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Acute Pancreatitis: Should We Use Antibiotics?

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Abstract

Acute pancreatitis is a common cause of hospitalization and a major source of morbidity worldwide. When it is severe, and especially when it progresses to include necrosis of the pancreas, the risk of infection rises and mortality increases. Early reports suggested prophylactic antibiotics given in severe pancreatitis prevent infection and death. More recent clinical trials do not support this benefit, and meta-analyses on the topic offer conflicting recommendations. In this article, we evaluate the body of published literature examining the use of antibiotics as a preventive measure in acute pancreatitis. The highest quality, currently available data fail to support prophylactic use of antibiotics, which should be added to treatment regimens only where infection has been proven.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. DeFrances CJ, Hall MJ. 2005 National hospital discharge survey. Adv Data. 2007;385:1–19.

    PubMed  Google Scholar 

  2. Froussard JL, Steer ML, Pastor CM. Acute pancreatitis. Lancet. 2008;371:143–52.

    Article  Google Scholar 

  3. Fagenholz PJ, Castillo CF, Harris NS, et al. Increasing United States hospital admissions for acute pancreatitis, 1988–2003. Ann Epidemiol. 2007;17:491–7.

    Article  PubMed  Google Scholar 

  4. Munsell MA, Buscaglia JM. Acute pancreatitis. J Hosp Med. 2010;5:241–50.

    Article  PubMed  Google Scholar 

  5. Gupta K, Wu B. In the clinic: acute pancreatitis. Ann Int Med. 2010, 153:ITC5-1to16.

    Google Scholar 

  6. Gaisano HY, Gorelik FS. New insights in to the mechanisms of pancreatitis. Gastroenterology. 2009;136:2040–4.

    Article  PubMed  CAS  Google Scholar 

  7. Park DH, Kim MH, Chari ST. Recent advances in autoimmune pancreatitis. Gut. 2009;58:1680–9.

    Article  PubMed  CAS  Google Scholar 

  8. Khan AS, Latif SU, Eloubeidi MA. Controversies in the etiologies of acute pancreatitis. JOP J Pancreas (Online). 2010;11:545–52.

    Google Scholar 

  9. Acute Pancreatitis Classification Working Group: Revision of the Atlanta classification of acute pancreatitis (3rd revision). Available at www.pancreasclub.com/resources/AtlantaClassification.pdf

  10. Greer SE, Burchard KW. Acute pancreatitis and critical illness: a tale of hypoperfusion and inflammation. Chest. 2009;136:1413–9.

    Article  PubMed  Google Scholar 

  11. Bai Y, Gao J, Zou DW, et al. Prophylactic antibiotics cannot reduce infected pancreatic necrosis and mortality in acute necrotizing pancreatitis: evidence from a meta-analysis of randomized controlled trials. Am J Gastroenterol. 2008;103:104–10.

    PubMed  Google Scholar 

  12. Modifi R, Patil PV, Suttie SA, et al. Risk assessment in acute pancreatitis. Br J Surg. 2009;96:137–50.

    Article  Google Scholar 

  13. Gan SI, Romagnuulo J. Admission hematocrit: a simple, useful and early predictor of severe pancreatitis. Dig Dis Sci. 2004;49:1946–52.

    Article  PubMed  Google Scholar 

  14. Martınez J, Johnson CD, Sanchez-Paya J, et al. Obesity is a definitive risk factor of severity and mortality in acute pancreatitis: an updated meta-analysis. Pancreatology. 2006;6:206–9.

    Article  PubMed  Google Scholar 

  15. Brown A, James-Stevenson T, Dyson T, et al. The Panc 3 score: a rapid and accurate test for predicting severity on presentation in acute pancreatitis. J Clin Gastroenterol. 2007;41:855–8.

    Article  PubMed  Google Scholar 

  16. Petrov MS, van Santvoort HC, Besselink MGH, et al. Enteral nutrition and the risk of mortality and infectious complications in patients with severe acute pancreatitis: a meta-analysis of randomized trials. Arch Surg. 2008;143:1111–7.

    Article  PubMed  Google Scholar 

  17. Wu XM, Ji KQ, Wang HY, et al. Total enteral nutrition in prevention of pancreatic necrotic infection in severe acute pancreatitis. Pancreas. 2010;39:248–51.

    Article  PubMed  CAS  Google Scholar 

  18. Stamatakos M, Stefanaki C, Kontzoglou K, et al. Walled-off pancreatic necrosis. World J Garoenterol. 2010;16:1707–12.

    Article  Google Scholar 

  19. van Santvoort HC, Bessleink MG, de Vries AC, et al. Early endoscopic retrograde cholangiopancreatography in predicted severe acute biliary pancreatitis: a prospective multicenter study. Ann Surg. 2009;250:68–75.

    Article  PubMed  Google Scholar 

  20. Zhang MM, Cheng JQ, Lu YR, et al. Use of pre-, pro- and synbiotics in patients with acute pancreatitis: a meta-analysis. Wold J Gastroenterol. 2010;16:3970–8.

    Article  Google Scholar 

  21. Craig RM, Dordal E, Myles L. The use of ampicillin in acute pancreatitis [letter]. Ann Intern Med. 1975;83:831–2.

    PubMed  CAS  Google Scholar 

  22. Howes R, Zuidema GD, Cameron JL. Evaluation of prophylactic antibiotics in acute pancreatitis. J Surg Res. 1975;18:197–200.

    Article  PubMed  CAS  Google Scholar 

  23. Finch WT, Sawyers JL, Schenker S. A prospective study to determine the efficacy of antibiotics in acute pancreatitis. Ann Surg. 1976;183:667–71.

    Article  PubMed  CAS  Google Scholar 

  24. Golub R, Siddiqui F, Pohl D. Role of antibiotics in acute pancreatitis: a meta-analysis. J Gastrointest Surg. 1998;2:496–503.

    Article  PubMed  CAS  Google Scholar 

  25. Pederzoli P, Bassi C, Vesentini S, et al. A randomized multicenter clinical trial of antibiotic prophylaxis of septic complications in acute necrotizing pancreatitis with imipenem. Surg Gynecol Obstet. 1993;176:480–3.

    PubMed  CAS  Google Scholar 

  26. Luiten EJ, Hop WC, Lange JF, et al. Controlled clinical trial of selective decontamination for the treatment of severe acute pancreatitis. Ann Surg. 1995;222:57–65.

    Article  PubMed  CAS  Google Scholar 

  27. Sainio V, Kemppainen E, Puolakkainen P, et al. Early antibiotic treatment in acute necrotising pancreatitis. Lancet. 1995;346:663–7.

    Article  PubMed  CAS  Google Scholar 

  28. Delcenserie R, Yzet T, Ducroix JP. Prophylactic antibiotics in treatment of severe acute alcoholic pancreatitis. Pancreas. 1996;13:198–201.

    PubMed  CAS  Google Scholar 

  29. Schwarz M, Isenmann R, Meyer H, et al. Antibiotic use in necrotizing pancreatitis. Results of a controlled study. Dtsch Med Wochenschr. 1997;122:356–61.

    Article  PubMed  CAS  Google Scholar 

  30. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials. 1996;17:1–12.

    Article  PubMed  CAS  Google Scholar 

  31. Guyatt GH, Sackett DL, Cook DJ, for the Evidence-Based Medicine Working Group. Users’ guides to the medical literature II. How to use an article about therapy or prevention. A. Are the results of the study valid? JAMA. 1993;270:2598–601.

    Article  PubMed  CAS  Google Scholar 

  32. Oxman AD, Cook DJ, Guyatt GH, for the Evidence-Based Medicine Working Group. Users’ guides to the medical literature VI. How to use an overview. JAMA. 1994;272:1367–71.

    Article  PubMed  CAS  Google Scholar 

  33. • Guyatt G, Drummond R, Meade M, et al. Users’ guides to the medical literature: a manual for evidence-based clinical practice. 2nd ed. New York: McGraw-Hill Professional; 2008. This book is a compilation of the Users’ Guides series published in JAMA beginning in 1993. It is an indispensable tool for the reader of medical literature, providing a framework for appraising the quality of published clinical trials and applying them to patient care.

    Google Scholar 

  34. Sharma VK, Howden CW. Prophylactic antibiotic administration reduces sepsis and mortality in acute necrotizing pancreatitis: a meta-analysis. Pancreas. 2001;22:28–31.

    Article  PubMed  CAS  Google Scholar 

  35. Heinrich S, Schafer M, Rousson V, et al. Evidence-based treatment of acute pancreatitis: a look at established paradigms. Ann Surg. 2006;243:154–68.

    Article  PubMed  Google Scholar 

  36. Villatoro E, Bassi C, Larvin M. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane Database Syst Rev. 2006;4:CD002941.

    PubMed  Google Scholar 

  37. Mazaki T, Ishii Y, Takayama T. Meta-analysis of prophylactic antibiotic use in acute necrotizing pancreatitis. Br J Surg. 2006;93:674–84.

    Article  PubMed  CAS  Google Scholar 

  38. Xiong GS, Wu SM, Wang ZH. Role of prophylactic antiobiotic administration in severe acute pancreatitis: a meta-analysis. Med Princ Pract. 2006;15:106–10.

    Article  PubMed  Google Scholar 

  39. Nordback I, Sand J, Saaristo R. Early treatment with antibiotics reduces the need for surgery in acute necrotizing pancreatitis—a single-center randomized study. J Gastrointest Surg. 2001;5:113–8.

    Article  PubMed  CAS  Google Scholar 

  40. Isenmann R, Runzi M, Kron M, et al. (German) Antibiotics in Severe Acute Pancreatitis Study Group: prophylactic antibiotic treatment in patients with predicted severe acute pancreatitis: a placebo-controlled, double-blind trial. Gastroenterology. 2004;126:997–1004.

    Article  PubMed  CAS  Google Scholar 

  41. Spicak J, Hejtmankova S, Cech P, et al. Antibiotic prophylaxis in large pancreatic necrosis: multicenter randomized trial with ciprofloxacin and metronidazole or meropenem. Gastroenterology. 2004;126 Suppl 2:A-229.

    Google Scholar 

  42. Dambrauskas Z, Gulbinas A, Pundzius J, et al. Meta-analysis of prophylactic parenteral antibiotic use in acute necrotizing pancreatitis. Medicina. 2007;43:291–300.

    PubMed  Google Scholar 

  43. Takeda K, Matsuno S, Ogawa M, et al. Continuous regional arterial infusion (CRAI) therapy reduces the mortality rate of acute necrotizing pancreatitis: results of a cooperative survey in Japan. J Hepatobiliary Pancreat Surg. 2001;8:216–20.

    Article  PubMed  CAS  Google Scholar 

  44. Bassi C, Mangiante G, Falconi M, et al. Prophylaxis for septic complications in acute necrotizing pancreatitis. J Hepatobiliary Pancreat Surg. 2001;8:211–5.

    Article  PubMed  CAS  Google Scholar 

  45. Manes G, Rabitti PG, Menchise A, et al. Prophylaxis with meropenem of septic complications in acute pancreatitis: a randomized, controlled trial versus imipenem. Pancreas. 2003;27:e79–83.

    Article  PubMed  Google Scholar 

  46. Maravi-Poma E, Gener J, Alvarez-Lerma F, et al. 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;29:1974–80.

    Article  PubMed  Google Scholar 

  47. • de Vries AC, Besselink MGH, Buskens E, et al. Randomized controlled trials of antibiotic prophylaxis in severe acute pancreatitis: relationship between methodological quality and outcome. Pancreatology 2007;7:531–8. This is a well done meta-analysis demonstrating an inverse association between methodologic quality and reported impact of antibiotic intervention on the outcome of mortality in ANP.

    Article  PubMed  Google Scholar 

  48. • Dellinger EP, Tellado JM, Soto NE, et al. Early antibiotic treatment for severe acute necrotizing pancreatitis: a randomized, double-blind, placebo-controlled study. Ann Surg. 2007;245:674–83. This RCT is a high quality study on prophylactic antibiotics for ANP by being double-blind and a relatively large, multicenter trial. It showed no benefit for meropenem on the outcomes of infected necrosis or mortality.

    Article  PubMed  Google Scholar 

  49. Hart PA, Bechtold ML, Marshall JB, et al. Prophylactic antibiotics in necrotizing pancreatitis: a meta-analysis. South Med J. 2008;11:1126–31.

    Article  Google Scholar 

  50. • Bai Y, Gao J, Zou DW, et al. Prophylactic antiobiotics cannot reduce infected pancreatic necrosis and mortality in acute necrotizing pancreatitis: evidence for a meta-analysis of randomized controlled trials. Am J Gastroenterol. 2008;103:104–10. This is a very well done meta-analysis that stratified validity/quality for its included trials and showed again that only lower quality trials report a benefit for antibiotics. It also contains methodological explanations for why earlier meta-analyses mistakenly found benefit for prophylactic antiobiotics in ANP.

    PubMed  Google Scholar 

  51. Jafri NS, Mahid SS, Idstein SR, et al. Antibiotic prophylaxis is not protective in severe acute pancreatitis: a systematic review and meta-analysis. Am J Surg. 2009;197:806–13.

    Article  PubMed  CAS  Google Scholar 

  52. Villatoro E, Mulla M, Larvin M. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane Database Syst Rev. 2010;5:CD002941.

    PubMed  Google Scholar 

  53. • Bai Y, Gao J, Zou DW, et al. Antibiotics prophylaxis in acute necrotizing pancreatitis: an update. Am J Gastroenterol. 2010;105:705–7. This brief article is an update of their earlier high quality meta-analysis, now containing additional randomized trials and including all three higher quality, double-blinded RCTs. They point out that they now include more patients with a biliary etiology for pancreatitis. This publication represents the most accurate meta-analysis to date of prophylactic antibiotics in ANP.

    Article  PubMed  CAS  Google Scholar 

  54. Xu T, Cai Q. Prophylactic antibiotic treatment in acute necrotizing pancreatitis: results from a meta-analysis. Scand J Gastroenterol. 2008;43:1249–58.

    Article  PubMed  CAS  Google Scholar 

  55. • García-Barrasa A, Borobia FG, Pallares R, et al. A double-blind, placebo-controlled trial of ciprofloxacin prophylaxis in patients with acute necrotizing pancreatitis. J Gastrointest Surg. 2009;13:768–74. This RCT is the newest double-blind study examining prophylactic antibiotics in ANP.

    Article  PubMed  Google Scholar 

  56. Egger M, Smith GD, Schneider M, et al. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315:629–34.

    PubMed  CAS  Google Scholar 

  57. Hennekens CH, DeMets D. The need for large-scale randomized evidence without undue emphasis on small trials, meta-analyses, or subgroup analyses. JAMA. 2009;302:2361–2.

    Article  PubMed  CAS  Google Scholar 

  58. • De Waele JJ. Use of antibiotics in severe acute pancreatitis. Expert Rev Anti Infect Ther. 2010;8:317–24. This article is a descriptive review of this topic, also drawing the conclusion that prophylactic antibiotics are not beneficial in acute necrotizing pancreatitis.

    Article  PubMed  Google Scholar 

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  1. Scripps Clinic and Scripps Green Hospital, 10666 North Torrey Pines Road, 404C, La Jolla, CA, 92037, USA

    Laura J. Nicholson

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  1. Laura J. Nicholson
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Correspondence to Laura J. Nicholson.

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Nicholson, L.J. Acute Pancreatitis: Should We Use Antibiotics?. Curr Gastroenterol Rep 13, 336–343 (2011). https://doi.org/10.1007/s11894-011-0198-4

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