Necrotizing pancreatitis

  • Andrew Rosser
    Andrew Rosser MSc MD MRCP FRCPath DTM&H is a Consultant in Infectious Diseases and Medical Microbiology at Southampton General Hospital, Southampton, UK. Conflicts of interest: none declared
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Published:October 29, 2021DOI:


      Acute pancreatitis is primarily caused by gallstone disease and excessive alcohol use. The clinical course is varied and those with severe disease may develop pancreatic necrosis and localized collections. Up to 30% of patients with pancreatic necrosis develop infection. This is difficult to diagnose but requires prompt treatment with antibiotics and often percutaneous, endoscopic or surgical intervention. The imprudent use of antibiotics risks the overgrowth of antibiotic-resistant organisms and makes the treatment of subsequent infections more challenging. Advances in biomarkers and imaging may improve the detection of infection, but the optimal timing of antibacterial and antifungal initiation and duration remain unresolved. Clinical trials are required to address these questions.


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        • Lee P.J.
        • Papachristou G.I.
        New insights into acute pancreatitis.
        Nat Rev Gastroenterol Hepatol. 2019; 16: 479-496
        • Roberts S.E.
        • Morrison-Rees S.
        • John A.
        • Williams J.G.
        • Brown T.H.
        • Samuel D.G.
        The incidence and aetiology of acute pancreatitis across Europe.
        Pancreatology: Off J Int Assoc Pancreatol (IAP) [et al]. 2017; 17: 155-165
        • Banks P.A.
        • Bollen T.L.
        • Dervenis C.
        • et al.
        Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus.
        Gut. 2013; 62: 102-111
        • Greenberg J.A.
        • Hsu J.
        • Bawazeer M.
        • et al.
        Clinical practice guideline: management of acute pancreatitis.
        Can J Surg Journal canadien de chirurgie. 2016; 59: 128-140
        • van Dijk S.M.
        • Hallensleben N.D.L.
        • van Santvoort H.C.
        • et al.
        Acute pancreatitis: recent advances through randomised trials.
        Gut. 2017; 66: 2024-2032
        • Bradley 3rd, E.L.
        • Allen K.
        A prospective longitudinal study of observation versus surgical intervention in the management of necrotizing pancreatitis.
        Am J Surg. 1991; 161 (discussion -5): 19-24
        • Mofidi R.
        • Duff M.D.
        • Wigmore S.J.
        • Madhavan K.K.
        • Garden O.J.
        • Parks R.W.
        Association between early systemic inflammatory response, severity of multiorgan dysfunction and death in acute pancreatitis.
        Br J Surg. 2006; 93: 738-744
        • De Waele J.J.
        Use of antibiotics in severe acute pancreatitis.
        Expert Rev Anti-infect Ther. 2010; 8: 317-324
        • Werge M.
        • Novovic S.
        • Schmidt P.N.
        • Gluud L.L.
        Infection increases mortality in necrotizing pancreatitis: a systematic review and meta-analysis.
        Pancreatology: Off J Int Assoc Pancreatology (IAP) [et al]. 2016; 16: 698-707
      1. IAP/APA evidence-based guidelines for the management of acute pancreatitis.
        Pancreatology: Off J Int Assoc Pancreatology (IAP) [et al]. 2013; 13: e1-e15
        • Besselink M.G.
        • van Santvoort H.C.
        • Boermeester M.A.
        • et al.
        Timing and impact of infections in acute pancreatitis.
        Br J Surg. 2009; 96: 267-273
        • Petrov M.S.
        • Chong V.
        • Windsor J.A.
        Infected pancreatic necrosis: not necessarily a late event in acute pancreatitis.
        World J Gastroenterol. 2011; 17: 3173-3176
        • Liu J.
        • Huang L.
        • Luo M.
        • Xia X.
        Bacterial translocation in acute pancreatitis.
        Crit Rev Microbiol. 2019; 45: 539-547
        • Mowbray N.G.
        • Ben-Ismaeil B.
        • Hammoda M.
        • Shingler G.
        • Al-Sarireh B.
        The microbiology of infected pancreatic necrosis.
        Hepatobiliary Pancreat Dis Int: HBPD INT. 2018; 17: 456-460
        • Würstle S.
        • Hapfelmeier A.
        • Wöhrle C.
        • et al.
        Changes in pathogen spectrum and antimicrobial resistance development in the time-course of acute necrotizing pancreatitis.
        J Gastroenterol Hepatol. 2019; 34: 2096-2103
        • Leppäniemi A.
        • Tolonen M.
        • Tarasconi A.
        • et al.
        WSES guidelines for the management of severe acute pancreatitis.
        • Watkins R.R.
        • Lemonovich T.L.
        Serum procalcitonin in the diagnosis and management of intra-abdominal infections.
        Expert Rev Anti-infect Ther. 2012; 10: 197-205
        • Mofidi R.
        • Suttie S.A.
        • Patil P.V.
        • Ogston S.
        • Parks R.W.
        The value of procalcitonin at predicting the severity of acute pancreatitis and development of infected pancreatic necrosis: systematic review.
        Surgery. 2009; 146: 72-81
        • Tissot F.
        • Lamoth F.
        • Hauser P.M.
        • et al.
        β-glucan antigenemia anticipates diagnosis of blood culture-negative intraabdominal candidiasis.
        Am J Respir Crit Care Med. 2013; 188: 1100-1109
        • van Baal M.C.
        • Bollen T.L.
        • Bakker O.J.
        • et al.
        The role of routine fine-needle aspiration in the diagnosis of infected necrotizing pancreatitis.
        Surgery. 2014; 155: 442-448
        • Ukai T.
        • Shikata S.
        • Inoue M.
        • et al.
        Early prophylactic antibiotics administration for acute necrotizing pancreatitis: a meta-analysis of randomized controlled trials.
        J Hepato-Biliary-Pancreatic Sci. 2015; 22: 316-321
        • Mourad M.M.
        • Evans R.
        • Kalidindi V.
        • Navaratnam R.
        • Dvorkin L.
        • Bramhall S.R.
        Prophylactic antibiotics in acute pancreatitis: endless debate.
        Ann R Coll Surg Engl. 2017; 99: 107-112
        • Lee H.S.
        • Lee S.K.
        • Park D.H.
        • et al.
        Emergence of multidrug resistant infection in patients with severe acute pancreatitis.
        Pancreatology: Off J Int Assoc Pancreatology (IAP) [et al]. 2014; 14: 450-453
        • Maguire C.
        • Agrawal D.
        • Daley M.J.
        • Douglass E.
        • Rose D.T.
        Rethinking carbapenems: a pharmacokinetic approach for antimicrobial selection in infected necrotizing pancreatitis.
        Ann Pharmacother. 2021; 55: 902-913
        • Rao G.G.
        • Steger A.
        • Tobin C.M.
        Linezolid levels in pancreatic secretions.
        J Antimicrob Chemother. 2001; 48: 931-932
        • Werge M.
        • Novovic S.
        • Roug S.
        • et al.
        Evaluation of local instillation of antibiotics in infected walled-off pancreatic necrosis.
        Pancreatology: Off J Int Assoc Pancreatology (IAP) [et al]. 2018; 18: 642-646
        • Sartelli M.
        • Chichom-Mefire A.
        • Labricciosa F.M.
        • et al.
        The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections.
        World J Emerg Surg: WJES. 2017; 12: 29
        • Qu R.
        • Ji Y.
        • Ling Y.
        • et al.
        Procalcitonin is a good tool to guide duration of antibiotic therapy in patients with severe acute pancreatitis. A randomized prospective single-center controlled trial.
        Saudi Med J. 2012; 33: 382-387
        • Singh R.R.
        • Mitchell W.
        • David Y.
        • et al.
        Pancreatic fungal infection in patients with necrotizing pancreatitis: a systematic review and meta-analysis.
        J Clin Gastroenterol. 2021; 55: 218-226
        • Reuken P.A.
        • Albig H.
        • Rödel J.
        • et al.
        Fungal infections in patients with infected pancreatic necrosis and pseudocysts: risk factors and outcome.
        Pancreas. 2018; 47: 92-98
        • Rasch S.
        • Mayr U.
        • Phillip V.
        • et al.
        Increased risk of candidemia in patients with necrotising pancreatitis infected with candida species.
        Pancreatology: Off J Int Assoc Pancreatology (IAP) [et al]. 2018; 18: 630-634
        • Felton T.
        • Troke P.F.
        • Hope W.W.
        Tissue penetration of antifungal agents.
        Clin Microbiol Rev. 2014; 27: 68-88
        • Pappas P.G.
        • Kauffman C.A.
        • Andes D.R.
        • et al.
        Clinical practice guideline for the management of candidiasis: 2016 update by the infectious diseases Society of America.
        Clin Infect Dis: Off Publ Infect Dis Soc Am. 2016; 62: e1-e50
        • De Waele J.J.
        • Vogelaers D.
        • Blot S.
        • Colardyn F.
        Fungal infections in patients with severe acute pancreatitis and the use of prophylactic therapy.
        Clin Infect Dis: Off Publ Infect Dis Soc Am. 2003; 37: 208-213
        • Al-Sarireh B.
        • Mowbray N.G.
        • Al-Sarira A.
        • Griffith D.
        • Brown T.H.
        • Wells T.
        Can infected pancreatic necrosis really be managed conservatively?.
        Eur J Gastroenterol Hepatol. 2018; 30: 1327-1331
        • van Grinsven J.
        • van Santvoort H.C.
        • Boermeester M.A.
        • et al.
        Timing of catheter drainage in infected necrotizing pancreatitis.
        Nat Rev Gastroenterol Hepatol. 2016; 13: 306-312
        • van Grinsven J.
        • van Dijk S.M.
        • Dijkgraaf M.G.
        • et al.
        Postponed or immediate drainage of infected necrotizing pancreatitis (POINTER trial): study protocol for a randomized controlled trial.
        Trials. 2019; 20: 239
        • Traverso L.W.
        • Kozarek R.A.
        Pancreatic necrosectomy: definitions and technique.
        J Gastrointest Surg: Off J Soc Surg Alimentary Tract. 2005; 9: 436-439
        • van Santvoort H.C.
        • Besselink M.G.
        • Bakker O.J.
        • et al.
        A step-up approach or open necrosectomy for necrotizing pancreatitis.
        N Engl J Med. 2010; 362: 1491-1502
        • van Brunschot S.
        • van Grinsven J.
        • van Santvoort H.C.
        • et al.
        Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial.
        Lancet (London, England). 2018; 391: 51-58
        • van Brunschot S.
        • van Grinsven J.
        • Voermans R.P.
        • et al.
        Transluminal endoscopic step-up approach versus minimally invasive surgical step-up approach in patients with infected necrotising pancreatitis (TENSION trial): design and rationale of a randomised controlled multicenter trial [ISRCTN09186711].
        BMC Gastroenterol. 2013; 13: 161
        • Boxhoorn L.
        • Voermans R.P.
        • Bouwense S.A.
        • et al.
        Acute pancreatitis.
        Lancet (London, England). 2020; 396: 726-734