AIIMS releases guidance on Antibiotics in Pancreatitis

All India Institute of Medical Sciences, Delhi has released AIIMS Antibiotics Policy which has been prepared by the Department of Medicine with Multidisciplinary collaboration. The guidance for Gastroenterological Infections includes Pancreatitis the salient features of which have been authored in the guidance.

The development of pancreatic infection is associated with the development of a deteriorating disease with subsequent high morbidity and mortality. There is agreement that in mild pancreatitis there is no need to use antibiotics; in severe pancreatitis it would appear to be a logical choice to use antibiotics to prevent secondary pancreatic infection and decrease associated mortality.

When to suspect

Any of the two present (pancreatitis)

• 
  

  Epigastric pain, radiating to back

  
  


• 
  

  Elevated serum amylase or lipase 3x (more specific) of normal

  
  


• 
  

  Imaging evidence: Infected pancreatic necrosis (Usually after 2nd week of illness)

  
  

• 
  

  Presence of air in the pancreatic or extra-pancreatic collection.

  
  


• 
  

  Persistent or new-onset organ failure

  
  


• 
  

  Persistent or new-onset SIRS

  
  

Antibacterial treatment indicated only if there is clinical/ radiological evidence of infected pancreatic necrosis

How to confirm

Confirmation of infected pancreatic necrosis requires radiological and microbiological diagnostic procedures. Among the radiological investigations ultrasound abdomen and contrast-enhanced computed tomography (CECT) scan is the investigation of choice.

• 
  

  CT with contrast to look for necrosis- best identified 5-7 days after symptoms

  
  


• 
  

  CT or US-guided aspirate or catheter drainage – gram stain, bacterial & fungal culture

  
  


• 
  

  Blood culture and sensitivity

  
  

Aetiology: Gram-negative (Enterobacteriaceae>Pseudomonas spp>Acinetobacter spp.) more common than Gram-positive (Staphylococcus spp., Enterococcus spp.)

Treatment:

Preferred: Inj Imipenem/Cilastatin 500 mg QID Or Inj Meropenem 1g TDS Or Inj Piperacillin-tazobactam 4.5g QID or Cefoperazone sulbactam 3g IV BD

Alternative: Inj Ceftazidime (2 g IV TDS) plus Inj Metronidazole (500mg IV TDS) Or Inj Cefepime (2 g IV TDS) Plus Inj Metronidazole (500mg IV TDS)

Remarks:

1) All patients of infected collections need inpatient treatment with parenteral antibiotics

2) Duration of therapy -7 to 14 days

3) Prophylactic antibiotic not indicated - the possibility of superinfection with resistant bacteria/candida increases

4) Infected necrosis usually presents in 2nd or 3rd week after onset of pancreatitis

5) One-third of patients with necrosis gets infected

6) 20% of patients - extra-pancreatic infection (BSI/UTI/pneumonia)