Intraabdominal sepsis: newer interventional and antimicrobial therapies for infected necrotizing pancreatitis

Recent advances in interventional techniques and antimicrobial therapy have significantly affected the morbidity and mortality of infected pancreatic necrosis. This review describes elements of this progress.

Operative management of infected pancreatic necrosis has consisted of formal laparotomy and debridement of the pancreatic necrosis/infection. Typically, the abdominal wound has been left open and the pancreatic bed has been reexplored at frequent intervals. This staged approach has been replaced by a single definitive operative procedure. More recently, laparoscopic techniques have been used, and provide the possibility of substantially lessened morbidity. The benefits of antimicrobial prophylaxis, typically with carbapenems, have been demonstrated in several clinical trials. The use of such broad-spectrum therapy has complicated the antimicrobial management of prophylaxis failures. A resistant flora is encountered in such patients, including gram-positive cocci, yeast, and gram-negative bacilli. This has been shown to mandate empiric therapy with combination regimens based on agents not used for prophylaxis.

These findings recommend the practice of routine antibacterial prophylaxis with systemic agents. Patients receiving such treatment should be monitored for colonization by yeast; surveillance cultures do not appear to be necessary because these critically ill patients have an inflammatory disease and frequently experience temperature elevations warranting cultures to rule out infection. If infection is documented by aspiration or intervention, aggressive antimicrobial therapy directed at organisms identified by Gram stain should be started. Classes of antimicrobial agents other than those used for prophylaxis should be used.