The role of antibiotic prophylaxis in severe acute pancreatitis
H. S. Ho and C. F. Frey
Department of Surgery, University of California, Davis Medical Center, Sacramento, USA.
OBJECTIVE: To assess the impact of intravenous (IV) antibiotic prophylaxis
on the incidence of pancreatic infection and the mortality rate in severe
acute pancreatitis. DESIGN: Restropective review of a cohort of 180
patients with severe acute pancreatitis. SETTING: A tertiary referral
center in Sacramento, Calif. INTERVENTION: The use of IV antibiotic
prophylaxis evolved during 3 periods from no antibiotics in 50 patients
(1982-1989), to nonprotocol use in 55 patients (1990-1992), to a 4-week
course of imipenem-cilastatin sodium (1993-1996) given to 75 patients
having Acute Physiology and Chronic Health Evaluation (APACHE) II scores
greater than 6 and pancreatic necrosis (> 15% of the gland),
peripancreatic necrosis, or peripancreatic collection. MAIN OUTCOME
MEASURES: Pancreatic infection and mortality. RESULTS: Without antibiotic
prophylaxis, the incidence of pancreatic infection was 76% (38/50).
Intravenous antibiotic prophylaxis reduced the infection rate of 45%
(25/55) (P = .03). The imipenem-cilastatin protocol further reduced the
infection rate to 27% (20/75) (P = .04). The mortality rates showed only a
decreasing trend, from 16% (1982-1989) to 7% (1990-1992) to 5% (1993-1996)
(P = .11). Patients with sterile severe acute pancreatitis had a mortality
rate of 2% (2/97); whereas 17% (14/83) of patients with infection succumbed
to the disease. Patients developing infection within the first 4 weeks from
the onset of illness had mortality rates ranging from 19% to 40%, compared
with 0% to 8% for those who became infected after 4 weeks. No patient with
pancreatic infection developing after 4 weeks died with the
imipenem-cilastatin protocol. CONCLUSIONS: Intravenous antibiotic
prophylaxis significantly reduced the infection rate in severe acute
pancreatitis, with only a trend toward improved survival. A prospective,
randomized, double-blind multicenter trial comparing the efficacy of
different types and/or combinations of antibiotic prophylaxis in severe
acute pancreatitis is indicated.
