Elsevier

Pancreatology

Volume 14, Issue 6, November–December 2014, Pages 436-443
Pancreatology

Review article
A systematic review of the extra-pancreatic infectious complications in acute pancreatitis

https://doi.org/10.1016/j.pan.2014.09.010Get rights and content

Abstract

Background and aim

Extra-pancreatic infectious complications in acute pancreatitis increase morbidity, but their incidence and association with infected pancreatic necrosis is unknown. Half of bacterial cultures of pancreatic necrosis are of non-enteric origin, raising the possibility of other sources of infection. The aim of this systematic review was to assess the incidence of extra-pancreatic infectious complications in acute pancreatitis, their timing, and relation to severity of pancreatitis and mortality.

Methods

A systematic review was performed using Ovid MEDLINE, Embase and Cochrane Libraries, following PRISMA guidelines. Search terms were “Pancreatitis” AND “Infection” AND (“Complication” OR “Outcome”).

Results

19 studies with 1741 patients were included. Extra-pancreatic infectious complication incidence was 32% (95% CI 23–41%), with the commonest being respiratory infection (9.2%) and bacteraemia (8.4%). Extra-pancreatic infectious complications were not associated with the predicted severity or the mortality of acute pancreatitis. Only 3 studies reported a relation of timing between extra-pancreatic and pancreatic infectious complications.

Conclusions

This is the first systematic review to evaluate the incidence of extra-pancreatic infectious complications in acute pancreatitis, which a third of patients with acute pancreatitis will develop. Implications are vigilance and prompt treatment of extra-pancreatic infection, to reduce possibility of progression to infected pancreatic necrosis.

Introduction

Acute pancreatitis is a complex disease, with an overall mortality rate of 5–10% that may increase up to 30% in the presence of infected necrosis [1], [2]. The main determinants of pancreatitis severity are persistent organ failure and infected (peri)pancreatic necrosis [1]. However, the presence of extra-pancreatic infectious complications (EPIC) in patients with acute pancreatitis has also been shown to influence morbidity and mortality [3], [4], [5].

The pathogenesis of infection of pancreatic necrosis is currently not completely understood. However, enteric translocation of bacteria by portal blood or mesenteric lymph has been proposed as a possible cause [6], [7]. On review of the bacteriology of infected pancreatic necrosis, close to half of the bacteria were not of enteric origin [8]. This suggests that other concurrent infections might be alternative bacterial sources for seeding pancreatic infection. The incidence and impact of pancreatic infectious complications has been extensively studied [1], but there has been no systematic study on the incidence and impact of EPIC or its temporal relationship to the development of infected pancreatic necrosis [9], [10].

The aim of this systematic review was to assess the incidence of EPIC in patients with acute pancreatitis, the timing of EPIC and pancreatic infection, and its potential impact on outcome in relation to severity of pancreatitis and mortality.

Section snippets

Literature search

An extensive search was performed of Ovid MEDLINE (1946 to present), Embase (1980 to present) and Cochrane Libraries. The search terms used were “Pancreatitis” AND “Infection” AND (“Complication” OR “Outcome”). Studies were limited to English language and human studies only. Papers were screened for eligibility by two authors independently (L.B. & T.H.) and any disagreement over study inclusion or exclusion was resolved by a third author (M.S.P.). References were also reviewed and eligible

Study identification

A total of 1041 papers were initially screened, from which 1002 papers were excluded after abstract review. Thirty-nine full text articles were assessed for eligibility (Fig. 1), with a further 20 articles excluded because the article was a meta-analysis [15], a population based study [5], only reported infections after surgery [16], and because prophylactic antibiotics were used from the time of admission as either a treatment group or as part of a hospital protocol [4], [17], [18], [19], [20]

Discussion

This is the first systematic review to evaluate the incidence of EPIC in acute pancreatitis, to investigate the timing of EPIC and pancreatic infection, and the relation of EPIC to severity of pancreatitis and mortality. It has shown that EPIC is common, with an overall incidence of 32% and does not appear to be related to the predicted severity or the mortality of acute pancreatitis. An association between the EPIC and pancreatic infectious complications has been suggested by some studies [3],

Acknowledgements

Lisa Brown was funded for her research during the time of performing this study by the Health Research Council of New Zealand and The Royal Australasian College of Surgeons.

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