Tellado Jose M
Department of Surgery, Hospital Gregorio Marañon, Madrid, Spain.
Curr Opin Crit Care. 2007 Aug;13(4):416-20. doi: 10.1097/MCC.0b013e32826388b2.
This review highlights recently reported strategies aimed at quantifying severity of illness earlier in the course of acute pancreatitis and at preventing secondary infection in pancreatic necrosis.
New and improved scoring models appear to suggest that the optimal interventional window is between 24 and 72 h of the onset of severe acute pancreatitis. Prospective randomized clinical trials in which patients with severe acute pancreatitis were treated with broad-spectrum antimicrobial regimens as prophylaxis, however, have demonstrated no benefit in terms of preventing late infection in pancreatic necrosis. In contrast, early enteral nutrition with various formulas and supplements, including probiotics, may confer a clinical advantage in terms of morbidity and mortality.
Continuing to advocate antimicrobial prophylaxis in severe acute pancreatitis is not reasonable, in view of the evidence now available from two large clinical trials. Current guidelines should be revised because of the potential harm to gastrointestinal ecology associated with long-term antibiotic treatment. A suitable alternative way to prevent bacterial overgrowth and secondary infection is lacking, however.
本综述重点介绍了近期报道的旨在早期量化急性胰腺炎病程中疾病严重程度以及预防胰腺坏死继发感染的策略。
新的和改进的评分模型似乎表明，最佳干预窗口是在重症急性胰腺炎发病后的24至72小时之间。然而，在将重症急性胰腺炎患者用广谱抗菌方案进行预防性治疗的前瞻性随机临床试验中，并未显示出在预防胰腺坏死晚期感染方面有任何益处。相比之下，采用包括益生菌在内的各种配方和补充剂进行早期肠内营养，可能在发病率和死亡率方面具有临床优势。
鉴于目前两项大型临床试验的证据，继续主张对重症急性胰腺炎进行抗菌预防是不合理的。由于长期抗生素治疗对胃肠道生态可能造成的危害，当前指南应予以修订。然而，目前缺乏预防细菌过度生长和继发感染的合适替代方法。
