CICM SAQ 2016.1 Q1

Background / Rationale:

Systemic antibiotics in severe acute pancreatitis (SAP) have a potential role in three areas:

• Infected pancreatic necrosis
  • Necrotising pancreatitis develops in about 15% and approx. half of these become infected with increased mortality
  • Majority of pancreatic infections are from gut derived organisms and may be polymicrobial. Common organisms include E coli, Klebsiella species, Enterobacter species, Proteus, Pseudomonas aeruginosa, Bacteroides species and Enterococcus
  • Should be suspected in patients with pancreatic necrosis who fail to improve after 7-10 days of hospitalisation
• Extra-pancreatic infections
  • Common (up to 20% of patients with SAP), e.g. bloodstream, pneumonia, UTI and associated with increased mortality
• Prophylaxis
  • Theoretically antibiotics could prevent or decrease infection rates and decrease mortality
  • Use of prophylactic antibiotics in SAP is controversial

Disadvantages:

• Development of resistant strains of bacteria and selection of fungal infections.

Evidence and Practice Guidelines:

• Infected pancreatic necrosis
  • In suspected infected necrosis or pancreatic abscess, use antibiotics in association with minimally invasive drainage or open surgery.
  • Therapeutic guidelines recommend Tazocin OR if allergic to penicillin’s 3rd generation cephalosporin and metronidazole OR meropenem OR quinolone and metronidazole.
• Extra-pancreatic infections
  • Antibiotics should be prescribed as clinically indicated.
  • Use of prophylactic antibiotics in pancreatitis
  • Controversial
  • Cochrane meta-analysis in 2010:
    • Trends towards increased survival and reduced rates of infections of pancreatic
      necrosis but not statistically significant
    • Trend towards less incidence of non-pancreatic infections
    • Of subgroup analysis regarding antibiotic therapy, only imipenem had
      statistically decreased infection rates of necrotic pancreas but no mortality
      benefit
    • Issues with under powering of studies, not limited to necrotic pancreatitis and
      heterogeneity of patients
    • Prophylactic antibiotics in established necrosis of acute pancreatitis not
      recommended.

Summary statement:

• In suspected infected pancreatic necrosis treat with surgical/percutaneous/endoscopic
  drainage and broad-spectrum antibiotics
• Routine use of prophylactic antibiotics with sterile necrosis to prevent infected necrosis is not
  recommended
• Antibiotics as indicated for extra-pancreatic infections
• Routine use of prophylactic antibiotics in severe acute pancreatitis is not recommended