Acute pancreatitis: Problems in adherence to guidelines
ABSTRACTAlthough evidence-based guidelines on managing acute pancreatitis are available, many physicians are not following them. The authors identify and discuss several problems in adherence to guidelines on testing, imaging, and treatment.
KEY POINTS
- Serum amylase and lipase levels are often needlessly measured every day.
- Often, severity assessments are not performed regularly or acted on.
- Often, not enough fluid is replaced, or fluid status is not adequately monitored.
- In many severe cases, enteral or parenteral feeding is not started soon enough.
- Computed tomography is not done in many patients with severe acute pancreatitis, or it is performed too soon.
- In many cases of suspected infected necrosis, fine-needle aspiration is not done.
- Broad-spectrum antibiotics are often used inappropriately in patients with mild acute pancreatitis and in patients with sterile necrotizing pancreatitis who are clinically stable and have no signs of sepsis.
SUSPECTED INFECTED NECROSIS
Problem: Fine-needle aspiration is not done in many cases of suspected infected necrosis.
Approximately one-third of patients with necrotizing pancreatitis develop infected necrosis. The death rate for patients with infected pancreatic necrosis is high—30%, compared with 12% in those with sterile necrosis.1 Differentiating sterile and infected necrosis is therefore essential.
Clinical signs such as fever are poor predictors of infection. Signs of SIRS can be present in both sterile and infected necrotizing pancreatitis.
Recommendation: Fine-needle aspiration of necrosis
For the reasons given above, the findings of necrosis on CT and persistent SIRS should prompt consideration of fine-needle aspiration with Gram stain and culture to differentiate sterile and infected necrosis (ACG guideline, level of evidence III).1 If infection is confirmed, surgical debridement should be strongly considered. Other less-invasive approaches such as endoscopic debridement can be used in selected cases.
Fine-needle aspiration of necrosis is too often neglected. In a cohort of German surgeons, only 55% complied with International Association of Pancreatology recommendations to perform biopsy to differentiate sterile from infected necrosis in patients with signs of sepsis.29
BROAD-SPECTRUM ANTIBIOTICS
Problem: Broad-spectrum antibiotics are often used inappropriately in patients with mild acute pancreatitis and in patients with sterile necrotizing pancreatitis who are clinically stable and have no signs of sepsis.
Antibiotics are not indicated in mild acute pancreatitis. A limited course of antibiotics is typically indicated in severe cases with suspected or proven infected necrosis (in conjunction with surgical necrosectomy). However, the use of antibiotics in sterile necrosis has been very controversial.
At least six small, nonblinded, randomized trials have evaluated the benefit of giving antibiotics prophylactically for presumed sterile necrosis. A recent Cochrane analysis of five of these trials (294 patients) suggested that patients who got antibiotics had a lower risk of death (odds ratio 0.37, 95% confidence interval [CI] 0.17–0.83) but no difference in the rates of pancreatic infection or surgery.30 These paradoxical results suggest that antibiotics may prevent death by preventing nonpancreatic infections (eg, pneumonia, line infections) rather than by preventing infection of necrotic pancreatic tissue. The five trials in the meta-analysis are limited by significant methodologic heterogeneity and by lack of double-blinding.
In spite of the overall lower death rate observed in the meta-analysis, the prophylactic use of antibiotics in sterile necrosis remains controversial. One concern is that patients given long prophylactic courses of antibiotics may develop resistant bacterial or fungal infections. However, the Cochrane and other meta-analyses have not shown a higher rate of fungal infections in those given antibiotics.31
Recommendation: No routine antibiotics for mild cases
The AGA guidelines recommend against routinely giving antibiotics in mild acute pancreatitis and do not provide strict recommendations for prophylactic antibiotic use in necrotizing acute pancreatitis.2 The guidelines state that antibiotics can be used “on demand” based on clinical signs of infection (eg, high fevers, rising leukocytosis, hypotension) or worsening organ failure.
If a purely prophylactic strategy is used, only patients at high risk of developing infection (eg, those with necrosis in more than 30% of the pancreas) should receive antibiotics. Antibiotics with high tissue-penetration should be used, such as imipenem-cilastin (Primaxin IV) or ciprofloxacin (Cipro) plus metronidazole (Flagyl).
Adherence to these guidelines is not optimal. For example, in an Italian multicenter study, 9% of patients with mild acute pancreatitis were treated with antibiotics.19 Moreover, many patients with proven infected necrosis received antibiotics that do not penetrate the pancreatic tissue very well.
