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Buddington KK, Pierzynowski SG, Holmes WE, Buddington RK. Selective and Concentrative Enteropancreatic Recirculation of Antibiotics by Pigs. Antibiotics (Basel) 2023; 13:12. [PMID: 38275322 PMCID: PMC10812520 DOI: 10.3390/antibiotics13010012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/13/2023] [Accepted: 12/16/2023] [Indexed: 01/27/2024] Open
Abstract
Antibiotics that are efficacious for infectious pancreatitis are present in pancreatic exocrine secretion (PES) after intravenous administration and above minimal inhibitory concentrations. We measured concentrations of four antibiotics by tandem liquid chromatography-mass spectroscopy in plasma and PES after enteral administration to juvenile pigs with jugular catheters and re-entrant pancreatic-duodenal catheters. Nystatin, which is not absorbed by the intestine nor used for infectious pancreatitis (negative control), was not detected in plasma or PES. Concentrations of amoxicillin increased in plasma after administration (p = 0.035), but not in PES (p = 0.51). Metronidazole and enrofloxacin that are used for infectious pancreatitis increased in plasma after enteral administration and even more so in PES, with concentrations in PES averaging 3.1 (±0.5)- and 2.3 (±0.6)-fold higher than in plasma, respectively (p's < 0.001). The increase in enrofloxacin in PES relative to plasma was lower after intramuscular administration (1.8 ± 0.5; p = 0.001). The present results demonstrate the presence of a selective and concentrative enteropancreatic pathway of secretion for some antibiotics. Unlike the regulated secretion of bile, the constitutive secretion of PES and intestinal reabsorption may provide a continuous exposure of pancreas tissue and the small intestine to recirculated antibiotics and potentially other therapeutic molecules. There is a need to better understand the enteropancreatic recirculation of antibiotics and the associated mechanisms.
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Affiliation(s)
| | - Stefan G. Pierzynowski
- Department of Biology, Lund University, Sölvegatan 35, 22362 Lund, Sweden;
- Department of Medical Biology, IMW, Jaczewskiego 2, 20-950 Lublin, Poland
| | - William E. Holmes
- Department of Chemical Engineering, University of Louisiana, Lafayette, LA 70503, USA;
| | - Randal K. Buddington
- Department of Health Sciences, University of Memphis, Memphis, TN 38152, USA
- Stonewall Research Facility, LSU Health Sciences, Stonewall, LA 71078, USA
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Würstle S, Hapfelmeier A, Wöhrle C, Dichtl K, Lahmer T, Rasch S, Huber W, Weber A, Algül H, Spinner C, Pichler M, Schmid RM, Mayerle J, Schneider J. Changes in pathogen spectrum and antimicrobial resistance development in the time-course of acute necrotizing pancreatitis. J Gastroenterol Hepatol 2019; 34:2096-2103. [PMID: 31157455 DOI: 10.1111/jgh.14748] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 05/06/2019] [Accepted: 05/27/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIM In contrast to the first peak of multi-organ failure in acute pancreatitis, the second peak is mostly triggered by septic complications. Our aim was to analyze the spectrum of pathogens and antimicrobial resistance development in relation to the time-course of the disease and its clinical outcome. METHODS One hundred twenty-two patients with acute necrotizing pancreatitis undergoing pancreas puncture at two tertiary academic medical centers in Germany were retrospectively analyzed. RESULTS At species level, there was a change in spectrum from Enterococcus faecalis (∆d150 - d1 = 14.6% - 16.7% = -2.1%) to Enterococcus faecium (∆d150 - d1 = 93.1% - 16.3% = 76.8%) (P < 0.001) and from Candida albicans (∆d150 - d1 = 39.7% - 23.6% = 16.1%) to non-albicans Candida spp. (∆d150 - d1 = 43.5% - 6.4% = 37.1%) (P = 0.005). Time-to-event analysis of acquired antimicrobial resistance showed that the overall number of patients with Enterobacteriaceae presented an antimicrobial susceptibility decrease by 59.7% (∆d1 - d100 = 87.0% - 27.3% = 59.7%). The cumulative incidence of multi-resistant bacteria increased with length of hospital stay (∆d150 - d1 = 49.1% - 3.1% = 46.0%) (P = 0.004). Multivariable logistic regression analysis in relation to the pathogen spectrum and antimicrobial resistance development showed a significantly higher mortality for non-albicans Candida spp. (P = 0.039, odds ratio [OR] = 3.32 [95% confidence interval [CI]: 1.07-10.35]), E. faecium (P = 0.009, OR = 3.73 [95% CI: 1.38-10.05]), and multi-resistant bacteria (P = 0.007, OR = 5.08 [95% CI: 1.55-16.66]). CONCLUSIONS Antimicrobial treatment of infected pancreatic necrosis becomes more challenging over time, owing to a change in spectrum favoring difficult-to-treat pathogens and an increase in multi-resistant bacteria associated with worse clinical outcomes (World Health Organization trial registration number: DRKS00014785).
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Affiliation(s)
- Silvia Würstle
- Department of Internal Medicine II, Technical University Munich, Munich, Germany
| | - Alexander Hapfelmeier
- Institute of Medical Informatics, Statistics and Epidemiology, Technical University Munich, Munich, Germany
| | - Caroline Wöhrle
- Department of Internal Medicine II, Technical University Munich, Munich, Germany
| | - Karl Dichtl
- Max von Pettenkofer-Institute, Medical Faculty, Ludwigs-Maximilian-University Munich, Munich, Germany
| | - Tobias Lahmer
- Department of Internal Medicine II, Technical University Munich, Munich, Germany
| | - Sebastian Rasch
- Department of Internal Medicine II, Technical University Munich, Munich, Germany
| | - Wolfgang Huber
- Department of Internal Medicine II, Technical University Munich, Munich, Germany
| | - Andreas Weber
- Department of Internal Medicine II, Technical University Munich, Munich, Germany
| | - Hana Algül
- Department of Internal Medicine II, Technical University Munich, Munich, Germany
| | - Christoph Spinner
- Department of Internal Medicine II, Technical University Munich, Munich, Germany
| | - Matthias Pichler
- Department of Internal Medicine II, Klinikum Groβhadern, Ludwigs-Maximilian-University Munich, Munich, Germany
| | - Roland M Schmid
- Department of Internal Medicine II, Technical University Munich, Munich, Germany
| | - Julia Mayerle
- Department of Internal Medicine II, Klinikum Groβhadern, Ludwigs-Maximilian-University Munich, Munich, Germany
| | - Jochen Schneider
- Department of Internal Medicine II, Technical University Munich, Munich, Germany
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Green DL, Cook JB, Triemer HL, Galloway JR. Vancomycin Concentrations in Necrotic Pancreatic Tissue: A Pilot Study. Hosp Pharm 2017. [DOI: 10.1177/001857870303800909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Purpose: To determine vancomycin concentrations in necrotic pancreatic tissue of intensive care unit (ICU) patients with acute necrotizing pancreatitis. Methods: The prospective, observational pilot study was conducted at a university-based tertiary hospital. The patient population consisted of 11 patients with necrotizing pancreatitis receiving vancomycin and undergoing necrosectomy. Tissue samples taken during surgical debridement were assayed for vancomycin by immunoassay. Patients were divided into steady state and nonsteady-state groups. Two patients were excluded because necrosectomy was not performed, and one tissue sample could not be assayed because of contamination. Results: The mean tissue concentration was 5.84 mcg/mL (ranging from 3.1 mcg/mL to 8.94 mcg/mL). Four patients in the nonsteady-state group, who each received a single dose of vancomycin, had a mean tissue concentration of 4.5 ± 1.68 mcg/mL, compared with 7.76 ± 1.05 mcg/mL for the four steady-state patients. Conclusion: The data shows that vancomycin is detectable in necrotic pancreas tissue but possibly not in concentrations sufficient to prevent or treat bacterial contamination in patients with pancreatic necrosis.
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Affiliation(s)
- David L. Green
- Department of Pharmaceutical Services; Emory University Hospital, Atlanta, GA
| | | | - Helen L. Triemer
- Kidney Transplant Service, Department of Pharmaceutical Services, Emory University Hospital
| | - John R. Galloway
- Surgical Intensive Care Unit, Department of Surgery, Emory University Hospital. At the time of the study, Dr. Cook was a Pharmacy Practice Resident at Emory University Hospital
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Arlt A, Erhart W, Schafmayer C, Held HC, Hampe J. Antibiosis of Necrotizing Pancreatitis. VISZERALMEDIZIN 2015; 30:318-24. [PMID: 26286761 PMCID: PMC4513830 DOI: 10.1159/000367948] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Necrotizing pancreatitis is a life-threatening presentation of acute pancreatitis. The mortality of 20-80% initially depends on the persistence of organ failure and systemic inflammatory response syndrome (SIRS) and, in the later course of the disease, on secondary infection of the necrosis. The questions whether prophylactic antibiotics aiming to prevent this infection should be administered and which antibiotic is the best to use, as well as the problem of fungal infection under antibiotic treatment are still intriguing and insufficiently solved. METHODS A search of the literature using PubMed was carried out, supplemented by a review of the programmes of the Digestive Disease Week (DDW) and the United European Gastroenterology Week (UEGW). RESULTS Despite the widely practised prophylactic antibiotic administration in severe pancreatitis, no evidence for the benefit of this strategy exists. One of the drawbacks might be a tendency for disastrous fungal infection under prophylactic antibiotics. Bacterial translocation from the gut in the second week after the onset of symptoms is the major source for infection of pancreatic necrosis and provides a clear indication for antibiotic treatment. However, routine fine-needle aspiration for a calculated antibiotic therapy cannot be recommended, and all other tests offer only indirect signs. Important factors such as enteral versus parenteral feeding and the method of necrosectomy are mostly neglected in the trials but seem to be essential for the outcome of the patient. CONCLUSIONS Even though most meta-analyses including the newer double-blind, placebo-controlled trials on prophylactic antibiotics showed no beneficial effects in the prevention of infection of necrosis and/or outcome of the patients, this strategy is still widely used in clinical routine. Since nearly all trials published so far show systematic problems (i.e. inaccurate definition of the severity of the disease, poor statistical testing, and neglect of differences in the route of nutrition), there is a need for randomized controlled prospective trials with exact definitions of the disease.
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Affiliation(s)
- Alexander Arlt
- Department of Internal Medicine I, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Wiebke Erhart
- Department of Internal Medicine I, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Clemens Schafmayer
- Department of General and Thoracic Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Hanns-Christoph Held
- Department of General, Thoracic and Vascular Surgery, University Hospital Dresden, Dresden University of Technology, Dresden, Germany
| | - Jochen Hampe
- Department of Internal Medicine I, University Hospital Dresden, Dresden University of Technology, Dresden, Germany
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Sung HY, Kim JI, Lee HJ, Cho HJ, Cheung DY, Kim SS, Cho SH, Kim JK. Acute pancreatitis secondary to ciprofloxacin therapy in patients with infectious colitis. Gut Liver 2014; 8:265-70. [PMID: 24827622 PMCID: PMC4026643 DOI: 10.5009/gnl.2014.8.3.265] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND/AIMS Ciprofloxacin is considered to be a safe and effective treatment for acute infectious colitis. However, this drug may cause drug-induced pancreatitis, albeit rarely. METHODS From March 2007 to February 2012, we studied 227 patients who were hospitalized for infectious colitis at St. Mary's Hospital. All of the patients received ciprofloxacin therapy for the treatment of infectious colitis. We observed a few cases of rare adverse events, including ciprofloxacin-induced acute pancreatitis diagnosed based on the Naranjo algorithm. RESULTS During ciprofloxacin therapy, seven of 227 patients (3.1%) developed rare pancreatitis as defined by the Naranjo algorithm; pancreatic enzyme activity was sporadically elevated with ciprofloxacin use. After ciprofloxacin administration, the average interval until the development of pancreatitis was 5.5 days (range, 4 to 7 days). On abdominal computed tomography, pancreatic swelling and homogenous enhancement was noted in three of seven patients. Complicating acute pancreatitis was gradually but completely resolved after cessation of ciprofloxacin administration. The mean recovery time was 11.3 days (range, 8 to 15 days). CONCLUSIONS We observed that ciprofloxacin-induced pancreatitis may occur with an incidence of approximately 3%. Ciprofloxacin-induced pancreatitis presents a short latency, suggesting an idiosyncratic hypersensitivity reaction. Practitioners should be aware that drug-induced pancreatitis can occur during ciprofloxacin therapy.
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Affiliation(s)
- Hye Young Sung
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jin Il Kim
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Hyun Jeong Lee
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Hyung Jun Cho
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Dae Young Cheung
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Sung Soo Kim
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Se Hyun Cho
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Jae Kwang Kim
- Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
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Activity of moxifloxacin, imipenem, and ertapenem against Escherichia coli, Enterobacter cloacae, Enterococcus faecalis, and Bacteroides fragilis in monocultures and mixed cultures in an in vitro pharmacokinetic/pharmacodynamic model simulating concentrations in the human pancreas. Antimicrob Agents Chemother 2012; 56:6434-6. [PMID: 23070164 DOI: 10.1128/aac.00872-12] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
The activities of moxifloxacin, imipenem, and ertapenem against pathogens causing severe necrotizing pancreatitis were studied in an in vitro pharmacokinetics/pharmacodynamics (PK/PD) model. Escherichia coli, Enterobacter cloacae, Enterococcus faecalis, and Bacteroides fragilis were exposed in monocultures and mixed cultures to concentrations of the three agents comparable to those in the human pancreas. Moxifloxacin was more active than the two carbapenems in monocultures and mixed cultures, reducing the numbers of CFU more drastically and more rapidly.
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Abstract
This work sought to define how pancreatitis affected antibiotic distribution in a perfused rat pancreas model. The distribution kinetics of four antibiotics were examined in control animals and animals with pancreatitis. Meropenem and piperacillin distributed into the extracellular space, and their distribution kinetics were unaffected by pancreatitis. In contrast, in pancreatic cells from animals with pancreatitis, ciprofloxacin showed a reduced uptake and clindamycin showed a reduced distribution.
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de-Madaria E, Martínez Sempere JF. [Antibiotic therapy in acute pancreatitis]. GASTROENTEROLOGIA Y HEPATOLOGIA 2009; 32:502-8. [PMID: 19616871 DOI: 10.1016/j.gastrohep.2009.01.182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2008] [Accepted: 01/07/2009] [Indexed: 12/27/2022]
Abstract
Infected pancreatic necrosis (IPN) is one of the main causes of mortality in patients with acute pancreatitis (AP). The choice of antibiotic therapy in AP should be based on penetration of the drug in the pancreas and the degree of coverage provided against the typical bacterial flora produced in IPN. Drugs such as imipenem, ciprofloxacin and metronidazole have been widely studied and seem to be ideal in the treatment of INP. Clinical practice guidelines recommend a carbapenem agent as the initial empirical treatment. When Gram-positive pathogens are isolated in pancreatic samples, vancomycin can be used alone or associated with a carbapenem. Currently, prophylactic antibiotic therapy for IPN is not supported by the scientific evidence, since both the best quality studies (double-blind) and the latest meta-analysis published have found no benefit of the use of this strategy.
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Affiliation(s)
- Enrique de-Madaria
- Unidad de Gastroenterología, Hospital General Universitario de Alicante, Alicante, España.
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Schenker S, Montalvo R. Alcohol and the pancreas. RECENT DEVELOPMENTS IN ALCOHOLISM : AN OFFICIAL PUBLICATION OF THE AMERICAN MEDICAL SOCIETY ON ALCOHOLISM, THE RESEARCH SOCIETY ON ALCOHOLISM, AND THE NATIONAL COUNCIL ON ALCOHOLISM 1998; 14:41-65. [PMID: 9751942 DOI: 10.1007/0-306-47148-5_3] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Alcoholic pancreatitis may be one of the most serious adverse consequences of alcohol abuse. Its diagnosis, as it has for many years, depends primarily on clinical acumen in interpreting properly the symptoms and signs of abdominal distress, buttressed by elevated pancreatic enzymes (amylase and lipase). More recently, the use of computerized tomography (CT) in selected situations has been both of confirmatory and prognostic value. Severity of abnormality by CT correlates reasonably well with a variety of clinical-laboratory clusters (APACHE system, Ranson's criteria, etc.) and aids in therapy. The pathogenesis of alcoholic pancreatitis is not fully defined. The ultimate picture is one of tissue autolysis by activated proteolytic enzymes. The triggers for such activation, however, are still not known. They are represented by three main theories: (1) large duct obstruction and/or increased permeability relative to pancreatic secretion, (2) small duct obstruction due to proteinaceous precipitates, and (3) a direct toxic-metabolic effect of ethanol on pancreatic acinar cells. While not mutually exclusive, we favor the last hypothesis as being most consistent with the effects of ethanol on other organ systems. The direct effects of ethanol and/or its metabolites may be mediated, at least in part, via oxidative stress or the generation of fatty acid ethyl esters. Autolysis (regardless of proximate mechanism(s)) leads to inflammation likely mediated via release of various cytokines. It also should be appreciated that "acute" pancreatitis (the topic of this chapter) likely represents an acute process within a chronic pancreatic exposure and injury from alcoholic abuse. The key question of why pancreatitis develops in only a small number of alcohol abusers is not resolved. Therapy depends on the severity of alcoholic pancreatitis, which is defined by clinical-laboratory and often CT criteria. Mild pancreatitis usually resolves acutely with alcohol abstention and supportive therapy. Severe pancreatitis has a significant morbidity and mortality, mainly related to the degree of pancreatic necrosis and infection. It requires meticulous combined medical-surgical care.
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Affiliation(s)
- S Schenker
- Department of Medicine, University of Texas Health Science Center at San Antonio 78284-7878, USA
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