CICM SAQ 2016.1 Q1

Question

Discuss the role of systemic antibiotic therapy in patients with severe acute pancreatitis.

Answer

Answer and interpretation

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

Pass rate: 83%

Highest mark: 8.0


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Emergency physician MA (Oxon) MBChB (Edin) FACEM FFSEM with a passion for rugby; medical history; medical education; and informatics. Asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | vocortex |

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