Infectious Diseases I

Additional late complications of peripancreatic necrosis include secondary pancreatic infection of

previously acute necrotic collections during the first 4 weeks after presentation and walled-off necrosis,

which may lead to pancreatic abscess that matures after 4 weeks or more.

The diagnosis of acute pancreatitis requires two of the following three features:

Acute and constant epigastric or right upper quadrant abdominal pain with or without nausea and

vomiting;

Serum amylase and/or lipase greater than 3 times the upper limit of normal; and

Characteristic findings of acute pancreatitis on CT scan or magnetic resonance imaging.

including hypotension.

Management of severe acute pancreatitis includes acute pain management, fluid resuscitation, supportive

care of systemic complications and organ failure, and nutrition support. Surgical debridement of

infected necrosis or drainage of pancreatic abscess should be considered.

Initial fluid management should be goal-directed titration of isotonic, crystalloid intravenous fluids

using clinical and biochemical targets of perfusion. Results of the ERICA Trial support moderate

fluid volumes over more aggressive resuscitation (N Engl J Med 2022;387:989-1000).

Patients should receive nutrition within 24 hours. Patients unable to eat orally should receive enteral

nutrition by nasogastric or nasojejunal access over parenteral nutrition.

Patients should be monitored and approriately treated for acute pain during acute pancreatitis.

Refer to chapter on management of pain in the ICU.

Empiric antibiotic therapy is indicated in patients with suspected or confirmed infected necrosis

or pancreatic abscess. The diagnosis of infected pancreatitis is difficult because the clinical

picture may mimic other infectious complications because of the likelihood of systemic signs of

inflammation.

Patients with suspected infected necrosis or pancreatic abscess should undergo radiographically

(e.g., ultrasonography, CT) guided drainage with culture of recovered material/fluid. Common

organisms associated with infected necrosis or pancreatic abscess include:

ii.

The antibiotics of choice include:

serious β-lactam allergies)

iii.

Antifungal therapy should be added to antibiotic therapy if yeast is identified on culture Gram

stain. Fluconazole is recommended unless there is a high suspicion for fluconazole-resistant

fungi.

iv.

Empiric antibiotics should be discontinued if pancreatic culture is negative, indicating sterile

pancreatitis. Patients with persistent SIRS should undergo repeat imaging and drainage of

identified abscess or fluid.