重症急性胰腺炎预防性抗生素治疗的荟萃分析

目的通过对有关文献的荟萃分析,探讨预防性抗生素治疗在重症急性胰腺炎(SAP)中的作用.方法检索1966年到2004年8月期间发表的有关预防性抗生素治疗SAP的作用方面的随机对照临床试验(RCT).按照入选标准,有6项临床试验纳入本研究,由2名作者各自独立地对入选研究中有关试验设计、研究对象的特征、研究结果等内容进行摘录,并用RevMan4.2软件进行分析.结果在SAP患者中,使用能在胰腺组织中达到有效浓度的广谱抗生素并不能减少胰腺感染(RR ＝ 0.77,95%可信区间为0.48 ～ 1.24,P ＝ 0.28),也不能减少手术干预(RR ＝ 0.84,95%可信区间为0.40～1.74,P ＝ 0.64),更不能降低死亡率(RR ＝ 0.54,95%可信区间为0.28 ～ 1.04,P ＝ 0.07),只有胰外感染的发生率有一定的减少(RR ＝ 0.52,95%可信区间为0.31 ～ 0.88,P ＝ 0.01).结论不建议在SAP患者中不加选择地预防性使用抗生素,但对于CT证实的坏死性胰腺炎,可以考虑抗生素预防性治疗.     

重症急性胰腺炎预防性应用抗生素的评价

感染与重症胰腺炎的结局差密切相关，动物研究显示预防性应用抗生素对重症胰腺炎是有益的，尽管临床上尚无充分的资料证明必须应用。如果选择预防性抗生素，氟喹诺酮类联合甲硝唑，或单用碳青霉烯类应当是最合适的。     

重症急性胰腺炎预防性应用抗生素的评价

感染与重症胰腺炎的结局差密切相关。动物研究显示预防性应用抗生素对重症胰腺炎是有益的,尽管临床上尚无充分的资料证明必须应用。如果选择预防性抗生素,氟喹诺酮类联合甲硝唑,或单用碳青霉烯类应当是最合适的。     

预防性应用抗生素在重症急性胰腺炎中的作用

急性胰腺炎是消化系常见急症，可分为轻症急性胰腺炎（MAP）和重症急性胰腺炎（SAP）。SAP症状较重，病死率高，患者主要死于早期毒血症、全身炎症反应综合征（SIRS）、多器官功能衰竭（MODS）等严重并发症和后期继发感染。随着重症监护、影像学、内镜检查和外科技术的发展，多数患者能度过早期SIRS、MODS等并发症，但后期继发感染仍是患者致死的主要危险因素。因此．目前早期应用抗生素能否预防SAP后期继发感染已成为研究热点。本文就预防性应用抗生素在SAP中作用的研究进展作一综述。     

预防性使用抗生素治疗重症急性胰腺炎的系统评价

目的 探讨重症急性胰腺炎（SAP）患者预防性抗感染治疗的作用.方法 计算机检索和手工检索收集1990年1月～2011年4月预防性抗感染治疗SAP的英文和中文临床随机对照研究,按纳入与排除标准选择文献,提取资料,应用RevMan 5.0软件对数据进行Meta分析,对预防性抗生素治疗SAP临床研究进行系统评价.结果 纳入随机对照研究10篇,共有SAP患者599例,其中304例随机给予预防性抗生素.分析显示,在SAP患者中预防性使用抗生素可以降低胰外感染的发生率[相对危险度（RR）为0.67,95％可信区间为0.46～0.99,P=0.04],但病死率（P＝0.26）、胰腺感染（P=0.06）和手术干预（P=0.19）发生率均不能降低.亚组分析显示在高质量和多中心组预防性使用抗生素可以降低胰外感染的发生率,P值分别为0.03和0.0003,其余各亚组中病死率、胰腺感染、手术干预及胰外感染的发生率均不能降低.结论 预防性使用抗生素治疗不能改善病死率,亦不能降低胰腺感染和手术干预的发生率,但可能降低了胰腺外感染发生率.     

重症急性胰腺炎预防性使用抗生素的认识和评价

胰腺坏死感染是重症急性胰腺炎(severe acute pancreatitis,SAP)最为严重的并发症,尽管预防性使用抗生素被广泛应用以期降低病死率,但其实际的作用却仍然存在争议.在此问题的基础上,我们总结了最近的研究SAP预防性使用抗生素的临床试验和指南.其结果并不支持所有的胰腺坏死均预防性抗生素,而仅推荐有大于30%胰腺坏死或胆源性患者使用<3 wk的亚胺培南或美罗培南,以降低感染性坏死和病死率.     

重症急性胰腺炎31例预防性抗生素应用分析

重症急性胰腺炎(severe acute pancreatitis,SAP)是在胰腺炎基础上并发胰腺坏死、假性囊肿、胰腺脓肿或器官衰竭。SAP死亡的患者中,多达80％伴有感染。一直以来抗生素在SAP患者治疗过程中占有重要地位。抗生素的应用对患者的病程、预后、费效关系、继发真菌感染等问题均有重要的相关性。本文就31例SAP患者住院治疗期间抗生素应用情况总结如下。     

重症急性胰腺炎抗生素的合理应用

急性胰腺炎是一种常见的消化科急症,其发病率近年有增高的趋势。大约有20％的患者为重症急性胰腺炎(SAP),死亡率较高,急性胰腺炎系活化的胰酶逸入胰腺间质致使胰腺自身消化的疾病,本属无菌性炎症,但在病程中如并发细菌感染,则致病情加重。     

重症急性胰腺炎预防性使用抗生素的荟萃分析

重症急性胰腺炎(SAP)占急性胰腺炎(AP)患者的10％ ～25％,病死率高达20％ ～ 30％.胰腺及胰周组织坏死感染是与病死率密切相关的独立因素,40％～75％的SAP患者会继发与细菌感染相关的并发症[1].20世纪70年代以来不断出现预防性静脉应用抗生素与安慰剂效果比较的临床研究,但结果不一致,且研究的样本数少,无法明确预防性使用抗生素的效果.各指南在对SAP患者是否预防性应用抗生素上未达成一致[2-3].为此,本研究对SAP预防性使用抗生素的临床效果进行荟萃分析.     

预防性使用抗生素对急性坏死性胰腺炎治疗作用的Meta分析

目的:评价预防性使用抗生素对治疗急性坏死性胰腺炎(acute necrotizing pancreatitis,ANP)的作用.方法:在Medline、PubMed、Springer、Ovid、Elsevier、Embase、CNKI、维普数据库中,检索1994-01/2011-10发表的文献.按入选标准,最终纳入5篇文献,使用RevMan5.1进行统计分析.结果:预防性使用抗生素治疗急性坏死性胰腺炎与对照组相比,并不能显著改善生存率(RR0.75,95%CI0.43-1.28,P=0.29),也不能降低胰腺感染(RR0.81,95%CI0.55-1.19,P=0.29)、胰外感染(RR0.79,95%CI0.59-1.06,P=0.12)及手术干预(RR0.78,95%CI0.45-1.36,P=0.37)等并发症的发生几率.结论:对于预防性使用抗生素治疗急性坏死性胰腺炎,根据现有的随机对照治疗尚不能说明其可以显著降低病死率和减少并发症的发生.     

Antibiotic prophylaxis in transarterial therapy of hepatocellular carcinoma: a meta-analysis

BACKGROUND:

The use of prophylactic antibiotics against postprocedure infection in patients undergoing transarterial therapy for hepatocellular carcinoma is controversial.

AIM:

To compare the effects of prophylactic antibiotic treatment and no prophylactic antibiotic treatment on infectious complications following transarterial procedures.

METHODS:

Clinical trials fulfilling predefined selection criteria were identified by searching several bibliographic databases; a meta-analysis was performed where appropriate.

RESULTS:

Four trials of inadequate quality consisting of 210 patients were included in the analysis. Only one case of possible postprocedure infection in each group was reported. The rate of patients developing fever (RR 0.91 [95% CI 0.61 to 1.35]), changes in peripheral white blood cell count or serum C-reactive protein levels, and the mean length of hospital stay (mean difference 0.20 [95% CI 0.75 to 1.14]) showed no significant intergroup differences between antibiotic and no antibiotic treatment. Furthermore, the results of the present study indicated that the incidence of bacteremia, septicemia, sepsis or hepatic abscess after transarterial therapy was rare.

CONCLUSION:

Antibiotic prophylaxis in patients undergoing transarterial therapy for hepatocellular carcinoma may not be routinely necessary. However, a more judicious use of antibiotics is recommended for patients who are at an increased risk of infection. Nevertheless, prospective trials on a larger scale are clearly needed.     

Hemodialysis and risk of acute pancreatitis: A systematic review and meta-analysis

BackgroundEpidemiological evidence indicates that hemodialysis may be a risk factor for acute pancreatitis. This meta-analysis was conducted with the aim of summarizing all available data and examining the present evidence.AimTo quantify the association between hemodialysis and the incidence of acute pancreatitis.MethodsThis meta-analysis included studies on the incidence of acute pancreatitis in patients with hemodialysis. We summarized the incidence of acute pancreatitis in hemodialysis patients, and compared the incidence of acute pancreatitis in hemodialysis patients with that in non-hemodialysis individuals. Pooled risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using a random-effects model.ResultsA total of 5 observational studies with 1059384 individuals were identified for the meta-analysis. Meta-analysis of these observational studies showed that the pooled prevalence of acute pancreatitis in hemodialysis patients was 1.1% (95% CI: 0.2%–2.3%). In addition, we found that hemodialysis was associated with an increased risk of acute pancreatitis (relative risk = 6.96; 95% CI 3.71–13.06).ConclusionThis meta-analysis confirmed that hemodialysis is associated with an increased risk of acute pancreatitis. More fundamental research should be carried out to elucidate the biological mechanisms.     

Prophylactic antibiotic treatment in acute necrotizing pancreatitis: Results from a meta-analysis

Objective. The effect of prophylactic antibiotic treatment on infection and survival of acute necrotizing pancreatitis (ANP) remains uncertain. The aim of this study was to assess the long-term efficacy of prophylactic antibiotic treatment for ANP. Material and methods. Searches were carried out of electronic databases including Medline, EMBASE, the Cochrane Controlled Trials Register, the Science Citation Index, and PubMed (updated to December 2007), and manual bibliographical searches were also conducted. A meta-analysis of all randomized controlled trials (RCTs) comparing prophylactic antibiotic treatment with placebo or no treatment was performed. Results. Eight RCTs including 540 patients were assessed. The outcomes included infected necrosis, death, non-pancreatic infection, surgical intervention, and length of hospital stay. Prophylactic antibiotic use leads to a significant reduction of infected necrosis (relative risk (RR) 0.69, 95% CI, 0.50–0.95; p=0.02), non-pancreatic infections (RR 0.66 95% CI, 0.48–0.91; p=0.01), and length of hospital stay (p=0.004) but was not associated with a statistically significant reduction in mortality (RR 0.76 95% CI, 0.50–1.18; p=0.22) and surgical intervention (RR 0.90 95% CI, 0.66–1.23; p=0.52). In a subgroup analysis, carbapenem was associated with a significant reduction in infected necrosis (p=0.009) and non-pancreatic infections (p=0.006), whereas other antibiotics were not. Conclusions. Prophylactic antibiotic treatment is associated with a significant reduction of pancreatic or peripancreatic infection, non-pancreatic infection, and length of hospital stay, but cannot prevent death and surgical intervention in acute necrotizing pancreatitis.     

Placement of prophylactic pancreatic stents to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis in high-risk patients: A meta-analysis

AIM:To assess the effectiveness of pancreatic stents for preventing pancreatitis in high-risk patients after endoscopic retrograde cholangiopancreatography(ERCP).METHODS:PubMed,Embase,Science Citation Index,and Cochrane Controlled Trials Register were searched to identify relevant trials published in English.Inclu-sion and exclusion criteria were used to screen for suitable studies.Two reviewers independently judged the study eligibility while screening the citations.The methodological quality of the included trials was assessed using the Jadad scoring system.All results were expressed as OR and 95%CI.Data were analyzed using Stata12.0 software.RESULTS:Ten eligible randomized controlled trials were selected,including 1176 patients.A fixed-effects model in meta-analysis supported that pancreatic duct stents significantly decreased the incidence of postERCP pancreatitis(PEP)in high-risk patients(OR=0.25;95%CI:0.17-0.38;P<0.001).Pancreatic stents also alleviated the severity of PEP(mild pancreatitis after ERCP:OR=0.33;95%CI:0.21-0.54;P<0.001;moderate pancreatitis after ERCP:OR=0.30;95%CI:0.13-0.67;P=0.004).The result of severe pancreatitis after ERCP was handled more rigorously(OR=0.24;95%CI:0.05-1.16;P=0.077).Serum amylase levels were not different between patients with pancreatic stents and control patients(OR=1.08;95%CI:0.82-1.41;P=0.586).CONCLUSION:Placement of prophylactic pancreatic stents may lower the incidence of post-ERCP pancreatitis in high-risk patients and alleviate the severity of this condition.     

Present and future of prophylactic antibiotics for severe acute pancreatitis

AIM: To investigate the role of prophylactic antibiotics in the reduction of mortality of severe acute pancreatitis (SAP) patients, which is highly questioned by more and more randomized controlled trials (RCTs) and meta-analyses.METHODS: An updated meta-analysis was performed. RCTs comparing prophylactic antibiotics for SAP with control or placebo were included for meta-analysis. The mortality outcomes were pooled for estimation, and re-pooled estimation was performed by the sensitivity analysis of an ideal large-scale RCT.RESULTS: Currently available 11 RCTs were included. Subgroup analysis showed that there was significant reduction of mortality rate in the period before 2000, while no significant reduction in the period from 2000 [Risk Ratio, (RR) = 1.01, P = 0.98]. Funnel plot indicated that there might be apparent publication bias in the period before 2000. Sensitivity analysis showed that the RR of mortality rate ranged from 0.77 to 1.00 with a relatively narrow confidence interval (P < 0.05). However, the number needed to treat having a minor lower limit of the range (7-5096 patients) implied that certain SAP patients could still potentially prevent death by antibiotic prophylaxis.CONCLUSION: Current evidences do not support prophylactic antibiotics as a routine treatment for SAP, but the potentially benefited sub-population requires further investigations.     

重症急性胰腺炎救治策略探讨

目的 探讨提高重症急性胰腺炎(SAP)救治成功率的治疗策略.方法 回顾性分析1992年至2009年收治的191例SAP患者的资料.分为1992年至2000年及2001年至2009年两个阶段.两组年龄、性别相仿.结果 2001年至2009年收治的SAP患者使用控制炎症反应药物的比例是88.7%(94/106),使用改善胰腺微循环药物的比例是93.4%(99/106),早期肠内营养的比例是58.5%(62/106),使用保护肠屏障功能药物的比例是98.1%(104/106),均较1992年至2000年这一阶段的22.4%(19/85)、43.5%(37/85)、29.4%(25/85)、17.6%(15/85)明显增高.1992年至2000年的手术中盆式开放引流术、胰腺坏死清创术比例较高;2001年至2009年以腹腔镜下引流、损伤控制性手术、CT 或B超引导下置管引流为主.2001年至2009年间外科手术比例从前一阶段的56.5%(48/85)降到32.1%(34/106);救治成功率从前一阶段的68.8%提高到84.0%.结论 药物研究的进展是提高SAP救治成功率的基础,手术是可供选择的治疗SAP的重要手段,个体化治疗方案有利于提高SAP的救治成功率.     

持续静滴山莨菪碱治疗重症急性胰腺炎——60例病例对照研究

目的　探讨持续静滴山莨菪碱治疗重症急性胰腺炎 (SAP)的价值。方法　将 6 0例住院收治 SAP,随机分为治疗组 (n=31)及标准对照组 (n=2 9) ,(治疗组每日山莨菪碱 4 0 ～ 10 0 mg,对照组常规使用奥曲肽 /思他宁 0 .2 5 mg/ h) ,比较两组病例的平均腹痛缓解天数、治愈所需住院天数、病死率及平均住院医疗费用。结果　治疗组平均腹痛缓解天数 2 .1d,平均住院天数 14 .7d,病死率 0 (0 / 31) ,平均住院医疗费用 5 797元 ;标准对照组平均腹痛缓解天数 6 .2 9d,平均住院天数 33.4 d,病死率 14 .0 %(4 / 2 9) ,平均住院医疗费用 2 184 4元。两组在平均腹痛缓解天数 (t=7.90 ,P<0 .0 0 1)、住院天数 (t=4 .19,P<0 .0 0 1)及住院费用 (t=2 .90 ,P<0 .0 1)上的比较均有显著统计学差异 ,病死率亦有显著性差异(χ2 =4 .5 8,P<0 .0 5 )。结论　内科治疗 SAP时 ,在常规治疗基础上 ,持续静滴山莨菪碱 ,可及时控制或减少并发症 ,显著缩短病程及住院天数 ,显著降低病死率及医疗费用。     

大承气汤治疗急性重症胰腺炎效果的Meta分析

结果:最终纳入16个研究,共894例受试者.Meta分析结果显示,大承气汤能有效促进各项生命体征和生理指标恢复,能够缩短患者的住院时间、降低治疗费用,能够有效降低并发症、病死率和转手术率,其差异有统计学意义.结论:加用大承气汤优于单独常规西医治疗,为当前急性重症胰腺炎的治疗提供了一种新的手段,在临床上具有良好的应用前景.     

Optimal initial diet in mild acute pancreatitis: A comprehensive meta-analysis of randomized control trials

ObjectiveWe performed a comprehensive systematic review and meta-analysis comparing initiation of full solid diet (FSD) versus stepwise diet to better define the management of patients with mild acute pancreatitis (AP).MethodsElectronic databases were searched through August 2, 2021 for trials comparing initial FSD versus stepwise advancement in patients with mild AP on length of hospital stay (LOHS). We stratified by whether diet was initiated early (within 24 h or immediately upon presence of bowel sounds).ResultsWe identified seven RCTs that compared LOHS in AP patients who received initial oral intake with solid diet versus stepwise diet. Across the studies a total of 305 patients were randomized to immediate FSD and 308 patients to sequential advancement. Patients who were initiated on a FSD had a significant reduction in total LOHS (Standardized Mean Difference (SMD) ?0.52 [95% CI -0.69, ?0.36]). There was no difference in post refeeding abdominal pain, tolerance of diet, or necessity to cease diet between the two groups. Sub-analysis of three studies that initiated FSD early reduced total LOHS (OR -0.95 [95% CI -1.26, ?0.65]) compared to those who received graded diet advancement as well as higher likelihood of tolerating the assigned diet (OR 6.8 [95% CI 1.2, 39.2]).ConclusionsOur meta-analysis shows that initiation of FSD reduces total LOHS in patients with mild AP and does not increase post refeeding abdominal pain. Though additional high-quality studies are needed, these findings support initial solid diet for AP and consideration of feeding within the first 24 h.