Management of infected pancreatic necrosis in the intensive care unit: a narrative review

D R J Wolbrink; E Kolwijck; J Ten Oever; K D Horvath; S A W Bouwense; J A Schouten

doi:10.1016/j.cmi.2019.06.017

Management of infected pancreatic necrosis in the intensive care unit: a narrative review

Clin Microbiol Infect. 2020 Jan;26(1):18-25. doi: 10.1016/j.cmi.2019.06.017. Epub 2019 Jun 22.

Authors

D R J Wolbrink¹, E Kolwijck², J Ten Oever³, K D Horvath⁴, S A W Bouwense¹, J A Schouten⁵

Affiliations

¹ Radboud University Medical Centre, Department of Surgery, Nijmegen, the Netherlands; Dutch Pancreatitis Study Group, the Netherlands(†).
² Radboud Centre for Infectious Diseases, Department of Medical Microbiology, Nijmegen, the Netherlands.
³ Radboud Centre for Infectious Diseases, Department of Internal Medicine, Nijmegen, the Netherlands.
⁴ University of Washington, Department of Surgery, Seattle, WA 98195, USA.
⁵ Radboud Centre for Infectious Diseases, Department of Intensive Care, Nijmegen, the Netherlands. Electronic address: jeroen.schouten@radboudumc.nl.

PMID: 31238118
DOI: 10.1016/j.cmi.2019.06.017

Abstract

Background: Severe acute pancreatitis is marked by organ failure and (peri)pancreatic necrosis with local complications such as infected necrosis. Infection of these necrotic collections together with organ failure remain the major causes of admission to an intensive care unit (ICU) in acute pancreatitis. Appropriate treatment of infected necrosis is essential to reduce morbidity and mortality. Overall knowledge of the treatment options within a multidisciplinary team-with special attention to the appropriate use of antimicrobial therapy and invasive treatment techniques for source control-is essential in the treatment of this complex disease.

Objectives: To address the current state of microbiological diagnosis, antimicrobial treatment, and source control for infected pancreatic necrosis in the ICU.

Sources: A literature search was performed using the Medline and Cochrane libraries for articles subsequent to 2003 using the keywords: infected necrosis, pancreatitis, intensive care medicine, treatment, diagnosis and antibiotic(s).

Content: This narrative review provides an overview of key elements of diagnosis and treatment of infected pancreatic necrosis in the ICU.

Implications: In pancreatic necrosis it is essential to continuously (re)evaluate the indication for antimicrobial treatment and invasive source control. Invasive diagnostics (e.g. through fine-needle aspiration, FNA), preferably prior to the start of broad-spectrum antimicrobial therapy, is advocated. Antimicrobial stewardship principles apply: paying attention to altered pharmacokinetics in the critically ill, de-escalation of broad-spectrum therapy once cultures become available, and early withdrawal of antibiotics once source control has been established. This is important to prevent the development of antimicrobial resistance, especially in a group of patients who may require repeated courses of antibiotics during the prolonged course of their illness.

Keywords: Diagnostics; Infected necrosis; Intensive care medicine; Necrotizing pancreatitis; Pancreatic infections; Pancreatitis; Treatment.

Publication types

Review

MeSH terms

Acute Disease
Anti-Bacterial Agents / therapeutic use*
Clinical Trials as Topic
Critical Illness
Disease Management*
Humans
Intensive Care Units*
Pancreatitis, Acute Necrotizing / drug therapy*
Pancreatitis, Acute Necrotizing / microbiology

Substances

Anti-Bacterial Agents