When should antibiotics be started in children with acute pancreatitis?

Antibiotic Indications in Pediatric Acute Pancreatitis

Antibiotics should NOT be started routinely in children with acute pancreatitis and are only indicated when there is confirmed or strongly suspected infected pancreatic necrosis, infected fluid collections, or documented extrapancreatic infections. 1, 2

Do NOT Use Prophylactic Antibiotics

• Routine prophylactic antibiotics are no longer recommended for children with acute pancreatitis, regardless of severity, as recent high-quality evidence shows they do not reduce mortality or morbidity. 1

• This applies even to severe pancreatitis with sterile necrosis—prophylaxis has consistently failed to demonstrate benefit in well-designed trials. 1

• The evidence against prophylaxis is strong: the 2019 World Society of Emergency Surgery guidelines (the most recent and authoritative source) provide a Grade 1A recommendation against routine prophylactic antibiotics. 1

When Antibiotics ARE Indicated

Start antibiotics immediately in these specific scenarios:

1. Confirmed or Strongly Suspected Infected Necrosis

• Antibiotics are always required when infected pancreatic necrosis is documented or highly suspected, combined with drainage (percutaneous or surgical). 1, 2

• Diagnosis is challenging because clinical signs of infection cannot be reliably distinguished from the inflammatory response of pancreatitis itself. 1

2. Infected Fluid Collections or Pancreatic Abscess

• Any infected peripancreatic fluid collection or abscess requires antibiotics plus appropriate drainage. 1, 2

3. Documented Extrapancreatic Infections

• Use antibiotics for proven biliary, respiratory, urinary, or line-related infections, guided by culture sensitivities. 1, 2

Diagnostic Approach to Identify Infection

Use these tools to determine if infection is present:

• Procalcitonin (PCT) is the most valuable serum marker for predicting infected pancreatic necrosis and should guide decision-making. 1

• Gas in the retroperitoneal area on CT imaging is highly indicative of infected pancreatitis (though only present in a minority of cases). 1

• CT-guided fine needle aspiration (FNA) with Gram stain and culture can confirm infection and guide antibiotic selection, but is no longer routinely used due to high false-negative rates and risk of introducing infection. 1

• If sepsis is suspected, obtain microbiological examination of sputum, urine, blood, and vascular catheter tips. 1, 2

Antibiotic Selection When Indicated

For confirmed infected necrosis, use antibiotics with excellent pancreatic tissue penetration:

• First-line: Carbapenems (meropenem 1g q6h or imipenem/cilastatin 500mg q6h by extended infusion) due to superior pancreatic penetration and broad coverage including anaerobes. 1, 2

• Alternative: Piperacillin/tazobactam provides coverage against gram-negative, gram-positive, and anaerobic organisms. 1

• Avoid aminoglycosides (gentamicin, tobramycin) as they fail to achieve adequate tissue concentrations in pancreatic necrosis. 1, 2

• Avoid quinolones despite good penetration, due to high worldwide resistance rates. 1, 2

• The empirical regimen should cover aerobic and anaerobic gram-negative and gram-positive organisms. 1

Duration of Therapy

• Limit antibiotic duration to 7-14 days maximum if adequate source control (drainage) is achieved. 1, 2

• Do not continue antibiotics beyond this period without documented persistent infection on culture. 1

• Ongoing signs of infection beyond 7 days warrant further diagnostic investigation rather than prolonged empiric therapy. 2

Special Considerations

• Prophylactic antibiotics before ERCP: Recommended prior to invasive procedures like ERCP in the setting of pancreatitis. 1, 2

• Consider antifungal therapy (liposomal amphotericin B or echinocandin) only in high-risk patients, though routine prophylactic antifungals are not recommended. 1, 2

• Controversial scenario: Some older guidelines suggested considering prophylaxis when CT shows >30% pancreatic necrosis, as infection risk is very low with less extensive necrosis, but current evidence does not support this practice. 1

Critical Pitfalls to Avoid

• Never use antibiotics in mild pancreatitis—there is universal agreement this provides no benefit. 1

• Do not drain asymptomatic fluid collections, as more than half resolve spontaneously and drainage risks introducing infection. 1

• Be aware that unnecessary antibiotic use may select for resistant organisms and fungal infections, though fungal infection rates remain <10%. 1

• The timing of infection in pancreatic necrosis is unpredictable and typically peaks in the second to fourth week after onset. 1