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Otsuka Y, Hara A, Minaga K, Sekai I, Kurimoto M, Masuta Y, Takada R, Yoshikawa T, Kamata K, Kudo M, Watanabe T. Leucine-rich repeat kinase 2 promotes the development of experimental severe acute pancreatitis. Clin Exp Immunol 2023; 214:182-196. [PMID: 37847786 PMCID: PMC10714192 DOI: 10.1093/cei/uxad106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 08/10/2023] [Accepted: 09/08/2023] [Indexed: 10/19/2023] Open
Abstract
Translocation of gut bacteria into the pancreas promotes the development of severe acute pancreatitis (SAP). Recent clinical studies have also highlighted the association between fungal infections and SAP. The sensing of gut bacteria by pattern recognition receptors promotes the development of SAP via the production of proinflammatory cytokines; however, the mechanism by which gut fungi mediate SAP remains largely unknown. Leucine-rich repeat kinase 2 (LRRK2) is a multifunctional protein that regulates innate immunity against fungi via Dectin-1 activation. Here, we investigated the role of LRRK2 in SAP development and observed that administration of LRRK2 inhibitors attenuated SAP development. The degree of SAP was greater in Lrrk2 transgenic (Tg) mice than in control mice and was accompanied by an increased production of nuclear factor-kappaB-dependent proinflammatory cytokines. Ablation of the fungal mycobiome by anti-fungal drugs inhibited SAP development in Lrrk2 Tg mice, whereas the degree of SAP was comparable in Lrrk2 Tg mice with or without gut sterilization by a broad range of antibiotics. Pancreatic mononuclear cells from Lrrk2 Tg mice produced large amounts of IL-6 and TNF-α upon stimulation with Dectin-1 ligands, and inhibition of the Dectin-1 pathway by a spleen tyrosine kinase inhibitor protected Lrrk2 Tg mice from SAP. These data indicate that LRRK2 activation is involved in the development of SAP through proinflammatory cytokine responses upon fungal exposure.
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Affiliation(s)
- Yasuo Otsuka
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Akane Hara
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Kosuke Minaga
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Ikue Sekai
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Masayuki Kurimoto
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Yasuhiro Masuta
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Ryutaro Takada
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Tomoe Yoshikawa
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Ken Kamata
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Tomohiro Watanabe
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Osaka, Japan
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2
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Otsuka Y, Kamata K, Minaga K, Watanabe T, Kudo M. Pancreatic colonization of fungi in the development of severe acute pancreatitis. Front Cell Infect Microbiol 2022; 12:940532. [PMID: 35967861 PMCID: PMC9372468 DOI: 10.3389/fcimb.2022.940532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 07/11/2022] [Indexed: 11/13/2022] Open
Abstract
Acute pancreatitis is a common emergent disorder, a significant population of which develops the life-threatening condition, called severe acute pancreatitis (SAP). It is generally accepted that bacterial infection is associated with the development and persistence of SAP. In addition to bacterial infection, recent clinical studies disclosed a high incidence of fungal infection in patients with SAP. Moreover, SAP patients with fungal infection exhibit a higher mortality rate than those without infection. Although these clinical studies support pathogenic roles played by fungal infection in SAP, beneficial effects of prophylactic anti-fungal therapy on SAP have not been proved. Here we summarize recent clinical findings as to the relationship between fungal infection and the development of SAP. In addition, we discuss molecular mechanisms accounting for the development of SAP in the presence of fungal infection.
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Affiliation(s)
| | - Ken Kamata
- *Correspondence: Ken Kamata, ; Tomohiro Watanabe,
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3
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Ning C, Zhu S, Zhou S, Lin C, Li J, Cao X, Bonsu AAFK, Shen D, Liu Z, Huang G. Multiple organ failure might be an indication for prophylactic antifungal therapy in acute pancreatitis. Infection 2021; 49:769-774. [PMID: 33988828 DOI: 10.1007/s15010-021-01625-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 05/03/2021] [Indexed: 12/28/2022]
Abstract
PURPOSE Significant conflicts regarding prophylactic antifungal treatment in acute pancreatitis (AP) exist among current literatures and guidelines. The key to resolving this controversial issue is to identify risk factors for intra-abdominal fungal infection (AFI) among patients with AP. METHODS A single-center, retrospective cohort of 826 patients with AP between January 2014 to December 2019 was analysed to study the risk factors of AFI. RESULTS Of the 826 patients with AP, 10 patients (1.2%) developed AFI, including 2 cases in moderately severe AP (MSAP) and 8 in severe AP (SAP). The incidence of AFI was significantly higher in patients with SAP compared with MSAP and mild AP (10.3 vs. 0.8% vs. 0, P < 0.001). SAP patients with AFI were more likely to have multiple organ failure (MOF) (OR = 13.4; 95% CI 1.6-115.5), organ failure lasting more than 1 week (OR = 5.1; 95% CI 1.0-27.0), and surgical intervention within first week of admission (OR = 7.4; 95% CI 1.0-53.6). Multivariable analysis identified MOF (OR = 14.3; 95% CI 1.2-173.8) as the only independent risk factor of AFI. CONCLUSION MOF might be the indication of prophylactic antifungal therapy in patients with AP.
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Affiliation(s)
- Caihong Ning
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, 87 Xiangya Rd, Changsha, 410008, Hunan, People's Republic of China.,Department of General Surgery, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Shuai Zhu
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, 87 Xiangya Rd, Changsha, 410008, Hunan, People's Republic of China.,Department of General Surgery, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Shuyi Zhou
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, 87 Xiangya Rd, Changsha, 410008, Hunan, People's Republic of China.,Department of General Surgery, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Chiayen Lin
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, 87 Xiangya Rd, Changsha, 410008, Hunan, People's Republic of China.,Department of General Surgery, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Jiarong Li
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, 87 Xiangya Rd, Changsha, 410008, Hunan, People's Republic of China.,Department of General Surgery, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Xintong Cao
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, 87 Xiangya Rd, Changsha, 410008, Hunan, People's Republic of China.,Department of General Surgery, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Abdul Aziz F K Bonsu
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, 87 Xiangya Rd, Changsha, 410008, Hunan, People's Republic of China.,Department of General Surgery, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Dingcheng Shen
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, 87 Xiangya Rd, Changsha, 410008, Hunan, People's Republic of China.,Department of General Surgery, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Zhiyong Liu
- Department of Intensive Care, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China
| | - Gengwen Huang
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, 87 Xiangya Rd, Changsha, 410008, Hunan, People's Republic of China. .,Department of General Surgery, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China. .,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, 410008, Hunan, China.
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4
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Ning C, Zhu S, Wei Q, Liu Z, Lin C, Li J, Cao X, Bonsu AAFK, Shen D, Peng M, Huang G. Candidemia indicates poor outcome in patients with infected pancreatic necrosis. Mycoses 2021; 64:684-690. [PMID: 33694198 DOI: 10.1111/myc.13266] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 03/01/2021] [Accepted: 03/08/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND Intra-abdominal fungal infection (AFI) and candidemia are common in patients with acute pancreatitis (AP), but with limited and conflicting reports on their clinical impacts. This study aims to evaluate the clinical impacts of AFI and candidemia in infected pancreatic necrosis (IPN). METHODS A single-centre, prospective cohort including 235 consecutive patients with IPN between January 2010 and September 2020 was analysed to study the clinical impacts of AFI and candidemia. RESULTS Of the 235 patients with IPN, 69 patients (29.4%) developed AFI and 13 patients (5.5%) developed candidemia. AFI was associated with higher intestinal leakage rate (27.5% vs 12.7%, P = .006), higher pancreatic fistula rate (53.6% vs 34.3%, P = .006) and longer hospital stays (72 vs 58 days, P = .003), but with similar mortality rate compared with patients without AFI (23.2% vs 24.7%, P = .806). However, candidemia was associated with significantly higher mortality rate compared with patients without candidemia (69.2% vs 21.6%, P < .001). Patients with candidemia had higher rate of multiple organ failure and AFI (69.2% vs 36.5%, P = .018; 69.2% vs 27.0%, P = .001, respectively). Multivariable analysis showed that age ≥ 50 years (OR = 2.8; 95% CI, 1.3-5.8; P = .007), severe category (OR = 11.2; 95% CI, 3.5-35.7; P < .001), multidrug-resistant organisms infection (OR = 2.5; 95% CI, 1.0-6.2; P = .039), candidemia (OR = 11.8; 95% CI, 2.5-56.5; P = .002), step-down surgical approach (OR = 3.2; 95% CI, 1.5-7.0; P = .004) were the independent predictors associated with higher mortality in IPN patients. CONCLUSION Although AFI did not increase the mortality of IPN, patients with candidemia carried significantly higher mortality.
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Affiliation(s)
- Caihong Ning
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, Changsha, China.,Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Shuai Zhu
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, Changsha, China.,Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Qin Wei
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, Changsha, China.,Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Zhiyong Liu
- Department of Intensive Care, Xiangya Hospital, Central South University, Changsha, China
| | - Chiayen Lin
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, Changsha, China.,Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Jiarong Li
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, Changsha, China.,Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Xintong Cao
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, Changsha, China.,Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Abdul Aziz F K Bonsu
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, Changsha, China.,Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Dingcheng Shen
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, Changsha, China.,Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
| | - Milin Peng
- Department of Intensive Care, Xiangya Hospital, Central South University, Changsha, China
| | - Gengwen Huang
- Department of Pancreatic Surgery, Xiangya Hospital, Central South University, Changsha, China.,Department of General Surgery, Xiangya Hospital, Central South University, Changsha, China.,National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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5
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Pancreatic Fungal Infection in Patients With Necrotizing Pancreatitis: A Systematic Review and Meta-analysis. J Clin Gastroenterol 2021; 55:218-226. [PMID: 33252558 DOI: 10.1097/mcg.0000000000001467] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/11/2020] [Indexed: 12/24/2022]
Abstract
GOAL The goal of this study was to study the incidence of fungal infection in necrotizing pancreatitis (NP) and its impact on mortality. BACKGROUND Infected pancreatic necrosis is a major contributor to morbidity and mortality in patients with NP. While pancreatic fungal infection (PFI) has frequently been identified in patients with NP, its effect on the clinical outcomes is unclear. MATERIALS AND METHODS A literature search was performed in Medline (Ovid), Embase (Ovid), and the Cochrane library. All prospective and retrospective studies that examined the incidence of fungal infection in NP with subgroup mortality data were included. For fungal infection of NP, studies with fungal isolation from pancreatic necrotic tissue were included. Newcastle Ottawa Scale and Joanna Briggs Institute's critical appraisal tool were used for bias assessment. RESULTS Twenty-two studies comprising 2151 subjects with NP were included for the quantitative analysis. The mean incidence of fungal infection was 26.6% (572/2151). In-hospital mortality in the pooled sample of NP patients with PFI (N=572) was significantly higher [odds ratio (OR)=3.95, 95% confidence interval (CI): 2.6-5.8] than those without PFI. In a separate analysis of 7 studies, the mean difference in the length of stay between those with and without fungal infection was 22.99 days (95% CI: 14.67-31.3). The rate of intensive care unit admission (OR=3.95; 95% CI: 2.6-5.8), use of prophylactic antibacterials (OR=2.76; 95% CI: 1.31-5.81) and duration of antibacterial therapy (mean difference=8.71 d; 95% CI: 1.33-16.09) were all significantly higher in patients with PFI. Moderate heterogeneity was identified among the studies on estimating OR for mortality (I2=43%) between the 2 groups. CONCLUSIONS PFI is common in patients with NP and is associated with increased mortality, intensive care unit admission rate, and length of stay. Further prospective studies are needed to better understand the pathophysiology of PFIs and to determine the role for preemptive therapeutic strategies, such as prophylactic antifungal therapy.
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Prevention of Infectious Complications in Acute Pancreatitis: Results of a Single-Center, Randomized, Controlled Trial. Pancreas 2019; 48:1056-1060. [PMID: 31404018 DOI: 10.1097/mpa.0000000000001368] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES This study aimed to investigate the efficiency of imipenem to prevent infectious complications in predicted severe acute pancreatitis (AP). METHODS Consecutive AP patients were randomized to imipenem 3 × 500 mg intravenously daily or an identical placebo. Exclusion criteria were prior AP, chronic pancreatitis, active malignancy, immune deficiency, active infection, concomitant antibiotic treatment, pregnancy, and patients younger than 18 years. Infectious complications including infected pancreatic necrosis, pneumonia, urinary tract infection, positive blood cultures, sepsis, and other infections were assessed as the primary outcome. Secondary outcomes included mortality, persistent organ failure, systemic inflammatory response syndrome, local complications, serious adverse events, and need for surgical intervention. RESULTS Forty-nine patients were randomized to each group. Infectious complications were present in 10 versus 12 of 49 patients (relative risk [RR], 0.833; 95% confidence interval [CI], 0.398-1.747). There were no significant differences in infected pancreatic necrosis (RR, 1.5; 95% CI, 0.262-8.588), pneumonia (RR, 1.5; 95% CI, 0.262-8.588), urinary tract infection (RR, 0.6; 95% CI, 0.152-2.374), positive blood cultures (RR, 0.5; 95% CI, 0.047-5.336), sepsis (RR, 0.333; 95% CI, 0.036-3.095), and other (RR, 1.333; 95% CI, 0.315-5.648). We found no significant differences in secondary outcomes. CONCLUSIONS Concordantly to available evidence, there is currently no ground to support prophylactic use of antibiotics in predicted severe AP.
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7
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Rasch S, Mayr U, Phillip V, Schmid RM, Huber W, Algül H, Lahmer T. Increased risk of candidemia in patients with necrotising pancreatitis infected with candida species. Pancreatology 2018; 18:630-634. [PMID: 30017450 DOI: 10.1016/j.pan.2018.07.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 07/09/2018] [Accepted: 07/11/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES Candida infections are frequent in necrotising pancreatitis. Candidemia is associated with very high mortality and its risk due to infected pancreatic necrosis is unknown. So we aimed to assess potential risk factors and the risk of candidemia in necrotising pancreatitis. METHODS We retrospectively searched our clinical database for the diagnosis necrotising pancreatitis from 2007 till March 2017 and entered relevant information in a database for statistical analysis. RESULTS in total, 136 patients met the inclusion criteria. Candida infected pancreatic necrosis were found in 54 patients and 7 patients developed candidemia. Patients with Candida infected necrosis had a significantly higher in hospital mortality (35.2% versus 13.4%, p = 0.003). The highest mortality was observed in patients with candidemia (57.1% versus 20.2%, p = 0.042). Male gender (OR 0.32, CI 0.13-0.78, p = 0.013) and post-ERCP pancreatitis (OR 4.32, CI 1.01-18.36, p = 0.048) had a significant impact on the risk of Candida infections of pancreatic necrosis. Candidemia was significantly more frequent in patients with Candida infected necrosis (11.1% versus 1.2%, p = 0.016). Candida albicans was the most common species followed by Candida glabrata. CONCLUSION Candidemia is a relevant complication of necrotising pancreatitis and associated with high mortality. If patients do not respond to antibiotic therapy empiric antifungal therapy should be discussed.
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Affiliation(s)
- Sebastian Rasch
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, München, Germany.
| | - Ulrich Mayr
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, München, Germany
| | - Veit Phillip
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, München, Germany
| | - Roland M Schmid
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, München, Germany
| | - Wolfgang Huber
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, München, Germany
| | - Hana Algül
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, München, Germany
| | - Tobias Lahmer
- Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar, Technische Universität München, Ismaninger Straße 22, 81675, München, Germany
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8
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Zacharioudakis IM, Zervou FN, Mylonakis E. Use of T2MR in invasive candidiasis with and without candidemia. Future Microbiol 2018; 13:1165-1173. [PMID: 29792512 DOI: 10.2217/fmb-2018-0079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
The mortality associated with invasive candidiasis remains unacceptably high. The T2 magnetic resonance (T2MR) assay is a novel US FDA-approved molecular diagnostic assay for the diagnosis of candidemia that can rapidly detect the five most commonly isolated Candida spp. In clinical trials, T2MR has exhibited good clinical sensitivity and specificity. Potential benefits from the adoption of T2MR technology in the diagnostic and therapeutic algorithms for invasive candidiasis can arise from timely diagnosis of disease, increased case detection, tailored therapy and decrease in empiric antifungal treatment. As everyday clinical experience with the assay is evolving, we discuss the utility of T2MR in invasive candidiasis with and without candidemia based on the currently available evidence regarding its performance.
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Affiliation(s)
- Ioannis M Zacharioudakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Providence, RI 02903, USA.,Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Fainareti N Zervou
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Providence, RI 02903, USA.,Department of Medicine, Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
| | - Eleftherios Mylonakis
- Infectious Diseases Division, Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
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9
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Abstract
OBJECTIVES The knowledge about pathogens and their antibiotic susceptibility patterns is essential to select an appropriate antibiotic. METHODS We investigated the microbiological profile in pancreatic and extrapancreatic infections, and antibiotic sensitivity pattern in patients with acute pancreatitis. RESULTS Of 556 patients with acute pancreatitis, only 189 developed bacterial infection; however, bacteremia was present in 42 patients (7.6%). Culture-proven infected pancreatic necrotic collection was present in 161 patients (29%). Escherichia coli and Klebsiella pneumoniae were the most common organisms. Among the bacterial infection cohort, 164 patients developed multidrug-resistant bacterial infection. Infection with multidrug-resistant bacteria, especially at multiple sites, increased mortality. Nearly 50% of patients (n = 94) acquired extremely drug-resistant bacterial infection at some time and emerged as key reason for prolonged hospital and intensive care unit stay. Colistin resistance and tigecycline resistance were documented in 2.1% and 17.2% of the specimens at admission and in 4.6% and 21% of specimens during the hospital stay. Of 556 patients, 102 patients developed fungal infection and 28 patients had only fungal infection without bacterial infection. CONCLUSIONS Colistin and tigecycline are best reserved as last-resort antibiotics. Fungal infection was found to be associated with increased mortality, median hospital stay, and intensive care unit stay.
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10
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Mazuski JE, Tessier JM, May AK, Sawyer RG, Nadler EP, Rosengart MR, Chang PK, O'Neill PJ, Mollen KP, Huston JM, Diaz JJ, Prince JM. The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection. Surg Infect (Larchmt) 2017; 18:1-76. [PMID: 28085573 DOI: 10.1089/sur.2016.261] [Citation(s) in RCA: 321] [Impact Index Per Article: 45.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations. METHODS Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council. RESULTS This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included. SUMMARY The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.
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Affiliation(s)
- John E Mazuski
- 1 Department of Surgery, Washington University School of Medicine , Saint Louis, Missouri
| | | | - Addison K May
- 3 Department of Surgery, Vanderbilt University , Nashville, Tennessee
| | - Robert G Sawyer
- 4 Department of Surgery, University of Virginia , Charlottesville, Virginia
| | - Evan P Nadler
- 5 Division of Pediatric Surgery, Children's National Medical Center , Washington, DC
| | - Matthew R Rosengart
- 6 Department of Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Phillip K Chang
- 7 Department of Surgery, University of Kentucky , Lexington, Kentucky
| | | | - Kevin P Mollen
- 9 Division of Pediatric Surgery, Department of Surgery, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Jared M Huston
- 10 Department of Surgery, Hofstra Northwell School of Medicine , Hempstead, New York
| | - Jose J Diaz
- 11 Department of Surgery, University of Maryland School of Medicine , Baltimore, Maryland
| | - Jose M Prince
- 12 Departments of Surgery and Pediatrics, Hofstra-Northwell School of Medicine , Hempstead, New York
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11
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Baronia AK, Azim A, Ahmed A, Gurjar M, Marak RSK, Yadav R, Sharma P. Invasive Candidiasis in Severe Acute Pancreatitis: Experience from a Tertiary Care Teaching Hospital. Indian J Crit Care Med 2017; 21:40-45. [PMID: 28197050 PMCID: PMC5278589 DOI: 10.4103/0972-5229.198325] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background: Invasive candidiasis (IC) is associated with increased morbidity in severe acute pancreatitis (SAP). There is limited information regarding the predisposing factors, Candida species distribution and in vitro susceptibility. Methodology: Current data have been derived from a larger prospective nonintervention study conducted on 200 critically ill patients which was done to study the antifungal prescription practices, collect epidemiological data, and perform an external validation of risk prediction models for IC under senior research associateship program of Council of Scientific and Industrial Research New Delhi. Of these critically ill patients, thirty had SAP and were included for analysis. Results: There were 23 males and 7 females. Out of eight patients (27%) who developed IC, three had isolated candidemia, two had isolated deep-seated candidiasis while three had both candidemia and deep-seated candidiasis. SAP patients with IC had a longer duration of Intensive Care Unit stay, hospital stay, days on mechanical ventilation and duration of shock. Mortality was not different between SAP patients with or without IC. Conclusion: There is a high rate of Candida infection in SAP. More studies are needed to generate epidemiological data and develop antifungal stewardship in this subset of high-risk population.
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Affiliation(s)
- Arvind Kumar Baronia
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Afzal Azim
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Armin Ahmed
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Rungmei S K Marak
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Reema Yadav
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Preeti Sharma
- Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Abstract
OBJECTIVES This study aimed to evaluate the influence of fungal infection and antifungal treatment on outcome in patients with walled-off pancreatic necrosis (WON). METHODS A retrospective description of fungal infections in a cohort of consecutive patients undergoing endoscopic, transmural drainage and necrosectomy for WON, treated in a tertiary referral center was reviewed. RESULTS Between 2005 and 2013, fungal infection in WON was documented in 57 (46%) of 123 patients. The most common isolates at first positive culture were Candida albicans (55%) and Candida glabrata (20%). Thirty-nine (70%) patients were treated with antifungals after the first fungal finding. There was no significant difference in mortality (21% vs 13%, P = 0.517) or organ failure (34% vs 33%, P = 0.903) between the group treated with adequate antifungals after the first fungal finding compared to the group not treated or treated inadequately.The in-hospital mortality was 18% (10 patients). Concomitant fungemia was found in 6 patients, of which 3 died, as opposed to 7 with fungi in the necrosis only (50% vs 14%, P = 0.027). CONCLUSIONS This study demonstrates a high incidence and associated high in-hospital mortality of fungal infection in WON, thus emphasizing the importance of fungal infections in WON.
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Pappas PG, Kauffman CA, Andes DR, Clancy CJ, Marr KA, Ostrosky-Zeichner L, Reboli AC, Schuster MG, Vazquez JA, Walsh TJ, Zaoutis TE, Sobel JD. Clinical Practice Guideline for the Management of Candidiasis: 2016 Update by the Infectious Diseases Society of America. Clin Infect Dis 2016; 62:e1-50. [PMID: 26679628 PMCID: PMC4725385 DOI: 10.1093/cid/civ933] [Citation(s) in RCA: 1872] [Impact Index Per Article: 234.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 11/02/2015] [Indexed: 02/06/2023] Open
Abstract
It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. IDSA considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.
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Affiliation(s)
| | - Carol A Kauffman
- Veterans Affairs Ann Arbor Healthcare System and University of Michigan Medical School, Ann Arbor
| | | | | | - Kieren A Marr
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | | | - Thomas J Walsh
- Weill Cornell Medical Center and Cornell University, New York, New York
| | | | - Jack D Sobel
- Harper University Hospital and Wayne State University, Detroit, Michigan
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Barauskas G, Ignatavičius P, Vitkauskienė A, Pundzius J, Dambrauskas Ž. Impact of etiology on course and outcomes of severe acute pancreatitis. MEDICINA-LITHUANIA 2015; 51:167-172. [PMID: 28705479 DOI: 10.1016/j.medici.2015.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 04/24/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Since the influence of etiological factors on the course and outcomes of acute pancreatitis (AP) is not fully understood yet, the aim of the study was to compare the outcomes of alcoholic and biliary severe acute pancreatitis (SAP). MATERIALS AND METHODS We investigated 81 patients with alcoholic and biliary SAP. Demographic data, etiologic factors, severity scores, intra-abdominal pressure, imaging studies, interventions, and treatment outcomes were prospectively entered into specially maintained database and subsequently analyzed. RESULTS No statistically significant difference was observed in the prevalence of SAP in biliary and alcoholic AP groups (P=0.429). Although, in the biliary SAP group patients were predominantly elderly women (P=0.003), the total in-hospital stay was longer in alcoholic SAP patients (P=0.021). The abdominal compartment syndrome developed more frequently (P=0.041) and necrosectomy was more frequently performed in alcoholic SAP group (not statistically significant). Although not statistically significant, a lower mortality rate among biliary SAP patients (25.0% vs. 13.5%) was observed. CONCLUSIONS We defined a trend toward decreased incidence of infected necrosis in larger volume (≥30%) pancreatic necrosis, absence of abdominal compartment syndrome, lower rate of necrosectomies, shorter in-hospital stay, and an insignificantly reduced mortality rate in biliary SAP patients, indicating more favorable course of biliary SAP.
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Affiliation(s)
- Giedrius Barauskas
- Department of Surgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Povilas Ignatavičius
- Department of Surgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania; Laboratory of Surgical Gastroenterology, Institute for Digestive System Research, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Astra Vitkauskienė
- Department of Laboratory Medicine, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Juozas Pundzius
- Department of Surgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Žilvinas Dambrauskas
- Department of Surgery, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania; Laboratory of Surgical Gastroenterology, Institute for Digestive System Research, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania.
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15
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Abstract
OBJECTIVES Intra-abdominal fungal infections (AFIs) complicating acute pancreatitis arise in the context of pancreatic necrosis. Our goal was to determine which risk factors contribute to AFI in patients with acute pancreatitis. METHODS Records were reviewed from 479 nontransfer patients admitted to our medical center with acute pancreatitis from 1985 to 2009. Using multivariable regression models, we identified risk factors for AFI. RESULTS Of 479 patients admitted with acute pancreatitis, 17 patients were subsequently found to have an AFI and 3 of these patients died. The mean length of stay for patients with an AFI was 24 days, and 76% were admitted to the intensive care unit. The patients with AFI were more likely to have received prophylactic antibiotics on admission (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.2-2.3) and total parenteral nutrition within 7 days of admission (OR, 1.4; 95% CI, 1.1-1.7) or to have necrosis on CT scan within 7 days of admission (OR, 1.4; 95% CI, 1.1-1.7). Multivariable regression models identified admission antibiotic use (OR, 1.6; 95% CI, 1.4-1.8) as the strongest predictor of AFI. CONCLUSIONS Admission antibiotics are the biggest risk factor for the development of intra-AFIs in acute pancreatitis. Prophylactic antibiotics to prevent infected necrosis should therefore be discouraged.
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Barauskas G, Ignatavičius P, Vitkauskienė A, Pundzius J, Dambrauskas Ž. Impact of etiology on course and outcomes of severe acute pancreatitis. Medicina (B Aires) 2015; 51:167-172. [DOI: 10.1016/j.medici.2015.04.002 free article] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023] Open
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17
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Schmidt PN, Roug S, Hansen EF, Knudsen JD, Novovic S. Spectrum of microorganisms in infected walled-off pancreatic necrosis - impact on organ failure and mortality. Pancreatology 2014; 14:444-9. [PMID: 25266641 DOI: 10.1016/j.pan.2014.09.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Revised: 09/02/2014] [Accepted: 09/03/2014] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Data on the microbial spectrum in infected pancreatic necrosis are scarce. Only few studies have addressed this issue in a larger, consecutive group of patients treated by a standardized algorithm. Since 2005 endoscopic, transmural drainage and necrosectomy (ETDN) has been the treatment of choice for walled-off necrosis in our centre. The present study evaluated the microbial spectrum of infected pancreatic necrosis and the possible relationship between infected necrosis, organ failure, and mortality. Furthermore, we investigated whether the aetiology of pancreatitis, use of external drainage, and antibiotic treatment influenced the microbial findings. METHODS Retrospective review of medical charts on 78 patients who underwent ETDN in our tertiary referral centre between November 2005 and November 2011. RESULTS Twenty-four patients (31%) developed one or more organ failures, 23 (29%) needed treatment in the intensive care unit (ICU), and 9 (11%) died during hospital admission. The prevailing microbial findings at the index endoscopy were enterococci (45%), enterobacteriaceae (42%), and fungi (22%). There was a significant association between the development of organ failure (p < 0.001), need of treatment in ICU (p < 0.002), in-hospital mortality (p = 0.039) and infected necrosis at the time of index endoscopy. Enterococci (p < 0.0001) and fungi (p = 0.01) were found more frequently in patients who died during admission as compared to survivors. CONCLUSION Different microbes in pancreatic necrosis may influence the prognosis. We believe that a detailed knowledge on the microbial spectrum in necrotizing pancreatitis may be utilized in the treatment to improve the outcome.
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Affiliation(s)
- Palle N Schmidt
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Denmark.
| | - Stine Roug
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Denmark
| | - Erik F Hansen
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Denmark
| | - Jenny D Knudsen
- Department of Clinical Microbiology, Copenhagen University Hospital Hvidovre, Denmark
| | - Srdan Novovic
- Department of Gastroenterology and Gastrointestinal Surgery, Copenhagen University Hospital Hvidovre, Denmark
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18
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Abstract
PURPOSE OF REVIEW The clinical spectrum of intra-abdominal fungal infections has not been systematically analyzed in the literature. RECENT FINDINGS Even though intra-abdominal fungal infections have been recognized with increasing frequency in the recent years, most clinical experience is limited to case reports or uncontrolled case series. These infections are more common than clinically recognized disease. The clinical presentation varies broadly depending on the organism and host's immune status, but it is frequently severe, difficult to treat, and associated with significant morbimortality. Predisposing factors, clinical characteristics, and advances in the management are discussed. SUMMARY Intra-abdominal fungal infections are increasingly important in clinical practice. Early recognition and a combined treatment approach, usually consisting of surgical intervention and systemic antifungal therapy, are required for improved outcomes.
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19
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Montravers P, Boudinet S, Houissa H. Candida and severe acute pancreatitis: we won't be fooled again. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:137. [PMID: 23659783 PMCID: PMC3672704 DOI: 10.1186/cc12613] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Several studies have suggested a role of candida in infected cases of severe acute pancreatitis. This commentary reports high incidence and mortality rates of candida infection in this setting and demonstrates the value of the colonization index to detect patients at risk for fungal infection. These findings indicate the need to review the place of antifungal therapy and prophylaxis.
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20
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Rao C, Bhasin DK, Rana SS, Gupta R, Gautam V, Singh K. Implications of culture positivity in acute pancreatitis: does the source matter? J Gastroenterol Hepatol 2013; 28:887-92. [PMID: 23425090 DOI: 10.1111/jgh.12161] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/20/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND AIMS Sepsis is an important complication and cause of morbidity and mortality in acute pancreatitis (AP). The source of sepsis may be infected pancreatic and peripancreatic collections and/or necrosis or extrapancreatic including infections in the bloodstream or respiratory and urinary tracts. We studied the implications of the source of sepsis on various outcome parameters in AP like persistent organ failure (POF), length of hospital (LOH) stay, and mortality. METHODS A retrospective analysis of culture reports of AP patients was done, and the outcome parameters were recorded. RESULTS Three hundred fifty-seven patients (229 M; age: 40.3 ± 14.04 years) of AP who had detailed culture reports were included. Eighty-four (23.5%) patients had pancreatic (or peripancreatic) source (group 1), 52 (14.6%) patients had other (extrapancreatic) sources (group 2), 20 (5.6%) patients were noted to have positive cultures from sources, which were both pancreatic and extrapancreatic (combined) sources (group 3), while 201 patients had sterile cultures. POF was seen in 147 (48%) patients (group 1: 67.8%; group 2: 65%; group 3: 90%; group 4: 34% [P < 0.001]). The mean LOH stay was 22.1 ± 20.26 days (group 1: 30.2 ± 20.64 days; group 2: 26.4 ± 26.82 days; group 3: 47.3 ± 32.60 days; group 4: 15.2 ± 11.34 days [P < 0.001]). Seventy (19.7%) patients succumbed to their illness (group 1 [22.9%]; group 2 [36.5%]; group 3 [40%]; group 4 [12%] [P < 0.001]). CONCLUSIONS POF and LOH stay were more common in patients with combined pancreatic and extrapancreatic sources of sepsis. Mortality was significantly higher in patients with sepsis (groups 1, 2, 3) compared with sterile groups.
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Affiliation(s)
- Chalapathi Rao
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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21
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Hall AM, Poole LAL, Renton B, Wozniak A, Fisher M, Neal T, Halloran CM, Cox T, Hampshire PA. Prediction of invasive candidal infection in critically ill patients with severe acute pancreatitis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R49. [PMID: 23506945 PMCID: PMC3733433 DOI: 10.1186/cc12569] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 03/08/2013] [Indexed: 11/24/2022]
Abstract
Introduction Patients with severe acute pancreatitis are at risk of candidal infections
carrying the potential risk of an increase in mortality. Since early diagnosis is
problematic, several clinical risk scores have been developed to identify patients
at risk. Such patients may benefit from prophylactic antifungal therapy while
those patients who have a low risk of infection may not benefit and may be harmed.
The aim of this study was to assess the validity and discrimination of existing
risk scores for invasive candidal infections in patients with severe acute
pancreatitis. Methods Patients admitted with severe acute pancreatitis to the intensive care unit were
analysed. Outcomes and risk factors of admissions with and without candidal
infection were compared. Accuracy and discrimination of three existing risk scores
for the development of invasive candidal infection (Candida score, Candida
Colonisation Index Score and the Invasive Candidiasis Score) were assessed. Results A total of 101 patients were identified from 2003 to 2011 and 18 (17.8%) of these
developed candidal infection. Thirty patients died, giving an overall hospital
mortality of 29.7%. Hospital mortality was significantly higher in patients with
candidal infection (55.6% compared to 24.1%, P = 0.02). Candida
colonisation was associated with subsequent candidal infection on
multivariate analysis. The Candida Colonisation Index Score was the most accurate
test, with specificity of 0.79 (95% confidence interval [CI] 0.68 to 0.88),
sensitivity of 0.67 (95% CI 0.41 to 0.87), negative predictive value of 0.91 (95%
CI 0.82 to 0.97) and a positive likelihood ratio of 3.2 (95% CI 1.9 to 5.5). The
Candida Colonisation Index Score showed the best discrimination with area under
the receiver operating characteristic curve of 0.79 (95% CI 0.69 to 0.87). Conclusions In this study the Candida Colonisation Index Score was the most accurate and
discriminative test at identifying which patients with severe acute pancreatitis
are at risk of developing candidal infection. However its low sensitivity may
limit its clinical usefulness.
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Zhou M, Chen B, Sun H, Chen X, Yu Z, Shi H, Yao J, Xu Z, Zhang Q, Andersson R. The efficiency of continuous regional intra-arterial infusion in the treatment of infected pancreatic necrosis. Pancreatology 2013; 13:212-5. [PMID: 23719590 DOI: 10.1016/j.pan.2013.02.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Revised: 02/15/2013] [Accepted: 02/16/2013] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Our aim was to investigate the efficiency of continuous regional intra-arterial infusion (CRAI) with antisecretory agents and antibiotics in the treatment of infected pancreatic necrosis. MATERIALS AND METHODS CRAI was used as a new clinical technique to treat acute pancreatitis patients during a 4-year period at the First Affiliated Hospital, Wenzhou Medical College, China. In this retrospective study, thirty-four patients with proven infected pancreatic necrosis were included. Twelve patients were treated with CRAI, and were matched according to age, sex, APACHE II scores, Ranson scores and remote organ dysfunction, with 22 patients with IPN treated surgically. The clinical outcome following surgery and CRAI were compared. RESULTS No difference was found between the two groups when comparing age, gender, APACHE II scores, Ranson scores and remote organ dysfunction (p > 0.05). The patients treated with CRAI had a lower incidence of complications (33.3% vs 72.7%), duration of hospitalization (27.1 ± 4.7 days vs 43.0 ± 12.0 days) and cost of hospitalization (4.09 ± 1.64 thousand RMB vs 8.77 ± 3.74 thousand RMB) as compared to patients treated with surgery (p < 0.05). The survival rate was significantly higher in the CRAI group as compared to the surgical group (91.7% vs 63.6%; p < 0.01). However, the two groups had similar rates of concomitant operative treatment and incidence of remote organ dysfunction (p > 0.05). CONCLUSIONS CRAI or CRAI in combination with abscess drainage seemingly improve the clinical outcome in patients with infected pancreatic necrosis. Further confirmative prospective randomized multicenter studies are warranted prior to broad introduction of the CRAI concept.
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Affiliation(s)
- Mengtao Zhou
- Department of Surgery, The First Affiliated Hospital, Wenzhou Medical College, 2 Fuxue Lane, Wenzhou, Zhejiang Province, China.
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Abstract
Intra-abdominal infections of pancreatic or peripancreatic necrotic tissue complicate the clinical course of severe acute pancreatitis (SAP) and are associated with significant morbidity. Fungal infection of necrotic pancreatic tissue is increasingly being reported. The incidence of intra-abdominal pancreatic fungal infection (PFI) varies from 5% to 68.5%. Candida albicans is the most frequently isolated fungus in patients with necrotizing pancreatitis. Prolonged use of prophylactic antibiotics, prolonged placement of chronic indwelling devices, and minimally invasive or surgical interventions for pancreatic fluid collections further increase the risk of PFI. Computed tomography- or ultrasound-guided fine-needle aspiration of pancreatic necrosis is a safe, reliable method for establishing pancreatic infection. Amphotericin B appears to be the most effective antifungal treatment. Drainage and debridement of infected necrosis are also critical for eradication of fungi from the poorly perfused pancreatic or peripancreatic tissues where the antifungal agents may not reach to achieve therapeutic levels. Fungal infection adversely affects the outcome of patients with SAP and is associated with increased morbidity, although the mortality rate is not increased specifically because of PFI. Although antifungal prophylaxis has been suggested for patients on broad-spectrum antibiotics, no randomized controlled trials have yet studied its efficacy in preventing PFI.
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Abstract
Severe acute pancreatitis (SAP) is associated with significant morbidity and mortality. The majority of deaths related to SAP are the result of infectious complications. Although bacterial infections are most commonly encountered, fungal infections are increasingly being recognized. Candida is the most common fungal infection. The occurrence of fungal infection in patients with acute pancreatitis adversely affects the clinical course, leading to a higher incidence of systemic complications, and possibly mortality as well. Important risk factors for fungal infection in patients with acute pancreatitis include broad-spectrum antibiotics, prolonged hospitalization and surgical/endoscopic interventions, use of total parenteral nutrition, and mechanical ventilation. Patients with higher severity of pancreatitis are at a greater risk. The pathogenesis of fungal infection in patients with acute pancreatitis is multifactorial. Translocation of microorganisms across the gut epithelium, lymphocyte dysfunction, and the virulence of the invading microorganisms play important roles. Histological demonstration of fungi remains the gold standard of diagnosis, but a positive biopsy is rarely obtained. The role of biomarkers in the diagnosis is being investigated. As early diagnosis and treatment can lead to improved outcome, a high index of suspicion is required for prompt diagnosis. Limiting the use of broad-spectrum antibiotics, early introduction of enteral nutrition, and timely change of vascular catheters are important preventive strategies. The role of antifungal prophylaxis remains controversial. Surgical necrosectomy with antifungal therapy is the most widely used treatment approach. Clinical trials on antifungal prophylaxis are needed, and indications for surgical intervention need to be clearly defined.
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Affiliation(s)
- Rakesh Kochhar
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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25
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Luo XP, Ye N, Xia BJ. Invasive fungal infection in patients with severe acute pancreatitis and respiratory failure: an analysis of 15 cases. Shijie Huaren Xiaohua Zazhi 2011; 19:1081-1084. [DOI: 10.11569/wcjd.v19.i10.1081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the clinical characteristics of invasive fungal infection (IFI) in patients with severe acute pancreatitis (SAP) and respiratory failure.
METHODS: The clinical data for patients with SAP and respiratory failure who were treated in ICU between June 2003 and September 2009 were retrospectively analyzed. Patients were divided into three groups according to body fluid culture results and clinical features: invasive fungal infection (IFI), bacterial infection (BI), and non-infection (NI). APACHE II score, length of mechanical ventilation (MV), intra-abdominal pressure, percentage of patients developing multiple organ dysfunction syndrome (MODS) three times or more, surgical intervention, continuous renal replacement therapy (CRRT), mortality, and time required to isolate pathogen were compared among the three groups. Affected regions and pathogen species distribution of IFI were also investigated.
RESULTS: IFI occurred in 27.27% (15/55) of patients with SAP and respiratory failure. Approximately 73.33% (11/15) of patients with IFI developed intra-abdominal fungal infection, with half of them (6/11) having ventilator-associated fungal pneumonia (VAFP). Compared to patients with BI and NI, patients with IFI had longer MV (19.53 d ± 4.88 d vs 14.14 d ± 4.26 d, 6.23 d ± 2.34 d, both P < 0.05), and higher rate of surgical intervention (86.67% vs 42.86%, 0.00%, both P < 0.05). Compared to patients with BI, the time required to isolate pathogen was longer in patients with IFI (10.13 d ± 2.59 d vs 5.14 d ± 2.21 d, P < 0.05) though they had similar mortality rate. Bacteria might be isolated before fungi were isolated in patients with intra-abdominal fungal infection and VAFP. Intra-abdominal fungal infection might be concomitant with enterococcal infection.
CONCLUSION: The abdomen is the main region affected by IFI in patients with SAP and respiratory failure. IFI patients often develop VAFP and concomitant bacteria infections. Appropriate management of intra-abdominal infection could improve poor prognosis in patients with SAP and respiratory failure.
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Abstract
Significant literature on the management of acute severe acute pancreatitis has emerged in recent years. The new information ranges from data on newer single or multiparameter severity assessment tools and classification systems to therapeutic modalities. However, a few basic issues-the ideal severity assessment modality, volume of intravenous fluids required in the first 48 to 72 h, and the role of prophylactic antibiotics-are still not clear and are subject to controversy. The International Working Group has devised the Revised Atlanta Classification, which will be published soon. This new classification is eagerly awaited worldwide, and hopefully clarifies many of the problems of the original Atlanta Classification. In this article, we discuss the developments that have arisen in the past 2 to 3 years concerning the classification, prognostication, and early management of severe acute pancreatitis.
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Affiliation(s)
- Rupjyoti Talukdar
- Miles and Shirley Fiterman Center for Digestive Diseases, 200 First Street SW, Mayo Clinic, Rochester, MN 55905, USA.
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27
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Abstract
Acute pancreatitis is a common cause for hospitalization that carries a substantial burden of disease in the United States and worldwide. Recent reports have encompassed a wide array of topics including new insights into the acinar cell pH microenvironment, signal pathways for acinar cell fate, and the innate immune response. Clinical researchers have reported new methods to assess disease severity, innovative techniques for management of local complications, the importance of early recognition of pancreatic or extrapancreatic infection, and prevention of disease recurrence. Recent data also suggest that specialized centers may be of benefit for the management of severe acute pancreatitis. This review summarizes a number of recent advances in basic and clinical science with an emphasis on findings that are relevant to clinicians who manage patients with acute pancreatitis.
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Affiliation(s)
- Bechien U Wu
- Center for Pancreatic Disease, Division of Gastroenterology, Hepatology, and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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28
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De Waele JJ. Use of antibiotics in severe acute pancreatitis. Expert Rev Anti Infect Ther 2010; 8:317-24. [PMID: 20192685 DOI: 10.1586/eri.10.3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Infectious complications in severe acute pancreatitis are an important problem and determine outcome in patients who survived the first inflammatory hit of the disease. Timely diagnosis of infected pancreatic necrosis is often challenging, but should not delay adequate treatment, which consists of source control and antibiotic treatment. Prophylactic antibiotics are not effective in reducing the incidence of (peri)pancreatic infection in patients with severe acute pancreatitis (or necrotizing pancreatitis). The only rational indication for antibiotics at this moment is documented infection. The spectrum of empiric antibiotics should cover both Gram-negative, Gram-positive and anaerobic microorganisms (also keeping in mind exposure to nosocomial microorganisms), and local ecology should be taken into account. Fungal infections are often present, and antifungal coverage should be considered, especially if multiple risk factors for invasive candidiasis are present. Currently, no tools are available to guide antimicrobial treatment.
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Affiliation(s)
- Jan J De Waele
- Department of Critical Care Medicine, Intensive Care Unit 1K12-C, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium.
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29
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Abstract
Our knowledge of acute pancreatitis is still far from complete and there is no unanimous agreement concerning the pathophysiological processes leading to typical alterations during the course of acute pancreatitis. We reviewed the paper published in the last decade on the pathophysiology and treatment of acute pancreatitis. It is difficult to translate the experimental therapeutic results into clinical practice. For example, lexipafant was efficacious in decreasing the severity and mortality of lethal pancreatitis in rats, but seems to have no effect on severe acute pancreatitis in humans. Thus, the main problem in acute pancreatitis, especially in the severe form of the disease, is the difficulty of designing clinical studies capable of giving reliable statistically significant answers regarding the benefits of the various proposed therapeutic agents previously tested in experimental settings. Thus, analgesia, supportive care, and treatment of the pulmonary and renal complications remain the cornerstones of the treatment of acute pancreatitis, especially in the severe form of the disease.
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Affiliation(s)
- Raffaele Pezzilli
- Ospedale Sant'Orsola-Malpighi, Dipartimento di Medicina Interna e Gastroenterologia, Bologna, Italy.
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Talukdar R, Vege SS. Recent developments in acute pancreatitis. Clin Gastroenterol Hepatol 2009; 7:S3-9. [PMID: 19896095 DOI: 10.1016/j.cgh.2009.07.037] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2009] [Revised: 07/25/2009] [Accepted: 07/28/2009] [Indexed: 02/07/2023]
Abstract
The incidence of acute pancreatitis (AP) has been increasing worldwide, but the major etiologies remain gallstones and alcohol. Several studies have reported that smoking is an independent risk factor for developing AP. Classification of AP has traditionally used the categories of mild and severe disease. However, a new intermediate category of moderately severe AP has been described with intermediate characteristics including a high incidence of local complications but a low mortality. Assessment criteria that can serve as early predictors of AP severity are often complex and not sufficiently accurate. However, several recently described criteria that rely on criteria such as the body mass index, physical findings, and simple laboratory measurements could prove useful if validated in large prospective studies. Many issues related to the therapy of AP are still unresolved. Although preliminary studies support the importance of early volume expansion for the treatment of acute pancreatitis, optimization of the amount and type of fluids will require further studies. Similarly, preliminary studies suggest that enteral nutrition might benefit patients with AP and could even be useful early in the course of disease. However, the timing and type of fluids as well as the intestinal infusion site require further study. Finally, issues related to the prophylactic use of antibiotics in patients with severe AP have not been resolved. While the process of clinical investigation moves slowly, progress has been made in clinical studies of AP.
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Affiliation(s)
- Rupjyoti Talukdar
- Miles and Shirley Fiterman Center for Digestive Diseases, Mayo Clinic, Rochester, Minnesota 55905, USA
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