Local Antibacterial Treatment in Patients With Infected Pancreatic Walled-Off Necrosis: A Systematic Review

Abstract

Introduction. Systemic antibacterial treatment in patients with infected pancreatic necrosis often fails to resolve the infection due to impaired penetration in necrotic areas. The endoscopic step-up approach based on endoscopic transmural drainage followed, if necessary, by endoscopic necrosectomy has become the standard of care in patients who do not respond to systemic antibiotics. The additional local administration of antibiotics may increase their concentration in necrotic tissue. Aim. To evaluate the efficacy of local infusion of antibacterial agents to the site of infection in addition to systemic treatment after endoscopic drainage to resolve the infection and decrease the need for necrosectomy in patients with walled-off infected pancreatic necrosis. Materials and methods. Major databases were searched for clinical studies assessing the efficacy of local perfusion of antibiotics for the treatment of infected pancreatic necrosis. Results. Four studies were included, two cohort studies and two single-case reports. The majority of patients with infected pancreatic necrosis developed polymicrobial infection. More than one-third of patients additionally had fungal infection. Local irrigation of antibiotics in patients with infected pancreatic necrosis resulted in the eradication of bacteria and fungi, avoiding necrosectomy in almost half of cases. No local or systemic side effects were reported with this strategy. Conclusions. Evidence evaluating the efficacy of local antibiotics for the treatment of infected pancreatic necrosis is scarce. Simultaneous local and systemic administration of antibiotics after endoscopic drainage could reduce the need for necrosectomy. Randomized clinical trials are needed to evaluate the impact of adding local to systemic antibiotics in the prognosis of patients with infected pancreatic necrosis.