Severe acute pancreatitis,S_c7, Academy for Infection Management 2006 (All Rights Reserved),History,33-year-old male Alcohol binge: vodka Awake and conversant Severe abdominal pain, vomiting, dyspnoea,Physical and laboratory examinations,Temperature 38.1C Pulse 96 bpm, respirations 20/min Blood pressure 110/70 mmHg Abdomen tender, distended, quiet Amylase 3500 IU/L Lipase 1100 IU/L AST 250 IU/L LDH 350 IU/L WBC count 16 000/mm3 Arterial blood gases: pH 7.30, PaCO2 32, PaO2 58, BE -5,Which evaluations would you perform to determine if the patient has severe pancreatitis?,C-reactive protein Computed tomography (CT) scan Severity scores Ranson score Glasgow (Imrie) score APACHE II or III score Balthazar score,Initial tests and treatment,Fluid resuscitation Chest radiography CT Calculation of Ranson score (at 48 hours),The patient has severe pancreatitis by CT criteria,Central necrosis of the pancreas 30% Peripancreatic oedema and inflammation,Ranson score: a pancreatitis-specific severity of illness score,Age 55 years WBC 16 000/mm3 Glucose 200 mg/dL LDH 350 IU/L AST 250 IU/L,Haematocrit decrease 10% points BUN increase 5 mg/dL Serum calcium 6 L,Present on admission,During the first 48 hours,The patient has eight positive Ranson criteria,SGOT 250 IU/L LDH 350 IU/L WBC count 16 000/mm3 PaO2 6 L Calcium concentration 0 percentage points,The predicted mortality rate for a Ranson score of 8 is 60% Eachempati et al. Arch Surg 2002,Figure reproduced with permission from Arch Surg,Would you start prophylactic antibiotics?,No Yes, with Ceftriaxone? Gentamicin plus metronidazole? Imipenem/cilastatin or meropenem? Ciprofloxacin plus metronidazole? Other? Yes, plus fluconazole,Penetration of pancreatic tissue and pancreatic juice by antimicrobial agents,Poor Aminoglycosides Vancomycin Variable Penicillins Cephalosporins Good Carbapenems Metronidazole Quinolones Fluconazole,Bassi et al. Antimicrob Agents Chemother 1994;38:830836,What is this patients risk of developing infection?,50%,Incidence of peripancreatic infection after acute pancreatitis,All episodes 3%7% Any pancreatic necrosis 20%70% Pancreatic necrosis 30% 15%30% Pancreatic necrosis 50% 40%70%,Beger et al. Gastroenterology 1986;91:433438 Beger et al. Pancreatology 2003;3:93101 Buchler et al. Ann Surg 2000;232:619625,Day 14,Day 7,Day 21,Should prophylaxis be given? for the entire at-risk period?,Pancreatic infections almost never occur before Day 7 The peak incidence is at Day 14,Beger et al. Gastroenterology 1986;91:433438,99% of data,95% of data,68% of data,How long would you administer antibiotic prophylaxis?,Would not administer prophylaxis 1 week 2 weeks 3 weeks Until ICU discharge,Should prophylaxis be administered for the entire risk period?,Prophylactic antibiotics for severe acute pancreatitis First double-blind, placebo-controlled trial,114 patients enrolled, 76 with necrosis Entry criteria C-reactive protein 150, or Necrosis on contrast-enhanced CT, and 120 mg/dL, or Multiple organ dysfunction score 2 points Meropenem 1 g q8h vs placebo Primary end-point Pancreatic/peripancreatic infection within 42 days,Dellinger et al. Ann Surg (in press),Prophylactic antibiotics for severe acute pancreatitis: trial results,Dellinger et al. Ann Surg (in press),The downside of prolonged antibiotic prophylaxis,Allergy Expense Resistance Superinfection,Prophylactic antibiotics for severe acute pancreatitis,Recovery of resistant bacteria,p0.0001,Isenmann et al. Gastroenterology 2004;126:997,What antibiotic regimen was prescribed initially?,This patient was NOT started on antibiotic prophylaxis,The patients condition improves,Resolution of leukocytosis Resolution of pain Oral intake resumed,The patient develops multiple organ dysfunction syndrome,Day 16 New fever and leukocytosis Increased abdominal distention ARDS Low VT ventilation PEEP Renal dysfunction What do you do now?,Repeat CT scan shows a large peripancreatic fluid collection,Small amount of still-perfused pancreas,What action(s) should be taken now?,Continue to observe Microbiological sampling Repeat CT scan with fine-needle aspiration Operate,What specimen(s) would you collect?,None Blood Sputum Peripancreatic fluid (fine-needle aspiration),Incidence of infected pancreatitis when sought by fine-needle aspiration,Results of culture and susceptibility testing,Patient underwent CT-guided fine-needle aspiration Peripancreatic fluid Proteus mirabilis (pan-sensitive) Blood No growth Urine No growth Sputum No growth,