Antibiotic Prophylaxis in Acute Necrotizing Pancreatitis

Abstract

Objective: To review the use of antibiotic prophylaxis in acute necrotizing pancreatitis. Background: Acute necrotizing pancreatitis is a complication that occurs in a minority of patients with acute pancreatitis, but has a high incidence of morbidity and mortality. Surgery and supportive care are important in the management of this disease. However, the role of antibiotic prophylaxis has been debated for decades. Data Sources: English-language clinical studies and review articles involving human subjects and appropriate in vitro data were located through a literature search (MEDLINE, January 1966-July 1998). Study Selection and Data Extraction: Relevant studies describing the use of antibiotic prophylaxis in acute necrotizing pancreatitis were reviewed. Data Synthesis: Earlier studies of antibiotic prophylaxis in patients with acute necrotizing pancreatitis did not show any benefit compared with placebo. Newer studies have shown a decrease in mortality and morbidity when antibiotic prophylaxis is given to patients with severe necrotizing pancreatitis. Conflicting results leave many questions unanswered, such as the effect of antibiotic use in resistance patterns, which antibiotic to use, duration of therapy, and cost-effectiveness of this strategy. Conclusions: With the available data, it is adequate to recommend that patients with at least 30% necrosis of the pancreas receive antibiotics to prevent infectious complications and to decrease potential mortality. Use of imipenem/cilastatin is supported by the largest prospective trial to date; however, the drug was compared with no treatment. Cefuroxime is the only drug shown to decrease mortality and should be considered an alternative that may be more cost-effective than therapy with imipenem/cilastatin. A comparison trial is needed before further recommendations are given.