THE ROLE OF ANTIBIOTIC-PROPHYLAXIS IN SEVERE ACUTE-PANCREATITIS

Objective: To assess the impact of intravenous (IV) antibiotic prophyl axis on the incidence of pancreatic infection and the mortality rate i n severe acute pancreatitis. Design: Restropective review of a cohort of 180 patients with severe acute pancreatitis. getting: A tertiary re ferral center in Sacramento, Calif. intervention: The use of IV antibi otic prophylaxis evolved during 3 periods from no antibiotics in 50 pa tients (1982-1989), to nonprotocol use in 55 patients (1990-1992), to a 4-week course of imipenem-cilastatin sodium (1993-1996) given to 75 patients having Acute Physiology and Chronic Health Evaluation (APACHE ) II scores greater than 6 and pancreatic necrosis (>15% of the gland) , peripancreatic necrosis, or peripancreatic collection. Main Outcome Measures: Pancreatic infection and mortality. Results: Without antibio tic prophylaxis, the incidence of pancreatic infection was 76% (38/50) . Intravenous antibiotic prophylaxis reduced the infection rate to 45% (25/55) (P=.03). The imipenem-cilastatin protocol further reduced the infection rate to 27% (20/75) (P=.04). The mortality rates showed onl y a decreasing trend, from 16% (1982-1989) to 7% (1990-1992) to 5% (19 93-1996) (P=.11). Patients with sterile severe acute pancreatitis had a mortality rate of 2% (2/97); whereas 17% (14/83) of patients with in fection succumbed to the disease. Patients developing infection within the first 4 weeks from the onset of illness had mortality rates rangi ng from 19% to 40%, compared with 0% to 8% for those who became infect ed after 4 weeks. No patient with pancreatic infection developing afte r 4 weeks died with the imipenem-cilastatin protocol. Conclusions: Int ravenous antibiotic prophylaxis significantly reduced the infection ra te in severe acute pancreatitis, with only a trend toward improved sur vival. A prospective, randomized, double-blind multicenter trial compa ring the efficacy of different types and/or combinations of antibiotic prophylaxis in severe acute pancreatitis is indicated.