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Meta-Analysis
. 2010 May 12;2010(5):CD002941.
doi: 10.1002/14651858.CD002941.pub3.

Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis

Eduardo Villatoro  1 , Mubashir Mulla, Mike Larvin
Affiliations
Meta-Analysis

Antibiotic therapy for prophylaxis against infection of pancreatic necrosis in acute pancreatitis

Eduardo Villatoro et al. Cochrane Database Syst Rev. .

Abstract

Background: Pancreatic necrosis may complicate severe acute pancreatitis, and is detectable by computed tomography (CT). If it becomes infected mortality increases, but the use of prophylactic antibiotics raises concerns about antibiotic resistance and fungal infection.

Objectives: To determine the efficacy and safety of prophylactic antibiotics in acute pancreatitis complicated by CT proven pancreatic necrosis.

Search strategy: Searches were updated in November 2008, in The Cochrane Library (Issue 2, 2008), MEDLINE, EMBASE, and CINAHL. Conference proceedings and references from found articles were also searched.

Selection criteria: Randomised controlled trials (RCTs) comparing antibiotics versus placebo in acute pancreatitis with CT proven necrosis.

Data collection and analysis: Primary outcomes were mortality and pancreatic infection rates. Secondary end-points included non pancreatic infection, all sites infection, operative rates, fungal infections, and antibiotic resistance. Subgroup analyses were performed for antibiotic regimen (beta-lactam, quinolone, and imipenem).

Main results: Seven evaluable studies randomised 404 patients. There was no statistically significant effect on reduction of mortality with therapy: 8.4% versus controls 14.4%, and infected pancreatic necrosis rates: 19.7% versus controls 24.4%. Non-pancreatic infection rates and the incidence of overall infections were not significantly reduced with antibiotics: 23.7% versus 36%; 37.5% versus 51.9% respectively. Operative treatment and fungal infections were not significantly different. Insufficient data were provided concerning antibiotic resistance.With beta-lactam antibiotic prophylaxis there was less mortality (9.4% treatment, 15% controls), and less infected pancreatic necrosis (16.8% treatment group, 24.2% controls) but this was not statistically significant. The incidence of non-pancreatic infections was non-significantly different (21% versus 32.5%), as was the incidence of overall infections (34.4% versus 52.8%), and operative treatment rates. No significant differences were seen with quinolone plus imidazole in any of the end points measured. Imipenem on its own showed no difference in the incidence of mortality, but there was a significant reduction in the rate of pancreatic infection (p=0.02; RR 0.34, 95% CI 0.13 to 0.84).

Authors' conclusions: No benefit of antibiotics in preventing infection of pancreatic necrosis or mortality was found, except for when imipenem (a beta-lactam) was considered on its own, where a significantly decrease in pancreatic infection was found. None of the studies included in this review were adequately powered. Further better designed studies are needed if the use of antibiotic prophylaxis is to be recommended.

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Conflict of interest statement

Professor Claudio Bassi was a co‐author of one of the RCTs reviewed (Pederzoli 1993), but did not participate in the meta‐analysis, discussion or conclusions. Professor Mike Larvin and Dr Eduardo Villatoro participated in the later stages of the international multi‐centre study on the role of meropenem for prophylaxis against infection in pancreatic necrosis (Dellinger 2007). The study was sponsored by Astra‐Zeneca who covered local administrative costs, and attendance for both at a mid‐study conference during 2004. Neither investigator has received personal remuneration, nor were they involved as members of the study planning, analysis, or writing committees.

Figures

1
1
Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
1.1
1.1. Analysis
Comparison 1 Antibiotics versus control, Outcome 1 Mortality.
1.2
1.2. Analysis
Comparison 1 Antibiotics versus control, Outcome 2 Infected Pancreatic Necrosis.
1.3
1.3. Analysis
Comparison 1 Antibiotics versus control, Outcome 3 Non‐Pancreatic Infections.
1.4
1.4. Analysis
Comparison 1 Antibiotics versus control, Outcome 4 All sites infections.
1.5
1.5. Analysis
Comparison 1 Antibiotics versus control, Outcome 5 Fungal Infection.
1.6
1.6. Analysis
Comparison 1 Antibiotics versus control, Outcome 6 Operative Treatment.
2.1
2.1. Analysis
Comparison 2 Beta‐lactam versus control, Outcome 1 Mortality (beta‐lactam).
2.2
2.2. Analysis
Comparison 2 Beta‐lactam versus control, Outcome 2 Infected Pancreatic Necrosis (beta‐lactam).
2.3
2.3. Analysis
Comparison 2 Beta‐lactam versus control, Outcome 3 Non‐Pancreatic Infections (beta‐lactam).
2.4
2.4. Analysis
Comparison 2 Beta‐lactam versus control, Outcome 4 All sites infections (beta‐lactam).
2.5
2.5. Analysis
Comparison 2 Beta‐lactam versus control, Outcome 5 Fungal Infection (beta‐lactam).
2.6
2.6. Analysis
Comparison 2 Beta‐lactam versus control, Outcome 6 Operative Treatment (beta‐lactam).
3.1
3.1. Analysis
Comparison 3 Quinolone versus control, Outcome 1 Mortality (quinolones).
3.2
3.2. Analysis
Comparison 3 Quinolone versus control, Outcome 2 Infected Pancreatic Necrosis (quinolones).
3.3
3.3. Analysis
Comparison 3 Quinolone versus control, Outcome 3 Fungal Infection (quinolones).
4.1
4.1. Analysis
Comparison 4 Imipenem versus control, Outcome 1 Mortality (imipenem).
4.2
4.2. Analysis
Comparison 4 Imipenem versus control, Outcome 2 Infected Pancreatic Necrosis (imipenem).
4.3
4.3. Analysis
Comparison 4 Imipenem versus control, Outcome 3 Non‐pancreatic infections (imipenem).
4.4
4.4. Analysis
Comparison 4 Imipenem versus control, Outcome 4 All sites infections (imipenem).
4.5
4.5. Analysis
Comparison 4 Imipenem versus control, Outcome 5 Fungal Infection (imipenem).
4.6
4.6. Analysis
Comparison 4 Imipenem versus control, Outcome 6 Operative Treatment (imipenem).
See this image and copyright information in PMC

Update of

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References to other published versions of this review

Villatoro 2003
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