重症急性胰腺炎的诊断与治疗(英文PPT)

Klebsiella pneumoniae (24%) Pseudomonas (11%)
Proteus(8%)
Aerobic streptococcus (7%)
Enterobacter (7%)
Bacteroides (6%)
Anaerobes (6%)
Fungal – antibiotics for long
Imipenum I
PI
Criticisms of antibiotic prophylaxis
Unequal distribution of severity of pancreatitis Mortality significantly reduced with prophylactic antibiotics in high risk patients 10days – 4 weeks
Duration - 14 days or more Fluconazole after 7 days of antibiotics
International Recommendations
American Society of gastroenterology Initiate antibiotics in severe acute pancreatitis (SAP)
German Society of gastroenterology Start antibiotics in SAP
CRP > 120mg/L Ranson> 3 APACHE II > 8 multiorgan failure
< 30% 百度文库mild)
57 %
35 %
> 30 - < 50% (mod) 22 %
23 %
> 50% (severe) 21 %
42 %
Duration 1 – 2 weeks 50%
3 weeks
71%
Pancreatic abscess > 4 weeks
Parameters for diagnosing pancreatic necrosis
Ranson’s score 3 necrosis 30 two or more fluid collections
Larger studies required to show a in mortality
Best choice - Imipenem – cilastatin quinolone + metrinidazole piperacillin - tazobactam
Poor accuracy in predicting severity
6. CECT – Gold standard > 48 hours – high comparability overall accuracy – 95% < 50 Hounsfield Unit – Nonperfused
Author
Drug
Patients Pan infection Mortality
Con- case Con- Case Con- case
trol
trol
trol
Pedeiroli et al ’93
Imipenum 33 41 30% 12% 12% 7%
Sainio et al , ‘95 Cefuroxime 30 30 40% 30% 23% 3%
Infection in acute pancreatitis
Acute pancreatitis: Interstitial: 80% Necrotizing: 20%
Infection dependent on - necrosis
Extent of necrosis Sterile (n = 155) Infected ( n = 71)
1. Ranson’s score > 3 < 48 hours
2. Apache II illness grading system > 10
3. C-reactive protein > 120 mg/L
4. Lactate dehydrogenase > 270 mg/L
5. Interleukin – 6
Monomicrobial
58% Polymicrobial 42%
Possible pathways for pancreatic infection Colon – bacterial translocation Lymphatics, Hematogenous, Transmural
Antibiotics in pancreatitis
Drug concentration pancreas/peripancreatic tissue Efficacy Factor ▪ Aminoglycosides Netilmycin 0.14 Tobramycin 0.12
▪ Ureidopenicillins Mezlocillin 0.71 Piperacillin 0.72
Delcenserie et al Ceftazidime+ 12 11 58% 0% 25% 9%
’96
M+A
Schwarz et al, Ofloxacin+ M 13 13 53% 61% 15% 0% ‘97
Bassi et al, ’98 Pefloxacin P 30 P 30 I 34% P 10% I 24% 10%
mortality morbidity
No Necrosis
0% 6%
Necrosis
23%
82%
Air in pancreas/peripancreatic space – infection
Bacteriologic findings of infected pancreatitis
E coli (35%) Enterococcus (24%)
▪ Cephalosporins Ceftrizoxime 0.76 Cefotaxime 0.78
Ceftriaxone 0.79
▪ Quinolones 0.87
Ciprofloxacin 0.86 Ofloxacin
Antibiotic prophylaxis in severe acute pancreatitis