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González-González JA, Castañeda-Sepúlveda R, Martínez-Vázquez MA, García-Compean D, Flores-Rendón AR, Maldonado-Garza HJ, Bosques-Padilla F, Garza-Galindo AA. [Clinical characteristics of acute pancreatitis in Mexico]. REVISTA DE GASTROENTEROLOGIA DE MEXICO 2012. [PMID: 23177790 DOI: 10.1016/j.rgmx.2012.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute pancreatitis (AP) etiology and frequency vary in relation to geographic region. AIMS To determine the etiology, frequency, and mortality of AP in a Mexican population. PATIENTS AND METHODS We carried out a prospective study of first episode AP patients over a period of 6 years. RESULTS A total of 605 patients with a mean age of 40 years were included in the study. Sixty-four percent of them presented with overweight and/or obesity determined through BMI. Etiology was biliary in 66.60%, it was due to alcohol consumption in 15.90%, hypertriglyceridemia in 7.80%, it was post-endoscopic retrograde cholangiopancreatography (ERCP) in 2.10%, and was undetermined in 7.20%. Pancreatic infection was suspected in 70 patients and they underwent CT-guided fine needle aspiration. Thirty-two of those patients were diagnosed with pancreatic infection in which Staphylococcus spp was the most common microorganism. Overall mortality was 5.00% (2.60% < 30 years and 10.00% > 70 years). Necrosis, pancreatic infection, and mortality were more frequent in the cases in which etiology was due to alcohol ingestion. CONCLUSIONS The most frequent AP etiology was biliary, but that caused by alcohol presented with more complications. Overall mortality was 5.00% and was higher in the elderly patients.
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Affiliation(s)
- J A González-González
- Servicio de Gastroenterología, Departamento de Medicina Interna, Hospital Universitario "Dr. José Eleuterio González", Monterrey, N.L., México
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Villatoro E, Mulla M, Larvin M. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane Database Syst Rev 2010; 2010:CD002941. [PMID: 20464721 PMCID: PMC7138080 DOI: 10.1002/14651858.cd002941.pub3] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pancreatic necrosis may complicate severe acute pancreatitis, and is detectable by computed tomography (CT). If it becomes infected mortality increases, but the use of prophylactic antibiotics raises concerns about antibiotic resistance and fungal infection. OBJECTIVES To determine the efficacy and safety of prophylactic antibiotics in acute pancreatitis complicated by CT proven pancreatic necrosis. SEARCH STRATEGY Searches were updated in November 2008, in The Cochrane Library (Issue 2, 2008), MEDLINE, EMBASE, and CINAHL. Conference proceedings and references from found articles were also searched. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing antibiotics versus placebo in acute pancreatitis with CT proven necrosis. DATA COLLECTION AND ANALYSIS Primary outcomes were mortality and pancreatic infection rates. Secondary end-points included non pancreatic infection, all sites infection, operative rates, fungal infections, and antibiotic resistance. Subgroup analyses were performed for antibiotic regimen (beta-lactam, quinolone, and imipenem). MAIN RESULTS Seven evaluable studies randomised 404 patients. There was no statistically significant effect on reduction of mortality with therapy: 8.4% versus controls 14.4%, and infected pancreatic necrosis rates: 19.7% versus controls 24.4%. Non-pancreatic infection rates and the incidence of overall infections were not significantly reduced with antibiotics: 23.7% versus 36%; 37.5% versus 51.9% respectively. Operative treatment and fungal infections were not significantly different. Insufficient data were provided concerning antibiotic resistance.With beta-lactam antibiotic prophylaxis there was less mortality (9.4% treatment, 15% controls), and less infected pancreatic necrosis (16.8% treatment group, 24.2% controls) but this was not statistically significant. The incidence of non-pancreatic infections was non-significantly different (21% versus 32.5%), as was the incidence of overall infections (34.4% versus 52.8%), and operative treatment rates. No significant differences were seen with quinolone plus imidazole in any of the end points measured. Imipenem on its own showed no difference in the incidence of mortality, but there was a significant reduction in the rate of pancreatic infection (p=0.02; RR 0.34, 95% CI 0.13 to 0.84). AUTHORS' CONCLUSIONS No benefit of antibiotics in preventing infection of pancreatic necrosis or mortality was found, except for when imipenem (a beta-lactam) was considered on its own, where a significantly decrease in pancreatic infection was found. None of the studies included in this review were adequately powered. Further better designed studies are needed if the use of antibiotic prophylaxis is to be recommended.
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Affiliation(s)
- Eduardo Villatoro
- University of NottinghamAcademic Division of Surgery, School of Graduate Entry MedicineDerby City General HospitalUttoxeter RoadDerbyDerbyshireUKDE22 3DT
| | - Mubashir Mulla
- University of NottinghamAcademic Division of Surgery, School of Graduate Entry MedicineDerby City General HospitalUttoxeter RoadDerbyDerbyshireUKDE22 3DT
| | - Mike Larvin
- University of NottinghamAcademic Division of Surgery, School of Graduate Entry MedicineDerby City General HospitalUttoxeter RoadDerbyDerbyshireUKDE22 3DT
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Villatoro E, Bassi C, Larvin M. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane Database Syst Rev 2006:CD002941. [PMID: 17054156 DOI: 10.1002/14651858.cd002941.pub2] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Acute pancreatitis is a common abdominal emergency with no specific treatment. Pancreatic necrosis may complicate severe attacks, detectable by computed tomography (CT). Necrosis can become infected, making surgical intervention necessary and increasing mortality to more than 40%. Experimental studies suggest that antibiotic therapy may prevent infection, but could promote resistance and fungal infection. OBJECTIVES To determine the effectiveness and safety of prophylactic antibiotics in acute pancreatitis complicated by pancreatic necrosis. SEARCH STRATEGY The Cochrane Library (Issue 1, 2006), MEDLINE (January 1966-December 2005), EMBASE (January 1980-December 2005) and CINAHL (January 1982-December 2005) were searched. We also examined Conference proceedings. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing antibiotics versus placebo in acute pancreatitis with CT proven necrosis were sought using a detailed search strategy without linguistic limitation. RCTs. Initial searching was undertaken in November 2001. Latest update: December 2005. DATA COLLECTION AND ANALYSIS Two reviewers extracted data independently for rates of primary end-points: mortality and pancreatic infection rates. Secondary end-points included: non pancreatic infection and operative rates. Adverse events: antibiotic resistance and fungal infections. Subgroup analyses: antibiotic regimen. MAIN RESULTS Five evaluable studies randomised 294 patients. Analysis suggested significantly less mortality with therapy (6%) versus controls (15.3%), odds ratio 0.37 (95% CI 0.17, 0.83). Infected pancreatic necrosis rates were not significantly different (therapy 20%, controls 27.8%), odds ratio 0.62 (95% CI 0.35, 1.09), and neither were operative treatment rates or non-pancreatic infection rates. Fungal infections were not significantly different at 4% with therapy versus 4.9% in controls, odds ratio 0.83 (95% CI 0.30, 2.27). There were no evaluable data on antibiotic resistance. Sub-group analysis was performed for antibiotic regimen: beta lactam (192 patients), and quinolone plus imidazole (102 patients). With beta lactam prophylaxis there was significantly less mortality (6.3%) versus controls (16.7%), odds ratio 0.34 (95% CI 0.13, 0.91), and infected pancreatic necrosis (15.6%) versus (29.2%) in controls, odds ratio 0.41 (95% CI 0.20, 0.85), but there were no significant differences in operative treatment rates or non-pancreatic infections. No significant differences were seen with quinolone plus imidazole. AUTHORS' CONCLUSIONS Antibiotic prophylaxis appeared to be associated with significantly decreased mortality but not infected pancreatic necrosis. Beta lactams were associated with significantly decreased mortality and infected pancreatic necrosis, but quinolone plus imidazole regimens were not. There were variations in methodological quality, treatment regimens, and a lack of data on adverse effects. Further better designed studies are needed to support antibiotic prophylaxis and, should these prove beneficial, to compare beta-lactams with quinolones directly.
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Affiliation(s)
- E Villatoro
- University of Nottingham, Division of GI Surgery, University of Nottingham School of Medicine, Clinical Science Buildings, Derby City General Hospital, Uttoxeter Road, Derby, Derbyshire, UK
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Navalho M, Pires F, Duarte A, Gonçalves A, Alexandrino P, Távora I. Percutaneous drainage of infected pancreatic fluid collections in critically ill patients: correlation with C-reactive protein values. Clin Imaging 2006; 30:114-9. [PMID: 16500542 DOI: 10.1016/j.clinimag.2005.09.026] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2005] [Revised: 09/07/2005] [Accepted: 09/07/2005] [Indexed: 01/27/2023]
Abstract
The objective of this study was to assess the efficacy of percutaneous catheter drainage, of early infected pancreatic fluid collections, in critically ill patients with severe acute pancreatitis. The patients in our series had a mean Ranson's score of 5.4. Nineteen (63.3%) of the 30 patients were cured with percutaneous drainage. In this group, the mean C-reactive protein value at the beginning of treatment was 172.8 U/l and 102.5 U/l at the end (P<.001). Cultures yielded multiple organisms in 23 patients (76.7%). The most frequently seen organisms were Escherichia coli, Staphylococcus aureus, and Enterococcus faecium.
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Affiliation(s)
- Márcio Navalho
- Radiology Department, University Hospital of Santa Maria, Avenida Professor Egas Moniz, 1649-035 Lisbon, Portugal.
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N/A, 孙 备. N/A. Shijie Huaren Xiaohua Zazhi 2005; 13:1574-1576. [DOI: 10.11569/wcjd.v13.i13.1574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023] Open
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Regimbeau JM, Dupont H. [Should patients with acute severe pancreatitis be given antibiotic prophylaxis?]. ACTA ACUST UNITED AC 2005; 129:596-8. [PMID: 15581821 DOI: 10.1016/j.anchir.2004.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- J M Regimbeau
- Service de chirurgie digestive, centre hospitalier et universitaire, université de Picardie Amiens Nord, place Victor-Pauchet, 80054 Amiens cedex 01, France.
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Nooteboom A, van der Linden CJ, Hendriks T. Whole blood-mediated endothelial permeability and adhesion molecule expression: a model study into the effects of bacteria and antibiotics. J Antimicrob Chemother 2005; 55:150-6. [PMID: 15650003 DOI: 10.1093/jac/dkh526] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
AIM To investigate whether the inflammatory response of cultured endothelial cells, as induced by conditioned plasma, depends on the bacterial species or type of antibiotic used for incubation with whole blood. MATERIALS AND METHODS Blood from healthy volunteers was stimulated ex vivo with different microorganisms, and with bacteria killed with different antibiotics. The resultant plasmas were incubated on monolayers of cultured human endothelial cells, followed by measurement of their permeability to albumin and expression of E-selectin and intercellular adhesion molecule-1. RESULTS Incubation of Escherichia coli in blood yielded plasmas that induced a marked increase in endothelial permeability and E-selectin expression. The response to Bacteroides fragilis or Enterococcus faecalis was generally weaker. Similar effects were observed after incubation of whole blood with lipopolysaccharide (LPS). Much of the permeability and adhesion molecule response to E. coli remained after removal of intact microorganisms from the culture. Whereas antibiotic treatment of E. coli with imipenem or cefuroxime resulted in a divergent production of tumour necrosis factor-alpha (TNF-alpha) in blood, no significant differences between these treatments were observed with respect to the plasma-induced endothelial response. CONCLUSION Bacteria differ in their capacity to generate a whole blood-mediated increase of endothelial permeability and adhesion molecule expression; this response depends, at least in part, on the presence of soluble bacterial components, such as LPS. Whereas treatment with various antibiotics may generate varying amounts of TNF-alpha, these differences are not translated into differences in endothelial permeability or adhesion molecule expression.
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Affiliation(s)
- Arjan Nooteboom
- Department of Surgery, University Medical Centre Nijmegen, PO box 9101, 6500 HB Nijmegen.
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Abstract
Antibiotics are important in the prophylaxis and treatment of surgical infections as well as in the management of nosocomial infections acquired postoperatively in surgical patients. Surgeons encounter a range of infectious conditions, including established single-pathogen infections of soft tissues, polymicrobial intra-abdominal infections, and resistant gram-negative nosocomial infections such as ventilator-associated and aspiration pneumonia. Preoperative antibiotic administration has been shown to reduce the risk of surgical site infections and is now an accepted part of the standard care for most surgical patients. In patients with established single-pathogen or polymicrobial infections requiring surgery, studies have shown appropriate empiric antibiotic therapy to be an important adjunct to surgical intervention and general supportive measures in improving patient outcome. Antibiotics are also essential for those who develop postoperative nosocomial infections. Empiric coverage of the most likely causative organisms, especially in synergistic polymicrobial mixed infections, is one of the keys to successful prophylaxis and treatment of surgical infections.
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Affiliation(s)
- D E Fry
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM 87131, USA.
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Solomkin JS, Mazuski JE, Baron EJ, Sawyer RG, Nathens AB, DiPiro JT, Buchman T, Dellinger EP, Jernigan J, Gorbach S, Chow AW, Bartlett J. Guidelines for the Selection of Anti-infective Agents for Complicated Intra-abdominal Infections. Clin Infect Dis 2003; 37:997-1005. [PMID: 14523762 DOI: 10.1086/378702] [Citation(s) in RCA: 379] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2003] [Accepted: 06/30/2003] [Indexed: 02/02/2023] Open
Affiliation(s)
- Joseph S Solomkin
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH 45267-0558, USA.
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Solomkin JS, Umanskiy K. Intraabdominal sepsis: newer interventional and antimicrobial therapies for infected necrotizing pancreatitis. Curr Opin Crit Care 2003; 9:424-7. [PMID: 14508156 DOI: 10.1097/00075198-200310000-00013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Recent advances in interventional techniques and antimicrobial therapy have significantly affected the morbidity and mortality of infected pancreatic necrosis. This review describes elements of this progress. RECENT FINDINGS Operative management of infected pancreatic necrosis has consisted of formal laparotomy and debridement of the pancreatic necrosis/infection. Typically, the abdominal wound has been left open and the pancreatic bed has been reexplored at frequent intervals. This staged approach has been replaced by a single definitive operative procedure. More recently, laparoscopic techniques have been used, and provide the possibility of substantially lessened morbidity. The benefits of antimicrobial prophylaxis, typically with carbapenems, have been demonstrated in several clinical trials. The use of such broad-spectrum therapy has complicated the antimicrobial management of prophylaxis failures. A resistant flora is encountered in such patients, including gram-positive cocci, yeast, and gram-negative bacilli. This has been shown to mandate empiric therapy with combination regimens based on agents not used for prophylaxis. SUMMARY These findings recommend the practice of routine antibacterial prophylaxis with systemic agents. Patients receiving such treatment should be monitored for colonization by yeast; surveillance cultures do not appear to be necessary because these critically ill patients have an inflammatory disease and frequently experience temperature elevations warranting cultures to rule out infection. If infection is documented by aspiration or intervention, aggressive antimicrobial therapy directed at organisms identified by Gram stain should be started. Classes of antimicrobial agents other than those used for prophylaxis should be used.
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Affiliation(s)
- Joseph S Solomkin
- Department of Surgery, University of Cincinnati College of Medicine, Ohio 45267-0558, USA.
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Abstract
Acute pancreatitis is an acute painful abdominal disease of sudden onset that ranges from a mild and self-limited illness to a severe and severe life-threatening condition. In spite of decades of intensive research, there are no causal therapeutic options. Treatment relies on supportive treatment principles based on adequate volume replacement to compensate for fluid loss in the intraperitoneal space and analgesics for pain relief. In cases with acute pancreatitis predicted to have a severe course of the disease, antibiotic therapy is recommended to avoid infection of pancreatic necrosis. Despite a substantial set of clinical trials in favor of antibiotic treatment to reduce morbidity, there is no general consensus on the prophylactic antibiotic treatment. Adequate nutritional support is required for patients with severe acute pancreatitis and a protracted course of the disease. Enteral nutrition appears to be superior to enteral nutrition.
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Affiliation(s)
- Stefan Kahl
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto von Guericke University, Magdeburg, Germany.
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Sun B, Li HL, Gao Y, Xu J, Jiang HC. Factors predisposing to severe acute pancreatitis: evaluation and prevention. World J Gastroenterol 2003; 9:1102-5. [PMID: 12717866 PMCID: PMC4611382 DOI: 10.3748/wjg.v9.i5.1102] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze factors predisposing to the infections associated with severe acute pancreatitis (SAP) and to work out ways for its prevention.
METHODS: Total 208 cases of SAP treated in this hospital from Jan. 1980 to Dec. 2001 were retrospectively analyzed.
RESULTS: Statistical difference in the incidence of the aforementioned infections was found between the following pairs: between the groups of bloody or non-bloody ascites, paralytic ileus lasting shorter or longer than 5 days, Ranson scores lower or higher than 5, hematocrit lower or higher than 45%, CT Balthazar scores lower or higher than 7 and between 1980.1-1992.6 or 1992.7-2001.12 admissions (χ2 > 3.84, P < 0.05), while no statistical difference was established between the groups of biliogenic and non-biliogenic pancreatitis, serum amylase < 200 U/L and ≥ 200 U/L, serum calcium < 2 mmol/L and ≥ 2 mmol/L or groups of total parenteral nutrition shorter or longer than 7 days (χ2 < 3.84, P > 0.05).
CONCLUSION: Occurrence of infection in patients with SAP is closely related with bloody ascites, paralytic ileus ≥ 5 days, Ranson scores ≥ 5, hematocrit ≥ 45% and CT Balthazar Scores ≥ 7, but not with pathogens, serum calcium and total parenteral nutrition (TPN). Comprehensive prevention of pancreatic infection and practice of individualized therapy contribute to reducing the incidence of infection.
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Affiliation(s)
- Bei Sun
- Department of General Surgery, First Clinical Hospital, Harbin Medical University, China.
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Gloor B, Worni M, Strobel O, Uhl W, Tcholakov O, Müller CA, Stahel PF, Droz S, Büchler MW. Cefepime tissue penetration in experimental acute pancreatitis. Pancreas 2003; 26:117-21. [PMID: 12604907 DOI: 10.1097/00006676-200303000-00005] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Antibiotic treatment represents a cornerstone in the management of severe acute pancreatitis. However, different antibiotic substances are currently used. In this study, we analyzed penetration of cefepime into pancreatic tissue in two models of acute pancreatitis. AIMS AND METHODOLOGY Following induction of acute pancreatitis, animals were treated with a single intravenous dose of cefepime (0.1 mg/g of body weight). At two different time points, blood and tissue samples were obtained for determination of cefepime concentration and microbiologic analysis. RESULTS Mean pancreatic tissue concentrations +/- SEM 30 minutes after drug administration were significantly higher in animals with either mild acute pancreatitis (113 +/- 22 mg/kg) or severe acute pancreatitis (75 +/- 22 mg/kg) than in control animals (30 +/- 6 mg/kg) (p < 0.005). The minimal inhibitory concentrations (MIC90) for organisms usually isolated from infected pancreatic necrosis vary between 0.05 and 8 mg/L, which is between nine and 1,500 times lower than the mean peak concentration found in necrotic pancreatic tissue. Seven hours 30 minutes after antibiotic administration, pancreatic cefepime concentrations were still above the MIC90 in 100% and 83% of animals with mild and severe disease, respectively. The infection rate of pancreatic tissue was significantly lower after antibiotic treatment and was similar after imipenem/cilastatin or cefepime treatment. CONCLUSION Because of its antibacterial coverage and proven tissue penetration in acute pancreatitis, cefepime should be studied in patients with severe acute pancreatitis.
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Affiliation(s)
- Beat Gloor
- Department of Visceral and Transplantation Surgery, University of Bern, Switzerland
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Papagoras D, Giamarellos-Bourboulis EJ, Kanara M, Douridas G, Paraskevopoulos I, Antzaklis G, Karayannacos P, Giamarellou H. Pancreatic concentrations of cefepime in experimental necrotizing pancreatitis. J Chemother 2003; 15:43-6. [PMID: 12678413 DOI: 10.1179/joc.2003.15.1.43] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
To evaluate the penetration of cefepime in the inflamed pancreas, three doses of 50 mg/kg were administered intramuscularly at 8-h intervals after induction of acute necrotizing pancreatitis using intraperitoneal injection of DL-ethionine in 35 rabbits and in 33 controls. Animals were sacrificed and concentrations of cefepime were determined by a microbiological assay. Cefepime reached its peak concentrations 60 min after the last drug dose when mean values of 46.05 microg/ml, 22.34 microg/g and 34.74 microg/ml were found in serum, pancreas and bile, respectively, in rabbits with acute necrotizing pancreatitis and 45.19 microg/ml, 12.68 microg/g and 20.77 microg/ml respectively in controls. Tissue/serum ratios of cefepime were 0.48, 0.23, 0.15 and 0.09 at 60, 90, 120 and 180 min, respectively, after the last dose of cefepime in rabbits with acute necrotizing pancreatitis and 0.28, 0.18, 0.16 and 0.16, respectively at 60, 90, 120 and 180 min in controls. It is concluded that the administration of cefepime in rabbits with acute necrotizing pancreatitis resulted in pancreatic tissue levels well above the MIC90s of the common pathogens involved in pancreatic superinfection, so that its administration might be proposed for the therapy of superinfection following acute necrotizing pancreatitis in humans.
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Affiliation(s)
- D Papagoras
- Department of Surgery, Sismanoglion General Hospital, Maroussi Attikis, Greece
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Bassi C, Larvin M, Villatoro E. Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis. Cochrane Database Syst Rev 2003:CD002941. [PMID: 14583957 DOI: 10.1002/14651858.cd002941] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Acute pancreatitis is a common acute abdominal emergency which lacks specific therapy. In severe attacks, areas of the pancreas may become necrotic. The mortality risk rises to >40% if sterile necrosis becomes superinfected, usually with gut derived aerobic organisms. Experimental and clinical studies indicate a window of opportunity of 1-2 weeks, when superinfection, and thus high-risk surgical debridement, may be prevented by administering systemic antibiotics to 'sterilise' tissues adjacent to necrotic areas. There are theoretical risks of encouraging antibacterial resistance and opportunistic fungal infections. OBJECTIVES To determine the effectiveness and safety of prophylactic antibiotic therapy in patients with severe acute pancreatitis who have developed pancreatic necrosis. SEARCH STRATEGY MEDLINE, EMBASE, and the Cochrane Library were searched. We also examined other sources including Conference Abstracts (published and unpublished data). SELECTION CRITERIA Randomised controlled trials (RCT) were sought using the search strategy detailed below. No linguistic limitations were applied. RCTs were selected in which antibacterial therapy was evaluated in patients with severe acute pancreatitis associated with pancreatic necrosis proven by intravenous contrast-enhanced computed tomography (CT). No linguistic limitations were applied. Searching was undertaken initially in November 2001 and updated in March 2003. DATA COLLECTION AND ANALYSIS Two reviewers extracted data from trial publications independently, concerning rates for the primary end-points: with respect to: all cause mortality and rates of infection of pancreatic necrosis (proven by microbiological examination of fine needle aspirate or operative specimens). In addition, secondary end-points included peri-pancreatic sepsis, remote sepsis (respiratory, urinary, central venous line sources), operative rates, length of hospital stay, adverse events including the incidence of drug resistant microorganisms and opportunistic fungal infection. MAIN RESULTS It was possible to evaluate mortality in all four included studies, and it demonstrated a survival advantage for antibiotic therapy (Odds ratio 0.32, p=0.02). Pancreatic sepsis (infected necrosis) was also measurable in all four studies and showed an advantage for therapy (Odds ratio 0.51, p=0.04). Extra-pancreatic infection could be evaluated in three studies, but showed no significant advantage for therapy (Odds ratio 0.47, p=0.05).Operative treatment data was available in three studies, but surgery rates were not significantly reduced (Odds ratio 0.55, p=0.08). Fungal infections showed no strongly increased preponderance with therapy (Odds ratio 0.83, p=0.7), but there were no data on infection with resistant organisms. Length of hospital stay could only be evaluated in two studies and was not significantly different. Sub-group analyses planned for the influence on outcome measures of the antibiotic regimen, the time of commencement of therapy in relation to symptom onset and/or hospitalisation, duration of therapy, and aetiology could not be performed as no data were available. REVIEWER'S CONCLUSIONS Despite variations in drug agent, case mix, duration of treatment and methodological quality (especially the lack of double blinded studies), there was strong evidence that intravenous antibiotic prophylactic therapy for 10 to 14 days decreased the risk of superinfection of necrotic tissue and mortality in patients with severe acute pancreatitis with proven pancreatic necrosis at CT. Further studies are required to confirm all of the benefits suggested (in particular the need for operative debridement), to provide more adequate data on adverse effects, to address the choice of antibacterial agents and effects of varying duration of therapy, and whether outcome is related to aetiology.
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Spieker MR. Diseases of the Pancreas. Fam Med 2003. [DOI: 10.1007/978-0-387-21744-4_89] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Howard TJ, Temple MB. Prophylactic antibiotics alter the bacteriology of infected necrosis in severe acute pancreatitis. J Am Coll Surg 2002; 195:759-67. [PMID: 12495307 DOI: 10.1016/s1072-7515(02)01494-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Use of appropriate prophylactic antibiotics has been shown to decrease infectious complications and mortality rate in patients with severe acute pancreatitis, but its influence on the bacteriology of secondary pancreatic infection is poorly defined. STUDY DESIGN Operative cultures from 61 consecutive patients with pancreatic necrosis treated during routine prophylactic antibiotic use (1993-2001) were compared with 34 consecutive patients with necrosis treated before routine antibiotic use (1977-1992). RESULTS The two groups of patients were similar in demographics, etiology of pancreatitis, and severity of illness. All patients in the antibiotic group received prophylactic antibiotics compared with only 38% (13 of 34) in the control group. Routine broad-spectrum prophylactic antibiotics altered the bacteriology of secondary pancreatic infection in severe acute pancreatitis from predominantly gram-negative coliforms (56% versus 26%, p = 0.005) to predominately gram-positive organisms (23% versus 52%, p = 0.009) without a significant increase in either the rate of beta-lactam resistance or fungal infections. The overall hospital stay in patients treated with prophylactic antibiotics was significantly reduced (61 +/- 24 days versus 41 +/- 28 days, p = 0.002), and there was a trend toward a decline in mortality rate in the antibiotic treatment group. CONCLUSION Routine broad-spectrum prophylactic antibiotic use has altered the bacteriology of secondary pancreatic infection in severe acute pancreatitis from predominantly gram-negative coliforms to predominantly gram-positive organisms without altering the rate of beta-lactam resistance or fungal superinfection.
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Affiliation(s)
- Thomas J Howard
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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Affiliation(s)
- B Gloor
- Department of Visceral and Transplantation Surgery, University of Bern, Inselspital, Bern, Switzerland
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Gloor B, Schmidt O, Uhl W, Büchler MW. Prophylactic antibiotics and pancreatic necrosis. Curr Gastroenterol Rep 2001; 3:109-14. [PMID: 11276377 DOI: 10.1007/s11894-001-0006-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
Recent controlled clinical studies suggest a positive effect of early antibiotic treatment on late morbidity and mortality in severe acute pancreatitis. In contrast, widespread use of antibiotics may lead to an increased number of fungal infections and multiresistant bacteria. Optimal choice, duration, and route of administration of the antibiotic agent(s) are far from being established. The additional administration of an antifungal agent with prophylactic intention cannot be supported by the currently available data.
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Affiliation(s)
- B Gloor
- Department of Visceral and Transplantation Surgery, University of Bern, Inselspital, CH 3010, Bern, Switzerland
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Laws HL, Kent RB. Acute Pancreatitis: Management of Complicating Infection. Am Surg 2000. [DOI: 10.1177/000313480006600209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Acute pancreatitis develops precipitously, changing the patient's condition from apparent good health to a critically ill status. Of patients who succumb, 80 per cent die from secondary infection in the pancreas-peripancreatic area. Infection supervenes in the second week or later after onset. Prophylactic antibiotic(s) appear to be helpful in avoiding, delaying, and/or lessening secondary sepsis. Once infection develops, treatment requires open debridement of necrotic material, drainage, and appropriate antibiotic therapy; or mortality will approach 100 per cent. Infecting organisms are commonly Escherichia coli, Klebsiella, Staphylococcus, Enterococcus, Bacteroides, and/or fungi. Antibiotics felt to be preferable for prophylactic therapy include 1) imipenem-cilastatin, 2) a quinolone + metronidazole, and 3) possibly an extended-spectrum penicillin. Treatment should be continued for 2 weeks or until recovery. Because fungus infections are occurring more often, prophylaxis with fluconazole may be warranted.
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Affiliation(s)
- Henry L. Laws
- Departments of Surgery, Carraway Methodist Medical Center and The Norwood Clinic, Inc., Birmingham, Alabama
| | - Raleigh B. Kent
- Departments of Surgery, Carraway Methodist Medical Center and The Norwood Clinic, Inc., Birmingham, Alabama
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