Journal»Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver
In the 20th century early management of acute pancreatitis often included surgical intervention, despite overwhelming mortality. The emergence of high-quality evidence (randomized controlled trials and meta-analyses) over the past two decades has notably shifted the treatment paradigm towards predominantly non-surgical management early in the course of acute pancreatitis. The present evidence-based review focuses on contemporary aspects of early management (which include analgesia, fluid resuscitation, antibiotics, nutrition, and endoscopic retrograde cholangiopancreatography) with a view to providing clear and succinct guidelines on early management of patients with acute pancreatitis in 2017 and beyond.
This Living FRISBEE (Living FRIendly Summary of the Body of Evidence using Epistemonikos) is an update of the summary published in August 2014, based on two systematic reviews appeared in January and February 2015. There is controversy about the effects of prophylactic antibiotics in acute pancreatitis. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified 18 systematic reviews including 19 randomised studies overall. We combined the evidence using meta-analysis and generated a summary of findings following the GRADE approach. We concluded that prophylactic antibiotics may reduce mortality and length of hospitalization in patients with acute pancreatitis, but the certainty of the evidence is low. The probability that future evidence change what we know is high.
There is controversy about the effects of prophylactic antibiotics in acute pancreatitis. Searching in Epistemonikos database, which is maintained by screening 19 databases, we identified 15 systematic reviews including 19 randomised studies overall. We combined the evidence using meta-analysis and generated a summary of findings following the GRADE approach. We concluded that prophylactic antibiotics may reduce mortality and length of hospitalization in patients with acute pancreatitis, but the quality of the evidence is low. The probability that future evidence change what we know is high.
OBJECTIVE: To review studies of antibiotic prophylaxis in acute necrotizing pancreatitis published in the last decade and update recommendations. DATA SOURCES: A search of PubMed (1998-July 2009) was conducted using the terms necrotizing pancreatitis, antibiotics, prophylaxis, and treatment. Clinical studies, meta-analyses, and review articles published in English were included. Additional references were obtained from article bibliographies. Randomized trials published before 1998 were included if indicated. STUDY SELECTION AND DATA EXTRACTION: Relevant studies or meta-analyses on antibiotic prophylaxis since our previous review in 1998 were evaluated; older data were included if still relevant. DATA SYNTHESIS: Since our previous review, 4 more randomized trials, including 2 double-blind trials, have been conducted. The blinded studies found no significant difference in mortality with antibiotic prophylaxis compared with placebo, while the unblinded studies found a significant decrease in infections. Given these disparate results, available guidelines and meta-analyses provide different conclusions, usually based on exclusion or inclusion of a single trial. Based on all available data, antibiotic prophylaxis should not be used in patients with necrotizing pancreatitis. Instead, a more measured, on-demand use of antibiotics is preferred. Antibiotics should be added if signs and symptoms of infection are present (eg, fever, leukocytosis, positive results of cultures). Given improvements in intensive care and nutritional support, recent trials have found a lower incidence of infected necrotizing pancreatitis than before. Therefore, future trials are likely to need higher numbers of patients. CONCLUSIONS: Use of antibiotic prophylaxis for patients with necrotizing pancreatitis is not indicated, based on 2 blinded trials. Instead, on-demand use of antibiotics appears to be appropriate. Given progress in intensive care and the high crossover rate in studies, the need for antibiotic prophylaxis may continue to be debated for decades.