重症急性胰腺炎继发感染的特点及防治进展

田浩; 李富兴; 宋少伟

doi:10.3969/j.issn.1001-5256.2019.02.048

重症急性胰腺炎继发感染的特点及防治进展

DOI: 10.3969/j.issn.1001-5256.2019.02.048

中国医科大学附属第一医院胰胆外科

详细信息

中图分类号: R576
计量
- 文章访问数: 266
- HTML全文浏览量: 26
- PDF下载量: 274
- 被引次数: 0
出版历程
- 收稿日期: 2018-10-10
- 出版日期: 2019-02-20

Features of infection secondary to severe acute pancreatitis and related control strategies

Department of Pancreatic and Biliary Surgery, The First Affiliated Hospital of China Medical University

摘要

摘要: 重症急性胰腺炎（SAP）是在临床中较为常见的急腹症、危重症,发生于病程中后期的感染并发症对SAP预后影响极大,且通常难以避免。介绍了胰腺及胰腺外继发感染的发病机制,并总结了近10年关于SAP继发感染的病原菌谱。对目前多项用以预防继发感染的策略进行汇总评价,简要叙述了SAP继发感染的外科干预进展。分析表明,SAP继发感染的发病机制、病原学特征、免疫学特征仍不十分明了,感染的防治策略多种多样,但除早期肠内营养之外,尚无确切有效预防感染的手段。关于经皮穿刺置管引流术时机等问题,或将有结论,外科干预措施在创伤递增法/升阶梯法（STEP-UP法）的理论基础上发展迅速,经内镜STEP-UP法治疗危重SAP患者较常规的STEP-UP法略有优势。
- 胰腺炎 /
- 感染 /
- 治疗学 /
- 综述
Abstract: Severe acute pancreatitis ( SAP) is an acute abdominal disease and a critical illness commonly seen in clinical practice. Infection complications in the middle and late stages of SAP have a great impact on the prognosis of SAP and are often difficult to avoid. This article introduces the pathogenesis of secondary pancreatic and extra-pancreatic infections and summarizes the pathogen spectrum of infections secondary to SAP in the past 10 years. This article also summarizes and evaluates the current strategies for preventing secondary infections and briefly describes the advances in surgical interventions for SAP secondary infections. These analyses show that the pathogenesis, pathogenic features, and immunological features of SAP secondary infection remain unclear. There are various control strategies for such infection, but there are still no effective measures to prevent infection except early enteral nutrition. Conclusions will be achieved on the issues including the timing of percutaneous catheter drainage, and surgical interventions have developed rapidly on the basis of the STEP-UP approach. Endoscopic STEP-UP approach is slightly superior to conventional STEP-UP approach in the treatment of critically ill patients with SAP.
- pancreatitis /
- infection /
- therapeutics /
- review

HTML全文

参考文献(68)

[1]Group of Pancreas Surgery, Chinese Society of Surgery, Chinese Medical Association.Guidelines for the management of acute pancreatitis (2014) [J].J Clin Hepatol, 2015, 31 (1) :17-20. (in Chinese) 中华医学会外科学分会胰腺外科学组.急性胰腺炎诊治指南 (2014) [J].临床肝胆病杂志, 2015, 31 (1) :17-20.

[2]SUN B, JI L.Concerns relating the surgical management of severe acute pancreatitis[J].Chin J Dig Surg, 2017, 16 (10) :987-990. (in Chinese) 孙备, 冀亮.重症急性胰腺炎外科干预应重视的问题[J].中华消化外科杂志, 2017, 16 (10) :987-990.

[3]TENNER S, BAILLIE, DEWITT J, et al.American College of Gastroenterology guideline:Management of acute pancreatitis[J].Am J Gastroenterol, 2013, 108 (9) :1400-1415, 1416.

[4]PETROV MS, SHANBHAG S, CHAKRABORTY M, et al.Organ failure and infection of pancreat-ic necrosis as determinants of mortality in patients with acute pancreatitis[J].Gastroenterology, 2010, 139 (3) :813-820.

[5]WERGE M, NOVOVIC S, SCHMIDT PN.Infection increases mortality in necrotizing pancreatitis:A systematic review and metaanalysis[J].Pancreatology, 2016, 16 (5) :698-707.

[6]FLINT RS.The role of the intestine in the pathophysiology and management of severe acute pancreatitis[J].HPB, 2003, 5 (2) :69-85.

[7]LIU H, LI W, WANG X, et al.Early gut mucosal dysfunction in patients with acute pancreatitis[J].Pancreas, 2008, 36 (2) :192-196.

[8]FISHMAN JE, LEVY G, ALLI V, et al.The intestinal mucus layer is a critical component of the gut barrier that is damaged during acute pancreatitis[J].Shock, 2014, 42:264-270.

[9]FRITZ S, HACKERT T, HARTWIG W, et al.Bacterial translocation and infected pancreatic necrosis in acute necrotizing pancreatitis derives from small bowel rather than from colon[J].Am J Surg, 2010, 200 (1) :111-117.

[10]MORAN RA, JALALY NY, KAMAL A, et al.Ileus is a predictor of local infection in patients with acute necrotizing pancreatitis[J].Pancreatology, 2016, 16 (6) :966-972.

[11] DELLINGER EP, TELLADO JM, SOTO NE, et al.Early antibiotic treatment for severe acute necrotizing pancreatitis:A randomized, double-blind, placebo-controlled study[J].Ann Surg, 2007, 245 (5) :674-683.

[12]BESSELINK MG, van SANTVOORT HC, BOERMEESTER MA, et al.Timing and impact of infections in acute pancreatitis[J].Br J Surg, 2009, 96 (3) :267-273.

[13]PANDO E, ALBERTI P, HIDALGO J, et al.The role of extrapancreatic infections in the prediction of severity and local complications in acute pancreatitis[J].Pancreatology, 2018.[Epub ahead of print]

[14]UEDA T, TAKEYAMA Y, YASUDA T, et al.Immunosuppression in patients with severe acute pancreatitis[J].J Gastroenterol, 2006, 41 (8) :779-784.

[15]KYLNPML, REPO H.Inflammation and immunosuppression in severe acute pancreatitis[J].World J Gastroenterol, 2010, 16 (23) :2867-2872.

[16]YANG N, LI B, YE B, et al.The long-term quality of life in patients with persistent inflammation-immunosuppression and catabolism syndrome after severe acute pancreatitis:A retrospective cohort study[J].J Crit Care, 2017, 42:101-106.

[17]BROWN LA, HORE TA, PHILLIPS AR, et al.A systematic review of the extra-pancreatic infectious complications in acute pancreatitis[J].Pancreatology, 2014, 14 (6) :436-443.

[18]LIU L, YAN H, LIU W, et al.Abdominal paracentesis drainage does not increase infection in severe acute pancreatitis:Aprospective study[J].J Clin Gastroenterol, 2015, 49 (9) :757-763.

[19]HE FQ, HUANG ZW, GUO J, et al.Spectrum and susceptibility of bacterial isolates from complicated infections among Patients with severe acute pancreatitis[J].World Chin J Dig, 2007, 15 (32) :3418-3422. (in Chinese) 何馥倩, 黄宗文, 郭佳, 等.重症急性胰腺炎并发感染的菌谱和耐药性[J].世界华人消化杂志, 2007, 15 (32) :3418-3422.

[20]XUE P, DENG LH, ZHANG ZD, et al.Infectious complications in patients with severe acute pancreatitis[J].Dig Dis Sci, 2009, 54 (12) :2748-2753.

[21]TSUI NC, ZHAO E, LI Z, et al.Microbiological findings in secondary infection of severe acute pancreatitis:A retrospective clinical study[J].Pancreas, 2009, 38 (5) :499-502.

[22]PENG YB, HUANG J, QIN S, et al.Investigation of distribution of bacteria and fungi in severe acute pancreatitis[J].Chin J Surg, 2010, 48 (7) :496-501. (in Chinese) 彭奕冰, 黄洁, 秦帅, 等.重症急性胰腺炎细菌和真菌的分布状况研究[J].中华外科杂志, 2010, 48 (7) :496-501.

[23]NOOR MT, RADHAKRISHNA Y, KOCHHAR R, et al.Bacteriology of infection in severe acute pancreatitis[J].JOP, 2011, 12 (1) :19-25.

[24]ISRAIL AM, PALADE R, CHIFIRIUC MC, et al.Spectrum, antibiotic susceptibility and virulence factors of bacterial infections complicating severe acute pancreatitis[J].Chirurgia, 2011, 106 (6) :743-752.

[25]SU MS, LIN MH, ZHAO QH, et al.Clinical study of distribution and drug resistance of pathogens in patients with severe acute pancreatitis[J].Chin Med J, 2012, 125 (10) :1772-1776.

[26]LEE HS, LEE SK, PARKDO H, et al.Emergence of multidrug resistant infection in patients with severe acute pancreatitis[J].Pancreatology, 2014, 14 (6) :450-453.

[27]LIU L, GAO Q.Analysis of bacterial spectrum and drug resistance in 50 cases of severe acute pancreatitis complicated with infection[J].Chin J Dig, 2015, 35 (10) :678-681. (in Chinese) 刘恋, 高青.重症急性胰腺炎50例合并感染的菌谱及耐药性分析[J].中华消化杂志, 2015, 35 (10) :678-681.

[28]WANG Y, ZHANG YJ, YE ML, et al.The distributions and clinical characteristics of pathogenic bacteria in severe acute pancreatitis patients with the secondary infection[J].J Pract Med, 2017, 33 (22) :3773-3776. (in Chinese) 王瑶, 张友健, 叶美玲, 等.重症急性胰腺炎继发感染的病原菌分布及临床特点分析[J].实用医学杂志, 2017, 33 (22) :3773-3776.

[29]MA HX, HE L, CAI SW, et al.Analysis of the spectrum and resistance of pathogen causing sepsis in patients with severe acute pancreatitis[J].Chin J Surg, 2017, 55 (5) :378-383. (in Chinese) 马焕先, 何蕾, 蔡守旺, 等.重症急性胰腺炎继发脓毒症的病原菌菌谱及耐药性分析[J].中华外科杂志, 2017, 55 (5) :378-383.

[30]BEHRMAN SW, BAHR MH, DICKSON PV.The microbiology of secondary and postoperative pancreatic infections:Implications for antimicrobial management[J].Arch Surg, 2011, 146 (5) :613-619.

[31]REUKEN PA, ALBIG H, RDEL J, et al.Fungal infections in patients with infected pancreatic necrosis and pseudocysts:Risk factors and outcome[J].Pancreas, 2018, 47 (1) :92-98.

[32]TARGARONA MODENA J, BARREDA CEVASCO L, ARROYOBASTO C, et al.Total enteral nutrition as prophylactic therapy for pancreatic necrosis infection in severe acute pancreatitis[J].Pancreatology, 2006, 6 (1-2) :58-64.

[33]WU XM, JI KQ, WANG HY, et al.Total enteral nutrition in prevention of pancreatic necrotic infection in severe acute pancreatitis[J].Pancreas, 2010, 39 (2) :248-251.

[34]WERESZCZYNSKA-SIEMIATKOWSKA U, SWIDNICKA-SI-ERGIEJKO A, SIEMIATKOWSKI A.Early enteral nutrition is superior to delayed enteral nutrition for the prevention of infected necrosis and mortality in acute pancreatitis[J].Pancreas, 2013, 42 (4) :640-646.

[35]JI L, LV JC, SONG ZF, et al.Risk factors of infected pancreatic necrosis secondary to severe acute pancreatitis[J].Hepatobiliary Pancreat Dis Int, 2016, 15 (4) :428-433.

[36]WU XM, LIAO YW, WANG HY, et al.When to initialize enteral nutrition in patients with severe acute pancreatitis?A retrospective review in a single institution experience (2003-2013) [J].Pancreas, 2015, 44 (3) :507-511.

[37]QI D, YU B, HUANG J.Meta-analysis of early enteral nutrition provided within 24 hours of admission on clinical outcomes in acute pancreatitis[J].JPEN J Parenter Enteral Nutr, 2018, 42 (7) :1139-1147.

[38]NALLY DM, KELLY EG, CLARKE M, et al.Nasogastric nutrition is effcacious in severe acute pancreatitis:A systematic review and meta-analysis[J].Br J Nutr, 2014, 112 (11) :1769-1778.

[39]SAWA H, UEDA T, TAKEYAMA Y, et al.Treatment outcome of selective digestive decontamination and enteral nutrition in patients with severe acute pancreatitis[J].J Hepatobiliary Pancreat Surg, 2007, 14 (5) :503-508.

[40]DANEMAN N, SARWAR S, FOWLER RA, et al.Effect of selective decontamination on antimicrobial resistance in intensive care units:A systematic review and meta-analysis[J].Lancet Infect Dis, 2013, 13 (4) :328-341.

[41]DAUTZENBERG MJD, BAYJANOV JR, LEVERSTEIN-van HALLMA, et al.Dynamics of colistin and tobramycin resistance among during prolonged use of selective decontamination of the digestive tract[J].Antimicrob Resist Infect Control, 2018, 7:67.

[42]BESSELINK MG, van SANTVOORT HC, BUSKENS E, et al.Probiotic prophylaxis in predicted severe acute pancreatitis:Arandomised, double-blind, placebo-controlled trial[J].Lancet, 2008, 371 (9613) :651-659.

[43]BONGAERTS GP.A reassessment of the PROPATRIA study and its implications for probiotic therapy[J].Nat Biotechnol, 2016, 34 (1) :55-63.

[44]TIAN X, PI YP, LIU XL, et al.Supplemented Use of Pre-, Pro-, and synbiotics in severe acute pancreatitis:An updated systematic review and Meta-analysis of 13 randomized controlled trials[J].Front Pharmacol, 2018, 9:690.

[45]WANG X, LI W, NIU C, et al.Thymosin alpha 1 is associated with improved cellular immunity and reduced infection rate in severe acute pancreatitis patients in a double-blind randomized control study[J].Inflammation, 2011, 34 (3) :198-202.

[46]AKINOSOGLOU K.Immune-modulating therapy in acute pancreatitis:fact or fiction[J].World J Gastroenterol, 2014, 20 (41) :15200-15215.

[47]YANG YZ, XIANG Y, CHEN M, et al.Clinical significance of dynamic detection for serum levels of MCP-1, TNF-αand IL-8 in patients with acute pancreatitis[J].Asian Pac J Trop Med, 2016, 9 (11) :1111-1114.

[48]DELLINGER EP, TELLADO JM, SOTO NE, et al.Early antibiotic treatment for severe acute necrotizing pancreatitis:A randomized, double-blind, placebo-controlled study[J].Ann Surg, 2007, 245 (5) :674-683.

[49]BEGER HG, RAU B, ISENMANN R, et al.Antibiotic prophylaxis in severe acute pancreatitis[J].Pancreatology, 2005, 5 (1) :10-19.

[50]JAFRI NS, MAHID SS, IDSTEIN SR, et al.Antibiotic prophylaxis is not protective in severe acute pancreatitis:A systematic review and meta-analysis[J].Am J Surg, 2009, 197 (6) :806-813.

[51]UKAI T, SHIKATA S, INOUE M, et al.Early prophylactic antibiotics administration for acute necrotizing pancreatitis:A meta-analysis of randomized controlled trials[J].J Hepatobiliary Pancreat Sci, 2015, 22 (4) :316-321.

[52]NAKAHARAI K, MORITA K, JO T, et al.Early prophylactic antibiotics for severe acute pancreatitis:A population-based cohort study using a nationwide database in Japan[J].J Infect Chemother, 2018, 24:753-758.

[53]MOURAD MM, EVANS R, KALIDINDI V, et al.Prophylactic antibiotics in acute pancreatitis:Endless debate[J].Ann RColl Surg Engl, 2017, 99 (2) :107-112.

[54]CACOPARDO B, PINZONE M, BERRETTA S, et al.Localized and systemic bacterial infections in necrotizing pancreatitis submitted to surgical necrosectomy or percutaneous drainage of necrotic secretions[J].BMC Surg, 2013, 13 (Suppl 2) :s50.

[55]MOULI VP, SREENIVAS V, GARG PK.Efficacy of conservative treatment, without necrosectomy for infected pancreatitis necrosis:A systematic review and meta-analysis[J].Gastroenterology, 2013, 144:333-340

[56]APARNA D, KUMAR S.Mortality and morbidity in necrotizing pancreatitis managed on principles of step-up approach:7years experience from a single surgical unit[J].World J Gastrointest Surg, 2017, 9 (10) :200-208.

[57]TUGAL D, LYNCH M, HUJER AM, et al.Multi-drug-resistant Klebsiella pneumoniae pancreatitis:A new challenge in a serious surgical infection[J].Surg Infect, 2015, 16 (2) :188-193.

[58]MOKA P, GOSWAMI P, KAPIL A, et al.Impact of antibioticresistant bacterial and fungal infections in outcome of acute pancreatitis[J].Pancreas, 2018, 47 (4) :489-494.

[59]WERGE M, NOVOVIC S, ROUG S, et al.Evaluation of local instillation of antibiotics in infected walled-off pancreatic necrosis[J].Pancreatology, 2018, 18 (6) :642-646.

[60]van SANTVOORT HC, BESSELINK MG, BAKKER OJ, et al.Astep-up approach or open necrosectomy for necrotizing pancreatitis[J].N Engl J Med, 2010, 362 (16) :1491-1502.

[61]TONG Z, SHEN X, KE L, et al.The effect of a novel minimally invasive strategy for infected necrotizing pancreatitis[J].Surg Endosc, 2017, 31 (11) :4603-4616.

[62]GOENKA MK, GOENKA U, MUJOO MY, et al.Pancreatic necrosectomy through sinus tract endoscopy[J].Clin Endosc, 2018, 51 (3) :279-284.

[63]WANG PF, LIU ZW, CAI SW, et al.Usefulness of three-dimensional visualization technology in minimally invasive treatment for infected necrotizing pancreatitis[J].World J Gastroenterol, 2018, 24 (17) :1911-1918.

[64]van BRUNSCHOT S, van GRINSVEN J, van SANTVOORT HC, et al.Endoscopic or surgical step-up approach for infected necrotising pancreatitis:A multicentre randomised trial[J].Lancet, 2018, 391 (10115) :51-58.

[65]HE WH, ZHU Y, ZHU Y, et al.The outcomes of initial endoscopic transluminal drainage are superior to percutaneous drainage for patients with infected pancreatic necrosis:A prospective cohort study[J].Surg Endosc, 2017, 31 (7) :3004-3013.

[66]BAKKER OJ, van SANTVOORT HC, van BRUNSCHOT S, et al.Endoscopic transgastric vs surgical necrosectomy for infected necrotizing pancreatitis:A randomized trial[J].JAMA, 2012, 307 (10) :1053-1061.

[67]van BRUNSCHOT S, HOLLEMANS RA, BAKKER OJ, et al.Minimally invasive and endoscopic versus open necrosectomy for necrotising pancreatitis:A pooled analysis of individual data for 1980 patients[J].Gut, 2018, 67 (4) :697-706.

[68] MIAO Y, HUANG DY, LI Q.From“archaeological style-like debridement”to“grave digging”:A historical inspiration and practical thinking of surgical treatment for severe acute pancreatitis[J].Chin J Dig Surg, 2018, 17 (1) :9-13. (in Chinese) 苗毅, 黄东亚, 李强.从“考古”到“盗墓”:重症急性胰腺炎外科治疗的历史启示与现实思考[J].中华消化外科杂志, 2018, 17 (1) :9-13.

施引文献

资源附件(0)

访问统计