What is the management of infected pancreatitis?

Management of Infected Pancreatitis

Antibiotics should only be administered when there is confirmed or strongly suspected infected pancreatic necrosis, not prophylactically in sterile necrosis or mild pancreatitis. 1

Diagnosis of Infected Pancreatic Necrosis

Confirmation of infected necrotic pancreatitis should be established through:

• CT-guided fine-needle aspiration (FNA) with positive Gram stain and culture
• Presence of gas in retroperitoneal area on CT imaging
• Clinical signs of infection (persistent fever, worsening clinical status, new-onset organ failure)
• Elevated serum markers (e.g., procalcitonin) 1

Management Algorithm

Step 1: Initial Assessment and Supportive Care

• Patients with severe pancreatitis and suspected infection should be managed in an ICU/HDU setting
• Full monitoring including peripheral venous access, central venous line, urinary catheter, and nasogastric tube
• Regular monitoring of vital signs, including hourly pulse, blood pressure, CVP, respiratory rate, oxygen saturation, urine output, and temperature 2
• Strict asepsis should be observed in the placement and care of invasive monitoring equipment 2

Step 2: Antibiotic Therapy for Confirmed Infection

When infection is confirmed:

• First-line antibiotic: Carbapenems (meropenem 1g q6h by extended infusion)
• Alternative options: Doripenem, imipenem/cilastatin, meropenem/vaborbactam, or eravacycline 1mg/kg q12h
• Standard duration: 4-7 days with adequate source control
• Re-evaluate if signs of infection persist beyond 7 days 1

Step 3: Source Control - The "Step-up" Approach (3Ds)

1. Delay: Postpone intervention in stable patients
2. Drain: Percutaneous or endoscopic drainage when feasible
3. Debride: Surgical intervention only when necessary 1

Surgical intervention should be considered for infected necrosis that doesn't respond to antibiotics and drainage.

Special Considerations

Antifungal Therapy

• Routine prophylactic antifungals are not recommended
• Consider adding an echinocandin in high-risk patients with prolonged antibiotic exposure 1

Antibiotic Duration and Resistance

• Prolonged antibiotic treatment (>15 days) increases the risk of developing antibiotic-resistant infections
• Avoid prophylactic antibiotics in sterile necrosis as this practice has not shown benefit in reducing mortality 1, 3

Multidisciplinary Approach

Management requires collaboration between:

• Gastroenterologists
• Surgeons
• Interventional radiologists
• Infectious disease specialists 1

Pitfalls to Avoid

1. Unnecessary prophylactic antibiotics: The most recent evidence does not support prophylactic antibiotics in sterile necrosis 4, 3
2. Delayed diagnosis of infection: Prompt diagnosis is crucial for timely intervention
3. Premature surgical intervention: The step-up approach with delayed intervention has shown better outcomes 1
4. Inadequate source control: Appropriate drainage is essential for antibiotic efficacy
5. Prolonged antibiotic courses: Can lead to resistant organisms and fungal superinfections 1

While some older studies suggested benefit from prophylactic antibiotics 5, 6, more recent and higher quality evidence indicates that antibiotics should be reserved for confirmed infected necrosis 1, 4, 3. This approach minimizes antibiotic resistance while ensuring appropriate treatment for those who truly need it.