ABSTRACT
Infectious complications in severe acute pancreatitis are associated with considerable morbidity and mortality. The course of the disease is often protracted, and patients often stay in the hospital for several weeks. Diagnosis of infected pancreatic necrosis is difficult, and the treatment consists of source control and antibiotic treatment. Antibiotic use should be rational in terms of a rational indication, a rational spectrum, and a rational duration. Prophylactic antibiotics are not effective in reducing the incidence of (peri)-pancreatic infection in patients with severe disease (or even documented necrotizing pancreatitis). The only rational indication for antibiotics is documented infection. The spectrum of empirical antibiotics should include both aerobic and anaerobic gram-negative and gram-positive microorganisms. Also, fungal infections are often present in these patients, and antifungal coverage or even prophylaxis should be considered, especially if multiple risk factors for invasive candidiasis are present. Although initiation of antibiotics may be a difficult decision, stopping antibiotic therapy often proves to be even more difficult. Currently, no tools are available to guide antimicrobial treatment. Antibiotic use is only effective if proper source control has been established.
KEYWORDS
Acute pancreatitis - infected pancreatic necrosis - necrotizing pancreatitis - severe acute pancreatitis - walled-off necrosis
REFERENCES
-
1
Working Party of the British Society of Gastroenterology .
UK guidelines for the management of acute pancreatitis.
Gut.
2005;
54
(Suppl 3)
iii1-iii9
-
2
Isenmann R, Rau B, Beger H G.
Bacterial infection and extent of necrosis are determinants of organ failure in patients with acute necrotizing pancreatitis.
Br J Surg.
1999;
86
(8)
1020-1024
-
3
Dellinger E P, Tellado J M, Soto N E et al..
Early antibiotic treatment for severe acute necrotizing pancreatitis: a randomized, double-blind, placebo-controlled study.
Ann Surg.
2007;
245
(5)
674-683
-
4
Wilmer A.
ICU management of severe acute pancreatitis.
Eur J Intern Med.
2004;
15
(5)
274-280
-
5
Al-Omran M, Albalawi Z H, Tashkandi M F, Al-Ansary L A.
Enteral versus parenteral nutrition for acute pancreatitis.
Cochrane Database Syst Rev.
2010;
(1)
CD002837
-
6
De Waele J J, Leppäniemi A K.
Intra-abdominal hypertension in acute pancreatitis.
World J Surg.
2009;
33
(6)
1128-1133
-
7
Besselink M G, van Santvoort H C, Boermeester M A Dutch Acute Pancreatitis Study Group et al.
Timing and impact of infections in acute pancreatitis.
Br J Surg.
2009;
96
(3)
267-273
-
8
van Westerloo D J, Schultz M J, Bruno M J, de Vos A F, Florquin S, van der Poll T.
Acute pancreatitis in mice impairs bacterial clearance from the lungs, whereas concurrent pneumonia prolongs the course of pancreatitis.
Crit Care Med.
2004;
32
(10)
1997-2001
-
9
Petrov M S, Shanbhag S, Chakraborty M, Phillips A R, Windsor J A.
Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis.
Gastroenterology.
2010;
139
(3)
813-820
-
10
Ranson J H, Rifkind K M, Roses D F, Fink S D, Eng K, Spencer F C.
Prognostic signs and the role of operative management in acute pancreatitis.
Surg Gynecol Obstet.
1974;
139
(1)
69-81
-
11
Harrison D A, D'Amico G, Singer M.
The Pancreatitis Outcome Prediction (POP) Score: a new prognostic index for patients with severe acute pancreatitis.
Crit Care Med.
2007;
35
(7)
1703-1708
-
12
Singh V K, Wu B U, Bollen T L et al..
A prospective evaluation of the bedside index for severity in acute pancreatitis score in assessing mortality and intermediate markers of severity in acute pancreatitis.
Am J Gastroenterol.
2009;
104
(4)
966-971
-
13
Knaus W A, Draper E A, Wagner D P, Zimmerman J E.
APACHE II: a severity of disease classification system.
Crit Care Med.
1985;
13
(10)
818-829
-
14
Papachristou G I, Muddana V, Yadav D et al..
Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis.
Am J Gastroenterol.
2010;
105
(2)
435-441, quiz 442
-
15
Delrue L J, De Waele J J, Duyck P O.
Acute pancreatitis: radiologic scores in predicting severity and outcome.
Abdom Imaging.
2010;
35
(3)
349-361
-
16
Mofidi R, Suttie S A, Patil P V, Ogston S, Parks R W.
The value of procalcitonin at predicting the severity of acute pancreatitis and development of infected pancreatic necrosis: systematic review.
Surgery.
2009;
146
(1)
72-81
-
17
Nordback I, Paajanen H, Sand J.
Prospective evaluation of a treatment protocol in patients with severe acute necrotising pancreatitis.
Eur J Surg.
1997;
163
(5)
357-364
-
18
Howard T J, Temple M B.
Prophylactic antibiotics alter the bacteriology of infected necrosis in severe acute pancreatitis.
J Am Coll Surg.
2002;
195
(6)
759-767
-
19
Gloor B, Müller C A, Worni M et al..
Pancreatic infection in severe pancreatitis: the role of fungus and multiresistant organisms.
Arch Surg.
2001;
136
(5)
592-596
-
20
De Waele J J, Vogelaers D, Blot S, Colardyn F.
Fungal infections in patients with severe acute pancreatitis and the use of prophylactic therapy.
Clin Infect Dis.
2003;
37
(2)
208-213
-
21
De Waele J J, Vogelaers D, Hoste E, Blot S, Colardyn F.
Emergence of antibiotic resistance in infected pancreatic necrosis.
Arch Surg.
2004;
139
(12)
1371-1375
-
22
De Waele J J.
Use of antibiotics in severe acute pancreatitis.
Expert Rev Anti Infect Ther.
2010;
8
(3)
317-324
-
23
Sainio V, Kemppainen E, Puolakkainen P et al..
Early antibiotic treatment in acute necrotising pancreatitis.
Lancet.
1995;
346
(8976)
663-667
-
24
Pederzoli P, Bassi C, Vesentini S, Campedelli A.
A randomized multicenter clinical trial of antibiotic prophylaxis of septic complications in acute necrotizing pancreatitis with imipenem.
Surg Gynecol Obstet.
1993;
176
(5)
480-483
-
25
Pezzilli R, Uomo G, Gabbrielli A ProInf-AISP Study Group et al.
A prospective multicentre survey on the treatment of acute pancreatitis in Italy.
Dig Liver Dis.
2007;
39
(9)
838-846
-
26
Isenmann R, Rünzi M, Kron M German Antibiotics in Severe Acute Pancreatitis Study Group et al.
Prophylactic antibiotic treatment in patients with predicted severe acute pancreatitis: a placebo-controlled, double-blind trial.
Gastroenterology.
2004;
126
(4)
997-1004
-
27
García-Barrasa A, Borobia F G, Pallares R et al..
A double-blind, placebo-controlled trial of ciprofloxacin prophylaxis in patients with acute necrotizing pancreatitis.
J Gastrointest Surg.
2009;
13
(4)
768-774
-
28
Villatoro E, Mulla M, Larvin M.
Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis.
Cochrane Database Syst Rev.
2010;
5
(5)
CD002941
-
29
Bai Y, Gao J, Zou D W, Li Z S.
Antibiotics prophylaxis in acute necrotizing pancreatitis: an update.
Am J Gastroenterol.
2010;
105
(3)
705-707
-
30
Jafri N S, Mahid S S, Idstein S R, Hornung C A, Galandiuk S.
Antibiotic prophylaxis is not protective in severe acute pancreatitis: a systematic review and meta-analysis.
Am J Surg.
2009;
(Feb)
12
-
31
de Vries A C, Besselink M G, Buskens E et al..
Randomized controlled trials of antibiotic prophylaxis in severe acute pancreatitis: relationship between methodological quality and outcome.
Pancreatology.
2007;
7
(5-6)
531-538
-
32
Mazaki T, Ishii Y, Takayama T.
Meta-analysis of prophylactic antibiotic use in acute necrotizing pancreatitis.
Br J Surg.
2006;
93
(6)
674-684
-
33
Sharma V K, Howden C W.
Prophylactic antibiotic administration reduces sepsis and mortality in acute necrotizing pancreatitis: a meta-analysis.
Pancreas.
2001;
22
(1)
28-31
-
34
Heinrich S, Schäfer M, Rousson V, Clavien P A.
Evidence-based treatment of acute pancreatitis: a look at established paradigms.
Ann Surg.
2006;
243
(2)
154-168
-
35
Maraví-Poma E, Gener J, Alvarez-Lerma F, Olaechea P, Blanco A, Domínguez-Muñoz J E. Spanish Group for the Study of Septic Complications in Severe Acute Pancreatitis .
Early antibiotic treatment (prophylaxis) of septic complications in severe acute necrotizing pancreatitis: a prospective, randomized, multicenter study comparing two regimens with imipenem-cilastatin.
Intensive Care Med.
2003;
29
(11)
1974-1980
-
36
Eggimann P, Jamdar S, Siriwardena A K.
Pro/con debate: antifungal prophylaxis is important to prevent fungal infection in patients with acute necrotizing pancreatitis receiving broad-spectrum antibiotics.
Crit Care.
2006;
10
(5)
229
-
37
Luiten E J, Hop W C, Lange J F, Bruining H A.
Controlled clinical trial of selective decontamination for the treatment of severe acute pancreatitis.
Ann Surg.
1995;
222
(1)
57-65
-
38
Otto W, Komorzycki K, Krawczyk M.
Efficacy of antibiotic penetration into pancreatic necrosis.
HPB (Oxford).
2006;
8
(1)
43-48
-
39
Drewelow B, Koch K, Otto C, Franke A, Riethling A K.
Penetration of ceftazidime into human pancreas.
Infection.
1993;
21
(4)
229-234
-
40
Adam U, Herms S, Werner U et al..
The penetration of ciprofloxacin into human pancreatic and peripancreatic necroses in acute necrotizing pancreatitis.
Infection.
2001;
29
(6)
326-331
-
41
Pappas P G, Kauffman C A, Andes D Infectious Diseases Society of America et al.
Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America.
Clin Infect Dis.
2009;
48
(5)
503-535
-
42
Senn L, Eggimann P, Ksontini R et al..
Caspofungin for prevention of intra-abdominal candidiasis in high-risk surgical patients.
Intensive Care Med.
2009;
35
(5)
903-908
-
43
Dellinger R P, Levy M M, Carlet J M et al..
Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2008.
Intensive Care Med.
2008;
34
(1)
17-60
-
44
Leppäniemi A, Kemppainen E.
Recent advances in the surgical management of necrotizing pancreatitis.
Curr Opin Crit Care.
2005;
11
(4)
349-352
-
45
van Santvoort H C, Besselink M G, Bakker O J Dutch Pancreatitis Study Group et al.
A step-up approach or open necrosectomy for necrotizing pancreatitis.
N Engl J Med.
2010;
362
(16)
1491-1502
Jan J De WaeleM.D. Ph.D.
Intensive Care Unit 1K12-C, Ghent University Hospital
De Pintelaan 185, 9000 Ghent, Belgium
eMail: jan.dewaele@UGent.be
