Management of infected pancreatic fluid collection

For the diagnosis and general management of acute pancreatitis, and information on assessing infective and noninfective causes, see Acute pancreatitis.

Specialist management in a high-dependency or intensive care unit is required for patients with severe acute pancreatitis.

Early diagnostic aspiration should not be performed to make the decision to start antibiotics because this may cause infection of previous sterile necrosis.

Management of infected pancreatic fluid collection involves endoscopic drainage, percutaneous aspiration or surgery, and antibiotic therapy.

Infected pancreatic fluid collections are commonly caused by intestinal flora, including Enterobacterales, Enterococci and anaerobesWolbrink, 2020. Candida species1 are more common after treatment with broad-spectrum antibiotic therapyWolbrink, 2020.

For empirical therapy of infected pancreatic fluid collections in adults and children, useAbdul-Aziz, 2024Dulhunty, 2024:

piperacillin+tazobactam intravenously. For dosage adjustment in adults with kidney impairment, see piperacillin+tazobactam dosage adjustment. See advice on modification and duration of therapy piperacillin + tazobactam piperacillin+tazobactam piperacillin+tazobactam

patients without septic shock and not requiring intensive care support: 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) 6-hourly

patients with septic shock or requiring intensive care support: 4+0.5 g (child: 100+12.5 mg/kg up to 4+0.5 g) administered as a loading dose over 30 minutes. After 3 hours, start a continuous infusion of 16+2 g (child: 400+50 mg/kg up to 16+2 g) administered over 24 hours23.

For patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin, as a 3-drug regimen, use:

1ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 2 g) intravenously, daily. For patients with septic shock or requiring intensive care support, use 1 g (child 1 month or older: 50 mg/kg up to 1 g) intravenously, 12-hourly. See advice on modification and duration of therapy ceftriaxone ceftriaxone ceftriaxone

OR

1cefotaxime 2 g (child: 50 mg/kg up to 2 g) intravenously, 8-hourly. For patients with septic shock or requiring intensive care support, use 2 g (child 1 month or older: 50 mg/kg up to 2 g) intravenously, 6-hourly. For dosage adjustment in adults with kidney impairment, see cefotaxime dosage adjustment. See advice on modification and duration of therapy cefotaxime cefotaxime cefotaxime

PLUS with either of the above drugs

metronidazole 500 mg (child: 12.5 mg/kg up to 500 mg) intravenously, 12-hourly. See advice on modification and duration of therapy metronidazole metronidazole metronidazole

PLUS

vancomycin intravenously; for initial dosing, see Vancomycin dosing in adults or Intermittent vancomycin dosing for young infants and children. Loading doses are recommended for critically ill adults. See advice on modification and duration of therapy. vancomycin vancomycin vancomycin

For patients who have had a severe immediate4 hypersensitivity reaction to a penicillin, the ceftriaxone- or cefotaxime-containing regimen (at the dosages above) can be considered if a beta-lactam antibiotic is strongly preferred (for considerations, see Severe immediate hypersensitivity: Implications of cross-reactivity between penicillins and cephalosporins).

For patients who have had a severe immediate4 hypersensitivity reaction to a penicillin in whom ceftriaxone or cefotaxime is not used, or for patients who have had a severe delayed5 hypersensitivity reaction to a penicillin, seek expert advice.

1 Some yeast species that were previously considered Candida species have been reclassified and are now considered candida-like and may be reported with a new name (eg Nakaseomyces glabratus, Pichia kudriavzevii)Borman, 2021. For a list of common Candida and related species and (if applicable) revised species names, see Common Candida and related species, and changes to nomenclature.Return
2 For patients with septic shock or requiring intensive care support, administering the total daily dose of piperacillin+tazobactam over 24 hours is preferred to ensure adequate drug exposure. If this is not possible (eg the patient is receiving other drugs via the same line), administer the standard dose (4+0.5 g [child: 100+12.5 mg/kg up to 4+0.5 g] intravenously, 6-hourly) as an extended infusion over 3 hours. If a 3-hour infusion is not possible, administer over 30 minutes. For more information, see Practical information on using beta lactams: penicillins.Return
3 The modified dosage of piperacillin+tazobactam for patients with septic shock or those requiring intensive care support is recommended to ensure adequate drug exposure, because pharmacokinetics may be altered in patients with critical illness (eg because of enhanced kidney clearance or changes in volume of distribution). Once the critical illness has resolved, consider switching to the standard dosage.Return
4 Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return
5 Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return