Use of antibiotics in acute pancreatitis: ten major concerns

Relevance of Procalcitonin Levels as a Marker of Severity and Predictor of Mortality, Initiation and Duration of Antibiotics in Patients Admitted with Acute Pancreatitis: A Retrospective Cohort Study

Introduction

Procalcitonin levels have been studied to predict the benefit of adding antibiotics in a patient with acute pancreatitis. Through this study, we are searching for any possible correlation between serum procalcitonin levels and the severity of acute pancreatitis (included acute on chronic cases) to determine whether procalcitonin levels can predict a benefit from antibiotic therapy in acute pancreatitis.

Methods

This is a retrospective cohort study involving patients with acute pancreatitis and acute on chronic pancreatitis. We included all hospitalized patients admitted to Kern Medical from January 2020 to October 2022 with a diagnosis of acute pancreatitis in a consecutive manner. The primary outcome studied was mortality related to the pancreatitis episode. Logistic regression was used to control numerous confounders.

Results

Based on univariate analysis of procalcitonin, we found starting antibiotics on the day of admission statistically significant. We also found the median differences in mortality to be mildly significant (difference = 0.79, p = 0.0640) based on procalcitonin values. In a multivariate analysis of ln(procalcitonin), we found lipase (p = 0.0249), duration of antibiotics (p = 0.0009), multi-organ failure (p = 0.0045) to be statistically significant, and lactate being mildly significant in the multivariate model (p = 0.0643).

Conclusion

The procalcitonin level can predict the initiation of antibiotics, duration of antibiotics, multi-organ failure, and mortality in patients with acute pancreatitis.

Antibiotic Utilization in Acute Pancreatitis: A Narrative Review

Acute pancreatitis is a complex inflammatory disease with significant morbidity and mortality. Despite advances in its management, the role of antibiotics in the prophylaxis and treatment of acute pancreatitis remains controversial. The aim of this comprehensive review is to analyze current evidence on the use of antibiotics in acute pancreatitis, focusing on prophylactic and therapeutic strategies. Prophylactic use aims to prevent local and systemic infections. However, recent studies have questioned the routine use of antibiotics for prophylaxis and highlighted the potential risks of antibiotic resistance and adverse effects. In selected high-risk cases, such as infected necrotizing pancreatitis, prophylactic antibiotic therapy may still be beneficial. As for therapeutic use, antibiotics are usually used to treat infected pancreatic necrosis and extrapancreatic infections. When selecting an antibiotic, the microbiologic profile and local resistance patterns should be considered. Combination therapy with broad-spectrum antibiotics is often recommended to cover both Gram-positive and Gram-negative pathogens. Recent research has highlighted the importance of individualized approaches to antibiotic use in acute pancreatitis and underscored the need for a tailored approach based on patient-specific factors. This review also highlights the potential role of new antimicrobial agents and alternative strategies, such as probiotics, in the management of acute pancreatitis.

Characteristics and risk factors for extrapancreatic infection in patients with moderate or severe acute pancreatitis

Background

How to detect acute pancreatitis (AP) complicated with infection early and how to arrange the treatment time are still the main problems in the world. There are few reports on the potential relationship between extrapancreatic infections and AP. The purpose of this article was to investigate the characteristics, influencing factors and prognosis of extrapancreatic infection in AP patients with modified Marshall score ≥2 on admission.

Materials and methods

We retrospectively analyzed AP admitted to emergency intensive care unit of Ruijin hospital within 72 h of onset from September 2019 to December 2021. In addition to the patients' baseline data, sites of infection and microorganisms outside the pancreas were collected. Microbial cultures were used to identify infections of the respiratory tract, blood, abdominal cavity, biliary tract, urinary tract and clostridium difficile in feces.

Results

144 patients with AP were included, of which extrapancreatic infection accounted for 40.28%. C-reactive protein, procalcitonin, blood urea nitrogen, serum creatinine, oxygenation index, modified Marshall score, BISAP score and APACHE II score were significantly increased in the extrapancreatic infection group. The risk factors of extrapancreatic infection included blood urea nitrogen, Modified Marshall score and duration of mechanical ventilation. The positive rates of pathogenic bacteria in sputum culture, blood culture, ascites culture and bile culture were significantly higher than those in the 1-3 days after admission. The infection begins to worsen as early as 4-7 days after the onset of symptoms. Extrapancreatic infection is associated with pancreatic necrosis, the rate of laparotomy, length of hospital stay and in-hospital mortality.

Conclusion

Our research has confirmed the need to prevent and monitor extrapancreatic infection in the early stage.

Abdominal Compartment Syndrome in Acute Pancreatitis: A Narrative Review

Abdominal compartment syndrome (ACS) represents a severe complication of acute pancreatitis (AP), resulting from an acute and sustained increase in abdominal pressure >20 mmHg, in association with new organ dysfunction. The harmful effect of high intra-abdominal pressure on regional and global perfusion results in significant multiple organ failure and is associated with increased morbidity and mortality. There are several deleterious consequences of elevated intra-abdominal pressure on end-organ function, including respiratory, cardiovascular, gastrointestinal, neurologic, and renal effects. It is estimated that about 15% of patients with severe AP develop intra-abdominal hypertension or ACS, with a mortality rate around 50%. The treatment of abdominal compartment syndrome in acute pancreatitis begins with medical intervention and percutaneous drainage, where possible. Abdominal compartment syndrome unresponsive to conservatory treatment requires immediate surgical decompression, along with vacuum-assisted closure therapy techniques, followed by early abdominal fascia closure.

Advances in research of early use of prophylactic antibiotics in severe acute pancreatitis

Severe acute pancreatitis (SAP) is a common critical digestive system disease with high mortality, which can lead to multiple organ failure. SAP is often accompanied by massive necrosis of the pancreas, which is prone to secondary infection. Infected pancreatic necrosis is associated with an increased mortality of SAP. Whether early prophylactic use of antibiotics in the treatment of SAP can reduce the incidence of secondary infection is still controversial. This paper reviews the research progress of prophylactic use of antibiotics in the treatment of secondary infection of SAP in recent years.

Comparison of Protein Carbonyl (PCO), Paraoxonase-1 (PON1) and C-Reactive Protein (CRP) as Diagnostic and Prognostic Markers of Septic Inflammation in Dogs

Reliable diagnostic and prognostic markers of sepsis are lacking, but essential in veterinary medicine. We aimed to assess the accuracy of C-Reactive Protein (CRP), protein carbonyls (PCO) and paraoxonase-1 (PON1) in differentiating dogs with sepsis from those with sterile inflammation and healthy ones, and predict the outcome in septic dogs. These analytes were retrospectively evaluated at admission in 92 dogs classified into healthy, septic and polytraumatized. Groups were compared using the Kruskal–Wallis test, followed by a Mann–Whitney U test to assess differences between survivors and non-survivors. Correlation between analytes was assessed using the Spearman’s test, and their discriminating power was assessed through a Receiver Operating Characteristic (ROC) curve. PON1 and CRP were, respectively, significantly lower and higher in dogs with sepsis compared with polytraumatized and clinically healthy dogs (p < 0.001 for both the analytes), and also in dogs with trauma compared with healthy dogs (p = 0.011 and p = 0.017, respectively). PCO were significantly increased in septic (p < 0.001) and polytraumatized (p < 0.005) as compared with healthy dogs. PON1 and CRP were, respectively, significantly lower and higher in dogs that died compared with survivors (p < 0.001 for both analytes). Ultimately, evaluation of CRP and PON1 at admission seems a reliable support to diagnose sepsis and predict outcomes.