Antibiotic Utilization in Acute Pancreatitis: A Narrative Review

Abstract

Acute pancreatitis is a complex inflammatory disease with significant morbidity and mortality. Despite advances in its management, the role of antibiotics in the prophylaxis and treatment of acute pancreatitis remains controversial. The aim of this comprehensive review is to analyze current evidence on the use of antibiotics in acute pancreatitis, focusing on prophylactic and therapeutic strategies. Prophylactic use aims to prevent local and systemic infections. However, recent studies have questioned the routine use of antibiotics for prophylaxis and highlighted the potential risks of antibiotic resistance and adverse effects. In selected high-risk cases, such as infected necrotizing pancreatitis, prophylactic antibiotic therapy may still be beneficial. As for therapeutic use, antibiotics are usually used to treat infected pancreatic necrosis and extrapancreatic infections. When selecting an antibiotic, the microbiologic profile and local resistance patterns should be considered. Combination therapy with broad-spectrum antibiotics is often recommended to cover both Gram-positive and Gram-negative pathogens. Recent research has highlighted the importance of individualized approaches to antibiotic use in acute pancreatitis and underscored the need for a tailored approach based on patient-specific factors. This review also highlights the potential role of new antimicrobial agents and alternative strategies, such as probiotics, in the management of acute pancreatitis.

Metagenomic next-generation sequencing, instead of procalcitonin, could guide antibiotic usage in patients with febrile acute necrotizing pancreatitis: a multicenter, prospective cohort study

“…Whether antibiotics ought to be initiated and what kinds of antibiotics should be used were still unanswered in febrile ANP. Previous studies have observed an excessive and inappropriate utilization of antibiotics in patients with ANP 4 , 24 . Similar results were also observed in the present study.…”

Exploring the Microbial Landscape: Gut Dysbiosis and Therapeutic Strategies in Pancreatitis—A Narrative Review

“…Regardless of the etiology, the pathogenesis of pancreatitis involves activation, leading to abnormal secretion of pancreatic enzymes. This is accompanied by a local inflammatory response through the release of pro-inflammatory cytokines, for example, tumor necrosis factor-alpha (TNF-α) and interleukin-1β (IL-1β), which further amplifies the inflammatory response, leading to the development of a systemic inflammatory syndrome [ 29 , 30 ]. By affecting the microcirculation at the intestinal level, followed by a decrease in tissue perfusion, the integrity of the intestinal barrier is altered [ 29 ].…”

“…Although not recommended, the clinical use of prophylactic antibiotics has become widespread, and studies report an antibiotic usage rate of 41–88% [ 101 ]. This global practice is correlated with significant risks, including increased prevalence of multi-drug-resistant bacteria and increased incidence of fungal infection [ 30 ].…”

“…Certain empiric antibiotics used in hospitalized patients could alter the dominant microbiota by reducing the abundance of Gram-negative organisms in the gastrointestinal tract, leading to the overgrowth of Gram-positive bacteria such as Enterococcus , which, as mentioned before, increases the risk of septicemia [ 31 ]. Current guidelines support the use of empiric antibiotics with both aerobic and anaerobic Gram-negative and Gram-positive bacteria coverage [ 30 ]. It is important to emphasize that the use of antibiotic therapy in AP should be part of an inclusive care approach that includes early hydration, pain management, and nutritional support, but also assessment of the need for invasive interventions, for example, drainage of infected collections or even necrosectomy, if the circumstances require it [ 95 ].…”

Antibiotic Stewardship in Surgical Departments

“…Taking into consideration local infectious complications along with extrapancreatic indications, antibiotic use could be justified in 20-40% of patients with acute pancreatitis. Patients with necrosis but no signs of organ failure and infection do not benefit from antibiotic administration, even if the evolution to severe or necrotizing pancreatitis is imminent [71]. However, up to 77% of the patients with severe pancreatitis may receive antibiotics, with 66% of them not even manifesting any signs of an infection [13,72].…”