Antibiotic prophylaxis in severe acute pancreatitis: the never-ending controversy.
Infections are the most common late cause of morbidity and mortality in severe acute pancreatitis. Between 1993 and 2004, a number of prospective controlled trials, meta-analyses, and guidelines all concluded that antibiotics were indicated for the prophylaxis of infections in severe acute pancreatitis. However, in 2004, the first prospective, double-blind, placebo-controlled trial was published showing no effect of prophylactic antibiotics, thus rekindling the controversy surrounding this subject. For those physicians who choose to use prophylactic antibiotics, their use should be limited to patients with pancreatic necrosis, and the choice of antibiotic should be guided by the drug's proven ability to penetrate into the pancreas. Evidence supports imipenem, meropenem, or cefepime for this indication. One third of patients will develop infection of pancreatic necrosis despite the use of prophylactic antibiotics. Vigilance must be maintained for evidence of recurrence of markers of inflammation or persistence beyond the first week, which would suggest the need for fine-needle aspiration and culture to detect infection. Physicians who choose not to use prophylactic antibiotics for pancreatic necrosis should be aware that they will need to initiate antibiotics in 54% to 77% of patients for either infection of pancreatic necrosis or extrapancreatic infections.
Oldfield
Edward C
EC
Division of Infectious Diseases, Department of Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA.
D000208:Acute Disease; D000818:Animals; D019072:Antibiotic Prophylaxis; D001291:Attitude of Health Personnel; D004195:Disease Models, Animal; D006801:Humans; D010195:Pancreatitis / Q000382:microbiology* / Q000517:prevention & control*; D018579:Patient Selection; D017410:Practice Guidelines as Topic; D012720:Severity of Illness Index