU-II study), performed in 1,265 ICUs in 75 countries.

RESULTS

Of the 13,796 patients in the study, 159 were admitted with SAP. One-hundred sixteen (73%) had infections: 31% intra-abdominal, 16% extra-abdominal, and 26% both. Gram-negative bacteria were more prevalent than gram-positive organisms, anaerobes, or fungi. Therapeutically, penicillins and other beta-lactams were used most frequently. Prophylactic antibiotics were administered to 24% of the patients with SAP.

CONCLUSIONS

Infections are frequent in patients admitted with SAP; most are intra-abdominal infections. Microbiology is diverse with gram-negative micro-organisms most frequently isolated. Most patients admitted to the ICU for SAP receive antibiotics at some point.

Mikrobiologie und Antiinfektiva

Bei einem 38-jährigen Patienten wurde eine Analfistel operiert. Am 3. postoperativen Tag kommt es zur akuten Verschlechterung des Gesundheitszustands mit hämodynamischer Instabilität und Fieber. Daraufhin wird der Patient in eine Klinik der Maximalversorgung verlegt. Beim Eintreffen im Schockraum ist der Patient somnolent und kaltschweißig. Der Blutdruck beträgt 70/40 mmHg, die Herzfrequenz 120/min und die Körpertemperatur 39,6°C. Das Hautkolorit ist blass-grau. Im Verlegungsbericht wird bei stark ödematös geschwollenem Skrotum der Verdacht auf eine Fournier-Gangrän nach Analfistel- OP gestellt. Der diensthabende Intensivmediziner muss nun parallel die hämodynamische Situation stabilisieren, mikrobiologisches Material gewinnen, eine kalkulierte antimikrobielle Therapie beginnen und weitere Maßnahmen zur Diagnosesicherung einleiten.

[Clinical characteristics of acute pancreatitis in Mexico]

BACKGROUND

Acute pancreatitis (AP) etiology and frequency vary in relation to geographic region.

AIMS

To determine the etiology, frequency, and mortality of AP in a Mexican population.

PATIENTS AND METHODS

We carried out a prospective study of first episode AP patients over a period of 6 years.

RESULTS

A total of 605 patients with a mean age of 40 years were included in the study. Sixty-four percent of them presented with overweight and/or obesity determined through BMI. Etiology was biliary in 66.60%, it was due to alcohol consumption in 15.90%, hypertriglyceridemia in 7.80%, it was post-endoscopic retrograde cholangiopancreatography (ERCP) in 2.10%, and was undetermined in 7.20%. Pancreatic infection was suspected in 70 patients and they underwent CT-guided fine needle aspiration. Thirty-two of those patients were diagnosed with pancreatic infection in which Staphylococcus spp was the most common microorganism. Overall mortality was 5.00% (2.60% < 30 years and 10.00% > 70 years). Necrosis, pancreatic infection, and mortality were more frequent in the cases in which etiology was due to alcohol ingestion.

CONCLUSIONS

The most frequent AP etiology was biliary, but that caused by alcohol presented with more complications. Overall mortality was 5.00% and was higher in the elderly patients.

Role of prophylactic antibiotics in the management of acute necrotizing pancreatitis: A meta-analysis

AIM: To evaluate the role of prophylactic antibiotics in the management of acute necrotizing pancreatitis.

METHODS: A computerized literature search of Medline, PubMed, Spring, Ovid, Elsevier, Embase, CNKI, and VIP databases was conducted to identify relevant articles published from January 1994 to October 2011. According to the inclusion criteria, 5 studies were selected. The data were analyzed using RevMan 5.1 software.

RESULTS: Our meta-analysis suggests that prophylactic antibiotic treatment did not significantly reduce morbility (RR = 0.75, 95%CI 0.43-1.28, P = 0.29) or the incidence of infected pancreatic necrosis (RR = 0.81, 95%CI 0.55-1.19, P = 0.29), nonpancreatic infection (RR = 0.79, 95%CI 0.59-1.06, P = 0.12), or surgical intervention (RR = 0.78, 95%CI 0.45-1.36, P = 0.37).

CONCLUSION: Prophylactic antibiotic treatment does not reduce the occurrence of infected pancreatic necrosis, nonpancreatic infection, surgical intervention or morbility in patients with acute necrotizing pancreatitis.

Acute pancreatitis: should we use antibiotics?

Acute pancreatitis is a common cause of hospitalization and a major source of morbidity worldwide. When it is severe, and especially when it progresses to include necrosis of the pancreas, the risk of infection rises and mortality increases. Early reports suggested prophylactic antibiotics given in severe pancreatitis prevent infection and death. More recent clinical trials do not support this benefit, and meta-analyses on the topic offer conflicting recommendations. In this article, we evaluate the body of published literature examining the use of antibiotics as a preventive measure in acute pancreatitis. The highest quality, currently available data fail to support prophylactic use of antibiotics, which should be added to treatment regimens only where infection has been proven.

Mikrobiologie und Antiinfektiva

Bei einem 38-jährigen Patienten wurde eine Analfistel operiert. Am 3. postoperativen Tag kommt es zur akuten Verschlechterung des Gesundheitszustands mit hämodynamischer Instabilität und Fieber. Daraufhin wird der Patient in eine Klinik der Maximalversorgung verlegt. Beim Eintreffen im Schockraum ist der Patient somnolent und kaltschweißig. Der Blutdruck beträgt 70/40 mmHg, die Herzfrequenz 120/min und die Körpertemperatur 39,6°C. Das Hautkolorit ist blass-grau. Im Verlegungsbericht wird bei stark ödematös geschwollenem Skrotum der Verdacht auf eine Fournier-Gangrän nach Analfistel-OP gestellt. Der diensthabende Intensivmediziner muss nun parallel die hämodynamische Situation stabilisieren, mikrobiologisches Material gewinnen, eine kalkulierte antimikrobielle Therapie beginnen und weitere Maßnahmen zur Diagnosesicherung einleiten.

Establishment of a secondary infection model of severe acute pancreatitis in swine

OBJECTIVE

Develop a swine model of secondary infection in severe acute pancreatitis (SAP).

METHODS

Twenty-seven female swine were divided into 3 groups (1-3). In the first experiment, a SAP model was developed by retrograde injection of sodium taurocholate and trypsin into the pancreatic duct. In the second experiment, the SAP model was used to develop a secondary infection model. In groups 1 to 3, 10⁸/mL or 10⁴/mL Escherichia coli or saline were respectively used to inoculate necrotic areas of the pancreas using computed tomographic guidance. Biochemical, histopathological, and imaging analyses were used to characterize disease presentation.

RESULTS

The survival rate was 85.2% (23/27) during the course of the 9-day experiment. The secondary infection rates in groups 1 to 3 were 100% (8/8), 37.5% (3/8), and 14.3% (1/7), respectively. In group 1, the infection rate was significantly higher in comparison to the other 2 groups (χ²=4.66 and 8.14, respectively, and both P<0.05). The biochemical and histopathological parameters and computed tomographic images indicated successful development of the SAP secondary infection model.

CONCLUSIONS

The swine model of SAP secondary infection was successfully developed using a 2-step method, which could serve as a platform for SAP studies that need complex experimental manipulations for longer time spans, especially for imaging research.