The weak evidence base for antibiotic prophylaxis in severe acute pancreatitis.
OBJECTIVE
The incidence of acute pancreatitis varies from 5 to 80 per 100,000 inhabitants throughout the world. The most common cause of death in these patients is infection of pancreatic necrosis by enteric bacteria, spurring the discussion of whether or not prophylactic antibiotic administration could be a beneficial approach. We therefore analyzed randomized clinical trials, which form the basis of guidelines and recommendations on this topic.


RESULTS
One trial demonstrated that antibiotic prophylaxis reduces mortality, but the statistical design of this trial was questionable. Another important trial, showing an effect of antibiotic prophylaxis on the incidence of pancreatic sepsis, used the wrong statistical test to analyze their data. An analysis with the correct test could not confirm this effect. Three randomized clinical trials demonstrated that antibiotic prophylaxis in severe acute pancreatitis could reduce the incidence of extrapancreatic infections. Two trials showed a significant reduction of the overall infection rate; while in one of them peripancreatic and extrapancreatic infections alone were not significantly different. Two double blinded studies could not demonstrate a significant effect of antibiotic prophylaxis on pancreatic/peripancreatic infection, extrapancreatic infection or mortality.


CONCLUSIONS
Our analysis shows that some of the reported significant effects of prophylactic antibiotic treatment are either questionable or less clinically relevant. With regards to reduction in mortality and the incidence of infected pancreatic necrosis, no convincing evidence exists which supports the routine administration of prophylactic antibiotics in severe acute pancreatitis.
Wittau
Mathias
M
Department of General, Visceral and Transplantation Surgery, University Hospital, Steinhoevelstr. 9, 89075 Ulm, Germany. mathias.wittau@uniklinik-ulm.de
Hohl
Kathrin
K
Mayer
Jens
J
Henne-Bruns
Doris
D
Isenmann
Rainer
R
D000208:Acute Disease; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D000890:Anti-Infective Agents / Q000008:administration & dosage; D019072:Antibiotic Prophylaxis; D002444:Cefuroxime / Q000627:therapeutic use; D002939:Ciprofloxacin / Q000008:administration & dosage; D004338:Drug Combinations; D006801:Humans; D008795:Metronidazole / Q000008:administration & dosage; D010195:Pancreatitis / Q000150:complications*; D019283:Pancreatitis, Acute Necrotizing / Q000517:prevention & control*; D016032:Randomized Controlled Trials as Topic; D016896:Treatment Outcome
D000900:Anti-Bacterial Agents; D000890:Anti-Infective Agents; D004338:Drug Combinations; D008795:Metronidazole; D002939:Ciprofloxacin; D002444:Cefuroxime