From the Guidelines
Antibiotics (ABs) should not be used prophylactically in the treatment of pancreatitis, except in cases where there is a strong suspicion of concurrent sepsis or septic shock, or in patients with infected necrosis.
Role of Antibiotics in Pancreatitis
- Prophylactic antibiotics are not recommended for patients with predicted severe acute pancreatitis (AP) and necrotizing pancreatitis, as they do not provide a clear benefit in reducing the risk of infected pancreatic and peripancreatic necrosis or mortality 1.
- Antibiotics are recommended to treat infected severe acute pancreatitis, but the diagnosis is challenging due to the clinical picture that cannot be distinguished from other infectious complications or from the inflammatory status caused by acute pancreatitis 1.
- Serum measurements of procalcitonin (PCT) may be valuable in predicting the risk of developing infected pancreatic necrosis, and CT-guided fine-needle aspiration (FNA) can confirm an infected severe acute pancreatitis and drive antibiotic therapy 1.
Choice of Antibiotics
- Antibiotics that penetrate pancreatic necrosis should be used in patients with infected necrosis, such as carbapenems, quinolones, and piperacillin/tazobactam 1.
- Empirical antibiotic regimens should include both aerobic and anaerobic Gram-negative and Gram-positive microorganisms, but routine prophylactic administration of antifungal is not recommended in patients with infected acute pancreatitis 1. In summary, antibiotics should only be used in the treatment of pancreatitis when there is a clear indication of infection, and the choice of antibiotic should be guided by the severity of the infection and the potential for resistance. 1
From the Research
Role of Antibiotics in Acute Pancreatitis
The use of antibiotics in the treatment of acute pancreatitis is a topic of ongoing debate. According to 2, there is no clear consensus on the use of prophylactic antibiotics in acute pancreatitis, with mixed evidence supporting and refuting their role. However, most studies have failed to demonstrate significant benefits from their routine use.
Indications for Antibiotic Use
Antibiotics are recommended for use in patients who develop sepsis, infected necrosis-related systemic inflammatory response syndrome, multiple organ dysfunction syndrome, or pancreatic and extra-pancreatic infection 2. Additionally, patients with severe acute pancreatitis may benefit from prophylactic antibiotics, particularly those with extensive sterile necrosis and persistent organ failure 3.
Choice of Antibiotics
The most effective antimicrobial agents for the treatment of acute pancreatitis are fluoroquinolones, imipenem-cilastatin, and metronidazole, which achieve adequate penetration into pancreatic juice and necrotic tissue and inhibit the growth of enteric bacteria 4.
Limitations and Concerns
There are several concerns and limitations to the use of antibiotics in acute pancreatitis, including:
- Excessive and unjustified use of antibiotics, which can lead to increased morbidity and mortality 5
- Lack of association between antibiotic use and severe outcomes, such as organ failure, infection of pancreatic necrosis, extrapancreatic infections, or mortality 3
- Need for individualized management based on clinical judgment and deep knowledge of recent guidelines 3
Biomarkers for Infection
Procalcitonin has been shown to be a better biomarker of early infection in acute pancreatitis compared to traditional markers such as white blood cell count and C-reactive protein 5, 3.
Key Findings
Key findings from the studies include:
- A meta-analysis of eight trials showing a positive benefit for antibiotics in reducing mortality, particularly in patients with severe pancreatitis who received broad-spectrum antibiotics 6
- A systematic review highlighting the lack of consensus on the start of antibiotic therapy in patients with no bacterial culture test 5
- A retrospective study showing that clinicians often initiate antibiotic therapy based on increased white blood cell count and/or elevated C-reactive protein, lipase, and amylase levels, despite these parameters showing no association with infection in the early phase of acute pancreatitis 5