From the Guidelines
Necrotizing pancreatitis treatment options and antibiotics: The primary treatment for infected necrotizing pancreatitis involves the use of antibiotics that can penetrate pancreatic necrosis, such as carbapenems or quinolones, although the latter should be used with caution due to resistance issues 1.
Treatment Options
- Antibiotics: should be chosen based on their ability to cover both aerobic and anaerobic Gram-negative and Gram-positive microorganisms, with options including piperacillin/tazobactam, carbapenems, and quinolones like ciprofloxacin and moxifloxacin 1.
- Surgical strategies: may include percutaneous drainage as a first-line treatment, which can delay the need for surgical intervention or even lead to complete resolution of infection in some cases 1.
- Minimally invasive surgical approaches: such as transgastric endoscopic necrosectomy or video-assisted retroperitoneal debridement (VARD), can result in less postoperative organ failure but may require more interventions 1.
Antibiotic Selection
- Aminoglycosides (e.g., gentamicin and tobramycin) are not recommended due to their poor penetration into pancreatic tissue 1.
- Acylureidopenicillins and third-generation cephalosporins have intermediate penetration and are effective against Gram-negative microorganisms but may not cover Gram-positive bacteria and anaerobes as well as piperacillin/tazobactam 1.
- Metronidazole shows good penetration into the pancreas and is effective against anaerobes 1.
Diagnosis and Management
- Procalcitonin (PCT) measurements may be valuable in predicting the risk of developing infected pancreatic necrosis 1.
- CT-guided fine-needle aspiration (FNA) for Gram stain and culture can confirm infected severe acute pancreatitis and guide antibiotic therapy, although it is not routinely used due to high false-negative rates 1.
- The American Gastroenterological Association (AGA) suggests against the use of prophylactic antibiotics in patients with predicted severe acute pancreatitis and necrotizing pancreatitis, based on low-quality evidence 1.
From the Research
Treatment Options for Necrotizing Pancreatitis
- The management of necrotizing pancreatitis requires a multidisciplinary approach, including gastroenterologists, surgeons, interventional radiologists, and specialists in critical care medicine, infectious disease, and nutrition 2.
- Treatment options include:
- Antimicrobial therapy for culture-proven infection or when infection is strongly suspected 2, 3, 4.
- Broad-spectrum intravenous antibiotics with the ability to penetrate pancreatic necrosis, such as carbapenems, quinolones, and metronidazole 2, 5, 4.
- Enteral feeding to decrease the risk of infected necrosis 2.
- Drainage and/or debridement of pancreatic necrosis in patients with infected necrosis or persistent unwellness 2.
- Percutaneous drainage, transmural endoscopic drainage, or surgical debridement as treatment options for walled-off pancreatic necrosis (WON) 2.
Antibiotics for Necrotizing Pancreatitis
- Prophylactic antibiotic treatment is not recommended for sterile necrosis, but may be useful in preventing infection of necrosis, septic complications, and mortality in patients with acute pancreatitis 3, 5, 4.
- Antibiotics such as fluoroquinolones and carbapenems have been shown to be effective in reducing pancreatic and extrapancreatic infections in patients with necrotizing pancreatitis 3, 5.
- The use of antibiotics should be reserved for established infection of pancreatic necrosis, and should be targeted against the specific microbes involved 4.
- Carbapenems, quinolones, and metronidazole are recommended for the treatment of infected necrosis due to their ability to penetrate pancreatic necrosis 2, 4.