Pancreatitis

The American Journal of Surgery (2009) 197, 806-813

Review

Antibiotic prophylaxis is not protective in severe acute pancreatitis: a systematic review and meta-analysis
Nadim S. Jafri, M.D., M.Sc.a,b, Suhal S. Mahid, M.D., Ph.D.c, Spencer R. Idsteinc, Carlton A. Hornung, Ph.D., M.P.H.a,b, Susan Galandiuk, M.D.c,*
Division of Internal Medicine, Department of Medicine, bDepartment ofEpidemiology and Population Health, cPrice Institute of Surgical Research and the Section of Colorectal Surgery, Department of Surgery, University of Louisville, School of Medicine, Louisville, KY 40292, USA KEYWORDS:
Antibiotic prophylaxis; Pancreatitis; Severe acute pancreatitis; Meta-analysis; RCTs Abstract BACKGROUND: The use of prophylactic systemic antibiotics to prevent infection and reducemortality in severe acute pancreatitis (SAP) remains a contentious issue. We assessed the clinical outcome of patients with SAP treated with prophylactic antibiotics compared with that of patients not treated with antibiotics. METHODS: We performed a systematic search of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials, using PubMed, Google Scholar, and Ovid as search engineswithout language restriction until the end of May 2008. We also manually searched the references of original/ review articles and evaluated symposia proceedings, poster presentations, and abstracts from major gastrointestinal and surgical meetings. Relative risks were calculated for individual trials and data were pooled using a fixed-effects model. Relative risk (RR) reduction, absolute riskreduction, and number needed to treat were calculated and are reported with 95% confidence intervals. RESULTS: Results were subjected to sensitivity analysis to determine heterogeneity among studies. We pooled 502 patients from 8 studies. Patient age ranged from 43 to 59 years, and length of stay ranged from 18 to 95 days. There were 253 patients with SAP who received prophylactic antibiotics, and 249patients were randomized to the placebo arm. Overall, there was no protective effect of antibiotic treatment with respect to mortality (RR, .76; 95% confidence interval [CI], .49 –1.16). With respect to morbidity, antibiotic prophylaxis did not protect against infected necrosis (RR, .79; 95% CI, .56 –1.11) or surgical intervention (RR, .88; 95% CI, .65–1.20). There was, however, an apparent benefit inregards to nonpancreatic infections (RR, .60; 95% CI, .44 –.82), with a RR reduction of 40% (95% CI, 18%–56%), absolute risk reduction of 15% (95% CI, 6%–23%), and number needed to treat of 7 (95% CI, 4 –17). CONCLUSIONS: Antibiotic prophylaxis of SAP does not reduce mortality or protect against infected necrosis, or frequency of surgical intervention. © 2009 Elsevier Inc. All rights reserved.
aPresented in part at the Annual Meeting of the American Gastroenterological Association at Digestive Disease Week, Washington DC, May 20-25, 2007 * Corresponding author. Tel.: 1-502-852-4568; fax: 1-502-852-8915. E-mail address: s0gala01@louisville.edu Manuscript received June 24, 2008; revised manuscript August 29, 2008

In the United States, 20% of patients admitted with acute pancreatitisdevelop severe acute pancreatitis (SAP)1 that may lead to a life-threatening condition associated with prolonged hospitalization, multiple surgical procedures, and death in some patients. SAP usually develops when parts of the pancreas become necrotic from the acute inflammation. Many of the complications are associated with the presence of this dead pancreatic tissue. SAP is a

0002-9610/$ - seefront matter © 2009 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2008.08.016

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Antibiotic prophylaxis and SAP

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serious and life-threatening disease and requires intensive and aggressive management of multiple organ failure and severe infectious complications that can develop in these patients. The International Symposium on Acute Pancreatitis described...