The Misuse of Antibiotics in Acute Pancreatitis Appears Widespread

The inappropriate use of antibiotics as prophylaxis and treatment in acute pancreatitis is common, highlighting the need for antibiotic stewardship and education to meet the challenge of increasing antimicrobial resistance, according to a study published in Pancreatology.

Acute pancreatitis is a frequent cause of both medical and surgical hospital admission worldwide. The incidence is rising consistently, further increasing its burden on healthcare services. Although most patients have a mild disease course, moderate or severe pancreatitis with necrosis and/or (multiple) organ failure will develop in approximately 20% of patients. Depending on whether necrosis is sterile or infectious, mortality rates vary from 13% to 33%.

Secondary infection of pancreatic necrosis, thought to occur because of bacterial translocation from the gut, is one of the most lethal complications of acute pancreatitis. Several trials have failed to demonstrate reduced infection rates of pancreatic necrosis through the use of prophylactic antibiotics. Therefore, international guidelines for the management of acute pancreatitis state that antibiotics should be used to treat only infectious complications and antibiotic prophylaxis is not recommended. The aim of this study was to analyze antibiotic use and its appropriateness from a national review of acute pancreatitis.

Data were collected from The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) study regarding the management of acute pancreatitis. Adult patients admitted to hospitals in England and Wales between January and June 2014 with a coded diagnosis of acute pancreatitis were included. Clinical and organizational questionnaires were used to collect patient data and data on antibiotic use, including indication and duration. A total of 712 complete clinician questionnaires were returned and included in the final analysis. Median age of participants was 61 (range 17-99) years and 54% of patients were male. The most common causes of acute pancreatitis in those selected for the study were gallstones (45%) and alcohol (21%).

Results showed that 62% of patients with acute pancreatitis received antibiotics during their care, with 891 separate prescriptions and 23 clinical indications. A maximum of 3 courses of antibiotics were prescribed, with 41% of patients receiving a second course and 24% receiving a third course. The 3 most common reasons cited for an additional course of antibiotics were the terms “unspecified,” “pancreatitis,” and “sepsis,” respectively, for first through third course. Those who received a first course of antibiotics were given any of 26 different antimicrobial agents (34% of prescriptions were for piperacillin/tazobactam) and 27 different agents — most commonly meropenem — were prescribed for a second course. In 19.38% of cases, the indication was deemed inappropriate by clinicians and in 18.3% of cases, the indication was deemed inappropriate by case reviewers. These findings indicate that the misuse of antibiotics in acute pancreatitis, both as prophylaxis and as treatment, is widespread, occurring in approximately one-fifth of cases according to this study.

Overall, the study authors concluded that, “Healthcare providers should ensure that antimicrobial polices are in place as part of an antimicrobial stewardship process. This should include specific guidance on their use and these policies must be accessible, adherence audited, and frequently reviewed.”

Reference

Barrie J, Jamdar S, Smith N, McPherson SJ, Siriwardena AK, O’Reilly DA. Mis-use of antibiotics in acute pancreatitis: insights from the United Kingdom’s National Confidential Enquiry into patient outcome and death (NCEPOD) survey of acute pancreatitis [published online May 24, 2018] Pancreatology. doi: 10.1016/j.pan.2018.05.485