Introduction The Atlanta classification divides patients with acute pancreatitis (AP) into two groups, mild and severe. The severe form (severe acute pancreatitis, SAP ) is best managed in HDU or ICU setting and is associated with high morbidity and mortality despite best efforts at early diagnosis and timely intervention. The use of antibiotics in SAP is controversial. The aim of the audit is to compare antibiotic use and mortality of patients admitted to the ICU against national standards.
Methods Retrospective audit of management and outcome of consecutive patients admitted to ICU with SAP during the period of 2007–2010. The timing of antibiotic use, the agent(s) used and the site of infection were compared.
Results Of 51 patients, 42 received antibiotics. 63% ( n = 32) of patients were started antibiotics within 48 hrs of hospital admission. The first choice antibiotics were cefuroxime and metronidazole in 45% of cases, co-amoxiclav and metronidazole in 12% of cases and tazocin ± metronidazole in 14% of cases. In 26% of cases a combination of imipenem ±fluconazole ± gentamicin ± vancomycin was used.
Three patients were confirmed to have pancreatic infections based on positive culture and 10 patients had extra-pancreatic infections. Four patients had bacteraemia, 4 had chest infections, 2 had UTI and one had Clostridium difficle. All extra-pancreatic infections had Gram negative bacilli as a causative organism.
Antibiotic use did not improve survival, nor was there any observed survival benefit when the different antibiotic agents were compared (p = 0.7 and 0.4 respectively). The timing of antibiotic use also does not appear to confer a survival benefit (p = 0.5). All patients with proven pancreatic infection died, there was not a significant difference in survival in those with extra-pancreatic infections (p = 0.2).
Conclusion Current guidelines recommend the use of antibiotics only in the presence of proven infection. Given that a majority of patients were commenced on antibiotics within 48hrs of admission and that only a minority were shown to have proven infection it would seem that adherence to this guideline has been poor. It has been suggested that early antibiotic use without proven infection may lead to increased antimicrobial resistance. This audit has demonstrated that early antibiotic use does not benefit survival in severe acute pancreatitis. The choice of agent is important as no single combination has been shown to be advantageous. The agent selected should be based upon clinical findings and laboratory evidence as to the organism(s) present and their susceptibilities. Further work could investigate whether antibiotic use might reduce morbidity in SAP. Other therapeutic strategies should be investigated in order to try to improve survival in this patient group.
Disclosure of Interest None Declared
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