EBM Journal Club GS 謝閔傑

題目 對於治療急性壞死性胰臟炎病患有需要使用抗生 素治療嗎？

實證醫學的 5 個步驟  步驟 1: 形成臨床問題  步驟 2: 尋找証據  步驟 3: 嚴謹評估証據  步驟 4: 臨床應用  步驟 5: 評估效果

步驟 1: 形成臨床問題  Type of Questions (1) Background questions (2) Foreground questions

Background Questions?  What is acute pancreatitis ?  What is acute necrotizing pancreatitis  What is the current principles to manage acute necrotizing pancreatitis?  All the above questions can be answered in the medical textbook or Up to date

Acute pancreatitis  Acute inflammation of the pancreas  Clinically mild to severe  Severe acute pancreatitis  pancreatic glandular necrosis  morbidity and mortality substantially higher necrosis  especially infected.

Presentation and Classification  rapid onset manifested  upper abdominal pain, vomiting, fever, tachycardia,  leukocytosis, elevated pancreatic enzymes  Gallstones and alcohol abuse are the most common causes

Severity  Several severity-of-illness classifications  Ranson's score is based on 11 clinical signs with prognostic importance; 5 are measured at the time of admission and the other 6 in the first 48 hours after admission  Acute Physiology and Chronic Health Evaluation (APACHE II) score  12 physiologic variables, the patient's age, and any history of severe organ-system insufficiency or immunocompromised state

Severe pancreatitis  >=3 Ranson's criteria  APACHE II score >= 8  Shock  Renal failure  Respiratory failure

Severe pancreatitis  Severe pancreatitis  morbidity of 82 %  mortality of 23 %  Mild  morbidity of 6 %  mortality of 0%  glandular necrosis increase, morbidity increase.  overall mortality in severe acute pancreatitis 30%  Deaths  Early mortality 1~2 weeks; multiple organ failure  Late mortality local or systemic infection

systemic and local complications  Acute respiratory distress syndrome  Acute renal failure  Shock  Coagulopathy  Hyperglycemia  Hypocalcemia  Local complicationsgastrointestinal bleeding, infected necrosis, and adjacent bowel necrosis  Late :pancreatic abscesses and pancreatic pseudocysts

Pancreatic Necrosis  International Symposium on Acute Pancreatitis in 1992: defined pancreatic necrosis as the presence of one or more diffuse or focal areas of nonviable pancreatic parenchyma  Pancreatic glandular necrosis  necrosis of peripancreatic fat  pancreatic necrosis represents a severe form of acute pancreatitis  Necrosis is present in approximately 20 to 30 percent of acute pancreatitis

Recognition of Pancreatic Necrosis  Radiographically by intravenous contrast- enhanced computed tomography (CT) of the abdomen.  Contrast-enhanced abdominal CT: gold standard noninvasive diagnosis of pancreatic necrosis  accuracy >= 90% when >=30% glandular necrosis.  pathologically at surgery or autopsy

Pancreatic Necrosis  Treatment policy shifted away from early surgical debridement ("necrosectomy") to aggressive intensive medical care  Prompt identification and prevention complications  Intensive care  Nutrition support  Infection prevention ?

Foreground Questions  PICO  P 代表 patient 或者 problem  I 代表 intervention 通常為診斷 (diagnostic) 或者是治療 (treatment)  C 代表 comparisons (comparative intervention)  O 代表 outcome

步驟 1: 形成臨床問題  對於治療急性壞死性胰臟炎病患有需要使用 抗生素治療嗎？  P: Patient –acute necrotizing pancreatitis 病患  I: Intervention – 接受 antibiotics 治療  C: Comparison – 不接受 antibiotics 治療  O: Outcome – 併發症或是死亡率是否有差別 ?

步驟 2: 尋找證據  醫學資料庫檢索 MEDLINE Best Evidence Cochrane Database of Systematic Reviews EBM ReviewsTherapeuticsLocal Holdings Articles in EnglishDiagnosisSystematic Reviews Research on Human Subjects PrognosisProtocols Latest UpdateEtiologyNew Reviews

步驟 2: 尋找證據  以 Medline 為例  以 Key word, Text word 查尋  Map to medical subject headings (MeSH)  And, Or, And Not 功能 : 可交集或聯集 Key word  限制功能 : Limited to ( 年代, 英文,Randomized controlled trial)

Cochrane library

Trial in 2003

Trial in 2007

RTC in 2009

Trial in 2009

The Evidence Pyramid

Grade of Recommendation Level of Evidence Therapy [A]1a Systemic review of RCTs 1b Single RCT 1c ‘All-or-none’ [B]2a Systemic review of cohort studies 2b Cohort study or poor RCT 2c ‘Outcomes’ research 3a Systemic review of case- control studies 3b Case-control study [C]4 Case series [D]5 Expert opinion, physiology, bench research

步驟 4: 臨床應用  應用於臨床病患  應以 effective, efficiency, equality 的理念應用 於病人  最終結果想法 (the end result idea) 的理想  制定醫療政策  Agent for Healthcare Research and Quality (AHRQ) in USA

結論  Acute necrotizing pancreatitis  Combination with  Intra-abdominal infection – Antibiotics treatment is necessary  No evidence of intra-abdominal infection- Prophylactic antibiotics is not necessary and not proved to be effective in reduction morbidity and morbidity

結論  How to prove intra-abdominal infection?  Ascites tapping  Paracentesis  CT guide aspiration  Blood culture: gram negative bacilli or anaerobe

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