Authors' objectives

To determine the effectiveness of prophylactic antibiotics in preventing the infectious complications of acute pancreatitis.

Searching

MEDLINE was searched for studies published in the English language from 1966 to present using the keywords 'pancreatitis' and 'antibiotics'.

Study selection

Assessment of study quality

No formal assessment of validity was undertaken.

Data extraction

The number of reviewers involved in data extraction was not reported. Data presented in tables in the review included primary diagnosis, number of patients, method or site of collection, drug, drug dosage, serum concentration, and pancreatic juice or tissue concentration.

Methods of synthesis

Results of the review

The number of reviewers involved in data extraction was not reported. Data presented in tables in the review included primary diagnosis, number of patients, method or site of collection, drug, drug dosage, serum concentration, and pancreatic juice or tissue concentration.

Dates of publication of studies ranged from 1973 to 1997. The earliest four studies were published in the 1970s and none reported any difference in rates of development of infection between treatment groups. The four most recently completed studies (including 3 RCTs with 157 patients and one retrospective review with 180 patients) were published in the 1990s and all reported a decrease in overall infectious complications in patients with moderate to severe disease. Imipenem significantly reduced pancreatic and non-pancreatic sepsis (P <= 0.01); cefuroxime reduced all infectious complications (P< 0.01) and deaths (P = 0.0284); a regime of ceftazidime, amikacin, and metronidazole reduced all infectious complications (P < 0.03); and protocol use of imipenem significantly reduced pancreatic infections compared with non protocol antibiotics (P = 0.04) and no antibiotics (P < 0.001). These four studies had different inclusion criteria, interventions, medical and surgical management of acute pancreatitis and end-points.

Authors' conclusions

Antibiotics were beneficial in reducing secondary infection rates in acute pancreatitis in four recently completed studies though four earlier studies had not reported any benefit. Based on these results, the authors suggest early antibiotic prophylaxis in patients with necrotizing pancreatitis but the best drug and duration of therapy are unknown.

CRD commentary

Some details of the primary studies are described in the text. Given the variability among studies a narrative review was appropriate. The discussion mentions the following methodological limitations of the primary studies: confounding by retrospective design; inclusion of interventions arms with administration of any antibiotic at the discretion of an individual physician; and lack of control for improvements in detection and management of pancreatitis over time. The authors discuss the terminology used to describe the severity of acute pancreatitis and give references to classification systems (see Other Publications of Related Interest no.1).

The aim was not clearly stated. The inclusion criteria were broad. By restricting the identified studies to those published in the English language retrieved from one database, other relevant studies may have been omitted. No details are given of methods used to select studies or extract data. Validity was not formally assessed. Reference was made in the text to Table 5 which is claimed to contain a summary of the benefit of prophylactic antibiotics from the four most recent studies but this table is not included in the paper. Reporting of statistical significance of results from primary studies was sometimes omitted.

The conclusions were based on results from 157 patients in 4 RCTs of unknown validity and thus were not strongly supported by the evidence presented.

Implications of the review for practice and research

Practice: The authors considered that antibiotics should be administered to patients with severe disease (as defined by a Ranson score of 3 or more, and two or more acute fluid collections or necrosis involving one third or more of the pancreas) as soon as the severity of disease is established based on Ranson criteria and computerised tomography findings.

Research: The authors did not state any implications for further research.

Bibliographic details

Kramer K M, Levy H. Prophylactic antibiotics for severe acute pancreatitis: the beginning of an era. Pharmacotherapy 1999; 19(5): 592-602. [PubMed: 10331822]

Other publications of related interest

1. Bradley EL. A clinically based classification system for acute pancreatitis. Arch Surg 1993;128:586-90.

Indexing Status

Subject indexing assigned by NLM

MeSH

Acute Disease; Anti-Bacterial Agents /therapeutic use; Clinical Trials as Topic; Forecasting; Humans; Pancreatitis /diagnosis /drug therapy /etiology /prevention & control

AccessionNumber

11999001015

Database entry date

30/09/2000

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.