Prophylatic Antibiotics in the ED

There are 2 situations in the ED that warrant the use of prophylactic antibiotics; some cases of acute pancreatitis and chest tube insertions.

(thank you K.B. for this valuable info!)

Regarding Acute Pancreatitis, There's a 2009 article which was published in the Current Infectious Disease Reports, discussing the issue of the prophylactic abx in two main conditions: Severe Acute Pancreatitis ( SAP ) and Gall Stone Acute Pancreatitis ( AP ).

SAP:
- most common bacteria is Gram negative mostly E.Coli. Gram positive ( staph. Aureus & staph epidermidis ) were observed more in patients who recieved prophylactic antibiotics
- Infections of pancreatic necrosis & abscess formation is obsereved in about 30% in patients with Necrotizing Pancreatitis( NP ) & 10% in AP.
- Mortality & Morbidity is strongly determined in SAP by the early development of MSOF , extent of the necrosis, and sepsis caused by infected necrosis.
-Based on high quality , double blinded, randomized , placebo-controlled trials, Abx prophylaxis in SAP has no clinical benefit for reducuing pancreatic infection, decreasing morbidity, and improving hospital mortality.
- Two recent Meta-Analysis concluded that evidence based data do not support abx prophylaxis.

Therefore, the use of antibiotic in SAP is recommended on demand in patients who have SAP with multiorgan dysfunction at admission ( < 72 h ) , shock , and for those who develop acute respiratory distress & clinical signs of sepsis and show extended ( >50% ) pancreatic necrosis .
- Rational antibiotic treatment ( according to the sensitivity ) is recommended .

AP:

- Abx treatment in recommended for patients who additionally have acute cholecyctitis or cholangitis ( with common bile duct lithiasis ) and Fever > 38.5 C.

[References:
THE USE OF ANTIBIOTICS FOR ACUTE PANCREATITIS : IS There a Role?
Hans G.Beger, MD, Frank Gansauge, MD, Bertram Poch, MD and Michael Schwarz, MD
Current Infectious Disease Report 2009, 11:101-107]


As for prophylaxis in Chest Tube Insertion:
- The role of presumptive antibiotics for the prevention of empyema and pneumonia following chest tube insertion remains controversial.
- Risk Factors for infections such as : mechanism of injury, hemothorax, retained hydrothorax, alcoholism, or presence of chronic disease should be considered.
-When administered, Abx should have mainly a gram positive coverage.
- There's no Level 1 recommendation, Level 2 says that there's insufficient data to support routine use of antibiotics in patients who undergo chest tube due to spontaneous pneumothorax. Level 3 suggests antibiotics for those who have traumatic pneumo/hemothorax AND have additional risk factors for infections. However, In emergency situation Abx use shouldn't delay the insertion of the chest tube.

[References:
Guidlines prepared by the Department of surgical education , Orlando Regional Medical Center]