Infection in acute pancreatitis

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Infection in acute pancreatitis

• Acute pancreatitis Interstitial 80
• Necrotizing 20
• Infection dependent on - necrosis

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• Duration 1 2 weeks 50
• 3 weeks 71
• Pancreatic abscess gt 4 weeks
• Parameters for diagnosing pancreatic necrosis
• 1. Ransons score gt 3 lt 48 hours
• 2. Apache II illness grading system gt 10
• 3. C-reactive protein gt 120 mg/L
• 4. Lactate dehydrogenase gt 270 mg/L
• 5. Interleukin 6
• Poor accuracy in predicting severity

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• 6. CECT Gold standard gt 48 hours high
  comparability
• overall accuracy 95
• lt 50 Hounsfield Unit Nonperfused
• mortality morbidity
• No Necrosis 0 6
• Necrosis 23 82
• Air in pancreas/peripancreatic space infection

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Pancreatic Infection

• unresolved organ failure
• persisting systemic toxicity high fever, ?
  TLC
• low grade fever, lt 15000 cells
• US/CT guided FNA necrosis fluid collection
• 20 22G needle
• Gram stain culture
• Avoid colon - oral contrast agent

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Influence of pancreatic infection on morbidity
and mortality
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Bacteriologic findings of infected pancreatitis

• E coli (35) Enterococcus (24)
• Klebsiella pneumoniae (24) Pseudomonas (11)
• Proteus (8) Aerobic streptococcus (7)
• Enterobacter (7) Bacteroides (6)
• Anaerobes (6) Fungal antibiotics
  for long
• Monomicrobial 58 Polymicrobial 42
• Possible pathways for pancreatic infection
• Colon bacterial translocation
• Lymphatics, Hematogenous, Transmural

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Antibiotics in pancreatitis

• Drug concentration pancreas/peripancreatic tissue
• Efficacy Factor
• Aminoglycosides Netilmycin 0.14
  Tobramycin 0.12
• Ureidopenicillins Mezlocillin 0.71
  Piperacillin 0.72
• Cephalosporins Ceftrizoxime 0.76
  Cefotaxime 0.78
• Ceftriaxone 0.79
• Quinolones Ciprofloxacin 0.86
  Ofloxacin 0.87
• Carbapenums Imipenum 0.98

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Antibiotic prophylaxis in severe acute
pancreatitis
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Criticisms of antibiotic prophylaxis

• Unequal distribution of severity of pancreatitis
• Mortality significantly reduced with prophylactic
  antibiotics in high risk patients 10days 4
  weeks
• Ransons score ? 3
• necrosis ? 30
• two or more fluid collections
• Larger studies required to show a ? in mortality

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• Best choice - Imipenem cilastatin
• quinolone metrinidazole
• piperacillin - tazobactam
• Duration - 14 days or more
• Fluconazole after 7 days of antibiotics

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International Recommendations

• American Society of gastroenterology
• Initiate antibiotics in severe acute pancreatitis
  (SAP)
• German Society of gastroenterology
• Start antibiotics in SAP
• CRP gt 120mg/L
• Ransongt 3
• APACHE II gt 8
• multiorgan failure
• British Society of gastroenterology
• Prophylactic antibiotics early in SAP

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Cost of antibiotics for 14-day therapy

• Imipenum cilastatin 1 g 8 hrly Rs.
  3000/day Rs.52,000
• Ciprofloxacin 200mg 12hrly Rs.100/day
• Metronidazole 500mg 8hrly Rs.45/day Rs.2100
• Ofloxacin 400mg 12hrly Rs.220/day
• Metronidazole 500mg 8hrly Rs.45/day Rs.3800
• PiperacillinTazobac- 4.5gms 8hrly Rs.2400/day Rs.
  35,000
• tamMetronidazole 500mg 8hrly Rs.45/day
• Cefatoxime 1gm 8hrly Rs.120/day
• Metronidazole 500mg 8hrly Rs.45/day Rs. 2310
• Ceftazidime 2gm 8hrly Rs.2100/day
• Metronidazole 500mg 8hrly Rs.45/day Rs.30,00
• Clindamycin 300mg 8hrly Rs.300/day Rs.4200

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Selective decontamination of the digestive tract
(SDD)

• Nonabsorbable antibiotics reduce aerobic gram-ve
  intestinal flora
• Decreased total infection rate 81 to 16
• ICU gmve septic complications decreased with
  SDD
• Hospitalization -- nosocomial gram negative flora
• SDD reduces intestinal flora
• improves survival
• reduces pancreatic infection (experimental
  animals)

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SDD in acute experimental pancreatitis

• Authors Animal Decontamination i inf-
  imor-
• Method Start ection tality
• Persky et al Dog Aureomycin 5-10d Not
  Yes before AEP studied
• Lange et al Rat Intestinal lavage
  Immediately Yes Yes
• kanamycin before AEP
• Isaji et al Mouse Bacitracin M Simultaneously No
  Yes
• neomycin with AEP
• Foitzik et al Rat Polymxin B 6h after AEP Yes No
• tobra ampho
• Gianotti et al Mouse Various 36h after Yes No
• antibiotics beginning of
• CDE diet

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Randomized controlled clinical trial on SDD

• Severe acute pancreatitis Balthazar grade D or E
• 50/102 treated with colistin sulphate,
  amphotericin
• norfloxacin short term cefotaxime,
• Overall infected necrosis 38 vs 18
• relaparotomy 3.1 vs 0.9
• mortality 35 vs 22

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Conclusions

• Indications of antibiotics in pancreatitis
• infected pancreatic necrosis
• prophylactic antibiotics in severe necrotizing
  pancreatitis
• Indications for selective digestive tract
  decontamination
• Inconclusive
• more studies required