Volume 4, Number 2; July 07, 2005
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Volume 4, Number 2; July 07, 2005 |
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58-year-old African-American male with 5 days right lower quadrant pain.
Recommended reading:
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Patient: 58-year-old African-American male with 5 days right lower quadrant pain. History of diabetes mellitus, cholelithiasis, hypercholesterolemia, appendectomy, heavy drinking, 1pd/day smoking. CT demonstrated pseudocyst on head of pancreas, hypervascular regions / lesions in the liver, cholelithiasis.
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Session Handout: Link Directly to Fulltext Article at Science Direct <1> Unique Identifier [PMID]: 12727412 Authors: Mitchell RM. Byrne MF. Baillie J. Institution: Division of Gastroenterology, Duke University Medical Center, Durham, NC 27710, USA. Title: Pancreatitis. [Review] [128 refs]
Source: Lancet. 361(9367):1447-55, 2003 Apr 26. Abstract: In the past decade, our understanding of the genetic basis, pathogenesis, and natural history of pancreatitis has grown strikingly. In severe acute pancreatitis, intensive medical support and non-surgical intervention for complications keeps patients alive; surgical drainage (necrosectomy) is reserved for patients with infected necrosis for whom supportive measures have failed. Enteral feeding has largely replaced the parenteral route; controversy remains with respect to use of prophylactic antibiotics. Although gene therapy for chronic pancreatitis is years away, our understanding of the roles of gene mutations in hereditary and sporadic pancreatitis offers tantalising clues about the disorder's pathogenesis. The division between acute and chronic pancreatitis has always been blurred: now, genetics of the disorder suggest a continuous range of disease rather than two separate entities. With recognition of pancreatic intraepithelial neoplasia, we see that chronic pancreatitis is a premalignant disorder in some patients. Magnetic resonance cholangiopancreatography and endoscopic ultrasound are destined to replace endoscopic retrograde cholangiopancreatography for many diagnostic indications in pancreatic disease. [References: 128]
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Clinical Question: 1) Why are prophylactic antibiotics administered to patients with acute episodes of pancreatitis?
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Readings:
Link Directly to Fulltext article in Ovid <3> Unique Identifier [PMID]: 14583957 Authors: Bassi C. Larvin M. Villatoro E. Title: Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis.[see comment]. [Review] [43 refs] Comments Comment in: ACP J Club. 2004 Jul-Aug;141(1):11; PMID: 15230559
Source: Cochrane Database of Systematic Reviews. (4):CD002941, 2003. 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. [References: 43] Publication Type: Journal Article. Review.
Link Directly to Fulltext Article Free on the Internet <11> Unique Identifier [PMID]: 15057739 Authors: Isenmann R. Runzi M. Kron M. Kahl S. Kraus D. Jung N. Maier L. Malfertheiner P. Goebell H. Beger HG. German Antibiotics in Severe Acute Pancreatitis Study Group. Institution: Department of Abdominal and Transplantational Surgery, University of Ulm, Germany. Title: Prophylactic antibiotic treatment in patients with predicted severe acute pancreatitis: a placebo-controlled, double-blind trial.[see comment]. Comments Comment in: Gastroenterology. 2004 Apr;126(4):1195-8; PMID: 15057759, Comment in: Gastroenterology. 2004 Sep;127(3):1015-6; author reply 1016; PMID: 15362072
Source: Gastroenterology. 126(4):997-1004, 2004 Apr. Abstract: BACKGROUND & AIMS: Antibiotic prophylaxis in necrotizing pancreatitis remains controversial. Until now, there have been no double-blind studies dealing with this topic. METHODS: A total sample size of 200 patients was calculated to demonstrate with a power of 90% that antibiotic prophylaxis reduces the proportion of patients with infected pancreatic necrosis from 40% placebo (PLA) to 20% ciprofloxacin/metronidazole (CIP/MET). One hundred fourteen patients with acute pancreatitis in combination with a serum C-reactive protein exceeding 150 mg/L and/or necrosis on contrast-enhanced CT scan were enrolled and received either intravenous CIP (2 x 400 mg/day) + MET (2 x 500 mg/day) or PLA. Study medication was discontinued and switched to open antibiotic treatment when infectious complications, multiple organ failure sepsis, or systemic inflammatory response syndrome (SIRS) occurred. After half of the planned sample size was recruited, an adaptive interim analysis was performed, and recruitment was stopped. RESULTS: Fifty-eight patients received CIP/MET and 56 patients PLA. Twenty-eight percent in the CIP/MET group required open antibiotic treatment vs. 46% with PLA. Twelve percent of the CIP/MET group developed infected pancreatic necrosis compared with 9% of the PLA group (P = 0.585). Mortality was 5% in the CIP/MET and 7% in the PLA group. In 76 patients with pancreatic necrosis on contrast-enhanced CT scan, no differences in the rate of infected pancreatic necrosis, systemic complications, or mortality were observed. CONCLUSIONS: This study detected no benefit of antibiotic prophylaxis with respect to the risk of developing infected pancreatic necrosis. Publication Type: Clinical Trial. Journal Article. Multicenter Study. Randomized Controlled Trial.
Link Directly to Fulltext Article at Publisher <13> Unique Identifier [PMID]: 14551680 Authors: Maravi-Poma E. Gener J. Alvarez-Lerma F. Olaechea P. Blanco A. Dominguez-Munoz JE. Spanish Group for the Study of Septic Complications in Severe Acute Pancreatitis. Institution: ICU, Servicio Navarro de Salud-Osasunbidea, Hospital Virgen del Camino, Irunlarrea 4, 31002, Pamplona, Spain. enrique.maravi.poma@cfnavarra.es Title: Early antibiotic treatment (prophylaxis) of septic complications in severe acute necrotizing pancreatitis: a prospective, randomized, multicenter study comparing two regimens with imipenem-cilastatin.[see comment]. Comments Comment in: Intensive Care Med. 2004 Jun;30(6):1248; PMID: 15105982
Source: Intensive Care Medicine. 29(11):1974-80, 2003 Nov. Abstract: OBJECTIVE: We compared two imipenem regimens for prevention of septic complications in patients with severe acute necrotizing pancreatitis (ANP). DESIGN AND SETTING: Prospective, randomized open clinical trial involving intensive care units of 14 Spanish Hospitals. PARTICIPANTS: 92 patients with ANP. INTERVENTIONS: Imipenem/cilastatin was administered at 500 mg four times daily starting at the time of diagnosis of ANP, within the first 96 h from the onset of symptoms. Patients were randomized to receive antibiotic prophylaxis either for 14 days (group 1) or at least for 14 days and as long as major systemic complications of the disease persisted (group 2). RESULTS: Antibiotic was maintained in group 2 for 19.7+/-10.9 days. The incidence of infected pancreatic necrosis, pancreatic abscess, and extrapancreatic infections was 11%, 17%, and 28% in group 1 and 17.4%, 13%, and 35% in group 2 (n.s.). Pancreatic or extrapancreatic infection by Candida albicans occurred in 7% and 22% of patients. Global mortality was 18.5% (10.9% secondary to septic complications), without differences between groups. In patients with persisting systemic complications at day 14 mortality was almost always secondary to septic complications and decreased from 25% (group 1) to 8.8% (group 2) by maintaining antibiotic prophylaxis. CONCLUSIONS: Compared to a 14-day imipenem prophylaxis, a longer antibiotic administration in patients with ANP is not associated with a reduction in the incidence of septic complications of the disease. However, prolonged imipenem administration in patients with persisting systemic complications tends to reduce mortality in ANP compared to a 14-days regimen. Publication Type: Clinical Trial. Journal Article. Multicenter Study. Randomized Controlled Trial.
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Resident Report / Department of Medicine & Grady Branch Library Emory University School of Medicine 2005 Edition Participating Faculty: Carlos Del Rio MD / Joyce Doyle MD / Lorenzo Difrancesco MD / Erich Folch MD / Alicia Hidron MD
Contact:
Karl Woodworth
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