Early prediction of infected pancreatic necrosis secondary to necrotizing pancreatitis

Construction and alidation of a severity prediction model for acute pancreatitis based on CT severity index: A retrospective case-control study

To construct and internally and externally validate a nomogram model for predicting the severity of acute pancreatitis (AP) based on the CT severity index (CTSI).A retrospective analysis of clinical data from 200 AP patients diagnosed at the Hefei Third Clinical College of Anhui Medical University from June 2019 to June 2022 was conducted. Patients were classified into non-severe acute pancreatitis (NSAP, n = 135) and severe acute pancreatitis (SAP, n = 65) based on final clinical diagnosis. Differences in CTSI, general clinical features, and laboratory indicators between the two groups were compared. The LASSO regression model was used to select variables that might affect the severity of AP, and these variables were analyzed using multivariate logistic regression. A nomogram model was constructed using R software, and its AUC value was calculated. The accuracy and practicality of the model were evaluated using calibration curves, Hosmer-Lemeshow test, and decision curve analysis (DCA), with internal validation performed using the bootstrap method. Finally, 60 AP patients treated in the same hospital from July 2022 to December 2023 were selected for external validation.LASSO regression identified CTSI, BUN, D-D, NLR, and Ascites as five predictive factors. Unconditional binary logistic regression analysis showed that CTSI (OR = 2.141, 95%CI:1.369-3.504), BUN (OR = 1.378, 95%CI:1.026-1.959), NLR (OR = 1.370, 95%CI:1.016-1.906), D-D (OR = 1.500, 95%CI:1.112-2.110), and Ascites (OR = 5.517, 95%CI:1.217-2.993) were independent factors influencing SAP. The established prediction model had a C-index of 0.962, indicating high accuracy. Calibration curves demonstrated good consistency between predicted survival rates and actual survival rates. The C-indexes for internal and external validation were 0.935 and 0.901, respectively, with calibration curves close to the ideal line.The model based on CTSI and clinical indicators can effectively predict the severity of AP, providing a scientific basis for clinical decision-making by physicians.

Dynamic nomogram for predicting infected pancreatic necrosis in female patients of childbearing age with hypertriglyceridemia-induced acute pancreatitis

BACKGROUND

Hypertriglyceridemia is a common cause of acute pancreatitis. Pregnant women are at risk of developing hypertriglyceridemia-induced acute pancreatitis (HTG-AP); however, whether pregnancy increases the risk of infected pancreatic necrosis (IPN) is unknown.

AIM

We aimed to assess the association between pregnancy and IPN.

METHODS

This 10-year retrospective cohort study was conducted at Jinling Hospital. Adult female patients of childbearing age with HTG-AP between January 2013 and September 2022 were screened. Logistic regression analyses were performed to assess the risk factors for IPN. Patients admitted within 7 days were assigned to the training and validation sets to develop a dynamic nomogram for IPN prediction.

RESULTS

489 patients were included, and 144 developed IPN. Logistic regression analyses revealed pregnancy (OR: 2.578 95% CI: 1.474-4.510) as an independent risk factor for IPN. Gestation weeks, ARDS, albumin level, and serum creatinine level were selected as the predictors of the dynamic nomogram for IPN prediction, with good discrimination in the training set (AUC 0.867 95% CI: 0.794-0.940) and validation set (AUC 0.957 95% CI: 0.885-1.000).

CONCLUSION

Pregnancy increases the risk of IPN in adult patients of childbearing age with HTG-AP, and the dynamic nomogram may help risk stratification for IPN.

Persistently High Procalcitonin and C-Reactive Protein Are Good Predictors of Infection in Acute Necrotizing Pancreatitis: A Systematic Review and Meta-Analysis

Infected necrotizing pancreatitis (INP) is associated with an increased risk of organ failure and mortality. Its early recognition and timely initiation of antibiotic therapy can save patients' lives. We systematically searched three databases on 27 October 2022. In the eligible studies, the presence of infection in necrotizing pancreatitis was confirmed via a reference test, which involved either the identification of gas within the necrotic collection through computed tomography imaging or the examination of collected samples, which yielded positive results in Gram staining or culture. Laboratory biomarkers compared between sterile necrotizing pancreatitis and INP were used as the index test, and our outcome measures included sensitivity, specificity, the receiver operating characteristic (ROC) curve and area under the ROC curve (AUC). Within the first 72 hours (h) after admission, the AUC of C-reactive protein (CRP) was 0.69 (confidence interval (CI): 0.62-0.76), for procalcitonin (PCT), it was 0.69 (CI: 0.60-0.78), and for white blood cell count, it was 0.61 (CI: 0.47-0.75). After the first 72 h, the pooled AUC of CRP showed an elevated level of 0.88 (CI: 0.75-1.00), and for PCT, it was 0.86 (CI: 0.60-1.11). The predictive value of CRP and PCT for infection is poor within 72 h after hospital admission but seems good after the first 72 h. Based on these results, infection is likely in case of persistently high CRP and PCT, and antibiotic initiation may be recommended.

One biomarker does not fit all: tailoring anti-infective therapy through utilization of procalcitonin and other specific biomarkers

INTRODUCTION

Considering the ongoing increase in antibiotic resistance, the importance of judicious use of antibiotics through reduction of exposure is crucial. Adding procalcitonin (PCT) and other biomarkers to pathogen-specific tests may help to further improve antibiotic therapy algorithms and advance antibiotic stewardship programs to achieve these goals.

AREAS COVERED

In recent years, several trials have investigated the inclusion of biomarkers such as PCT into clinical decision-making algorithms. For adult patients, findings demonstrated improvements in the individualization of antibiotic treatment, particularly for patients with respiratory tract infections and sepsis. While most trials were performed in hospitals with central laboratories, point-of-care testing might further advance the field by providing a cost-effective and rapid diagnostic tool in upcoming years. Furthermore, novel biomarkers including CD-64, presepsin, Pancreatic stone and sTREM-1, have all shown promising results for increased accuracy of sepsis diagnosis. Availability of these markers however is currently still limited and there is insufficient evidence for their routine use in clinical care.

EXPERT OPINION

In addition to new host-response markers, combining such biomarkers with pathogen-directed diagnostics present a promising strategy to increase algorithm accuracy in differentiating between bacterial and viral infections. Recent advances in microbiologic testing using PCR or nucleic amplification tests may further improve the diagnostic yield and promote more targeted pathogen-specific antibiotic therapy.

Prediction of infected pancreatic necrosis in acute necrotizing pancreatitis by the modified pancreatitis activity scoring system

OBJECTIVES

Infected pancreatic necrosis (IPN) is a significant complication of acute necrotizing pancreatitis (ANP). Early identification of patients at high risk of IPN would enable appropriate treatment, but there is a lack of valid tools. This study aimed to assess the performance of the Pancreatitis Activity Scoring System (PASS) and its modifications (by removing or reducing the weight of opioid usage) in predicting IPN in a cohort of predicted severe ANP patients.

METHODS

Data was prospectively collected in the TRACE trial (2017-2020) involving 16 sites across China. The predictive performance of PASS, modified PASS (mPASS), and conventional indices were assessed by the area under the receiver operating characteristic curve (AUC), Hosmer-Lemeshow Ĉ-test, Brier score, and Fagan's nomogram. Multivariate logistic regression analysis (MLRA) was used to define the relationship between the best-performing PASS/mPASS model and IPN.

RESULTS

A total of 508 subjects were enrolled (median age, 43 years; 62.8% males) in the original trial, and 122 developed IPN (24%) within 90 days after randomization. Compared with non-IPN patients, the scores of PASS and its modified models were significantly higher in the IPN patients (all p < 0.001). Among the PASS and its modifications, mPASS-4 had the largest AUC, the lowest Brier score, and good calibration. The mPASS-4 model demonstrated an AUC of 0.752 in predicting IPN (the optimal cut-off for the mPASS-4 was 292.5) and outperformed the conventional indices. The MLRA results showed that mPASS-4 >292.5 was an independent risk factor of IPN (OR: 3.6, 95% CI: 2.1-6.3).

CONCLUSION

The PASS and its modifications during the first week of ANP onset predict the development of IPN, with mPASS-4 performing best. The mPASS-4 model simplifies the original PASS, increasing the likelihood of clinical implementation.

Dynamics of Serum Procalcitonin Can Predict Outcome in Patients of Infected Pancreatic Necrosis: A Prospective Analysis

BACKGROUND

Timely intervention can alter outcome in patients of infected pancreatic necrosis (IPN) but lacks adequate biomarker. Role of serum procalcitonin (PCT) in the management of IPN is understudied, and hence, this study was planned.

METHODOLOGY

All patients of acute pancreatitis with IPN without prior intervention were included. Baseline demographic, radiological and laboratory parameters were documented. PCT was measured at baseline, prior to intervention, and thereafter every 72 h. Patients were grouped into those having baseline PCT < 1.0 ng/mL and those with PCT ≥ 1.0 ng/mL and various outcome measures were compared.

RESULTS

Of the 242 patients screened, 103 cases (66 males; 64.1%) with IPN were grouped into 2: PCT < 1.0 ng/mL (n = 29) and PCT ≥ 1.0 ng/mL (n = 74). Patients with baseline PCT ≥ 1.0 ng/mL had significantly more severe disease scores. 16 out of 19 patients with rise in PCT on day-7 post-intervention expired. PCT ≥ 1.0 ng/mL group had higher need for ICU (p = 0.001) and mortality (p = 0.044). PCT > 2.25 ng/mL (aOR 22.56; p = 0.013) at baseline and failure in reduction of PCT levels to < 60% of baseline at day-7 post-intervention (aOR 53.76; p = 0.001) were significant mortality predictors.

CONCLUSION

Baseline PCT > 1.0 ng/mL is associated with poor outcome. PCT > 2.25 ng/mL and failure in reduction of PCT levels to < 60% of its baseline at day-7 post-intervention can identify high-mortality risk patients.

A Rapid Prognostic Score Based on Bedside Arterial Blood Gas Analysis (ABG) Established for Predicting 60-Day Adverse Outcomes in Patients with Acute Pancreatitis in the Emergency Department

Objective

To establish a rapid and concise prognosis scoring system for pancreatitis in the emergency department based on bedside arterial blood gas analysis (ABG).

Methods

A single-center, retrospective cohort study was used to establish the new scoring system, and a validation group was used to verify it. The primary endpoint was 60-day death, and secondary endpoints were 28-day death, admission to the intensive care unit (AICU), requirement for mechanical ventilation (MV) and persistent organ failure (POF). Receiver operating characteristic (ROC) curves was drawn to validate the predictive value of the new scoring system. The performance of the new scoring system was compared with that of conventional predictive scoring.

Results

443 patients were in the derivation group and 217 patients in the validation group, of which 27 and 25 died during follow-up. A total of 443 patients in the derivation group, 27 of whom died during the follow-up period. Multivariate regression analysis showed that mental status, hematocrit (HCT), base excess (BE) and Serum ionic calcium (Ca²⁺) were independent risk factors for 60-day mortality of pancreatitis, and they were used to create a new scoring system (MHBC). In the derivation and validation, the ability of MHBC (AUC= 0.922, 0.773, respectively) to predict 60-day mortality from pancreatitis was no less than that of APACHE II (AUC= 0.838, 0.748, respectively) and BISAP (AUC= 0.791, 0.750, respectively), while, MHBC is more quickly and concisely than APACHE II and BISAP. Compared with MHBC less than or equal to 2, when MHBC is greater than 2, the 28-day mortality, 60-day mortality and the incidence of AICU, MV and POF increased significantly (P <0.001).

Conclusion

The MHBC can quickly and concisely evaluate the 60-day mortality, 28-day mortality, and the incidence of AICU, MV and POF of patients with acute pancreatitis in the emergency department.

Identification of early predictors for infected necrosis in acute pancreatitis

Background

In acute pancreatitis, secondary infection of pancreatic necrosis is a complication that mostly necessitates interventional therapy. A reliable prediction of infected necrotizing pancreatitis would enable an early identification of patients at risk, which however, is not possible yet.

Methods

This study aims to identify parameters that are useful for the prediction of infected necrosis and to develop a prediction model for early detection. We conducted a retrospective analysis from the hospital information and reimbursement data system and screened 705 patients hospitalized with diagnosis of acute pancreatitis who underwent contrast-enhanced computed tomography and additional diagnostic puncture or drainage of necrotic collections. Both clinical and laboratory parameters were analyzed for an association with a microbiologically confirmed infected pancreatic necrosis. A prediction model was developed using a logistic regression analysis with stepwise inclusion of significant variables. The model quality was tested by receiver operating characteristics analysis and compared to single parameters and APACHE II score.

Results

We identified a total of 89 patients with necrotizing pancreatitis, diagnosed by computed tomography, who additionally received biopsy or drainage. Out of these, 59 individuals had an infected necrosis. Eleven parameters showed a significant association with an infection including C-reactive protein, albumin, creatinine, and alcoholic etiology, which were independent variables in a predictive model. This model showed an area under the curve of 0.819, a sensitivity of 0.692 (95%-CI [0.547–0.809]), and a specificity of 0.840 (95%-CI [0.631–0.947]), outperforming single laboratory markers and APACHE II score. Even in cases of missing values predictability was reliable.

Conclusion

A model consisting of a few single blood parameters and etiology of pancreatitis might help for differentiation between infected and non-infected pancreatic necrosis and assist medical therapy in acute necrotizing pancreatitis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02490-9.

Indian College of Radiology and Imaging Consensus Guidelines on Interventions in Pancreatitis

Acute pancreatitis (AP) is one of the common gastrointestinal conditions presenting as medical emergency. Clinically, the severity of AP ranges from mild to severe. Mild AP has a favorable outcome. Patients with moderately severe and severe AP, on the other hand, require hospitalization and considerable utilization of health care resources. These patients require a multidisciplinary management. Pancreatic fluid collections (PFCs) and arterial bleeding are the most important local complications of pancreatitis. PFCs may require drainage when infected or symptomatic. PFCs are drained endoscopically or percutaneously, based on the timing and the location of collection. Both the techniques are complementary, and many patients may undergo dual modality treatment. Percutaneous catheter drainage (PCD) remains the most extensively utilized method for drainage in patients with AP and necrotic PFCs. Besides being effective as a standalone treatment in a significant proportion of these patients, PCD also provides an access for percutaneous endoscopic necrosectomy and minimally invasive necrosectomy. Endovascular embolization is the mainstay of management of arterial complications in patients with AP and chronic pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the percutaneous management of complications of pancreatitis.

Dynamic nomogram for persistent organ failure in acute biliary pancreatitis: Development and validation in a retrospective study

BACKGROUND

Persistent organ failure (POF) increases the risk of death in patients with acute biliary pancreatitis (ABP). Currently, there is no early risk assessment tool for POF in patients with ABP.

AIMS

To establish and validate a dynamic nomogram for predicting the risk of POF in ABP.

METHODS

This was a retrospective study of 792 patients with ABP, with 595 cases in the development group and 197 cases in the validation group. Least absolute shrinkage and selection operator regression screened the predictors of POF, and logistic regression established the model (P < 0.05). A dynamic nomogram showed the model. We evaluated the model's discrimination, calibration, and clinical effectiveness; used the bootstrap method for internal validation; and conducted external validation in the validation group.

RESULTS

Neutrophils, haematocrit, serum calcium, and blood urea nitrogen were predictors of POF in ABP. In the development group and validation group, the areas under the receiver operating characteristic curves (AUROCs) were 0.875 and 0.854, respectively, and the Hosmer-Lemeshow test (P > 0.05) and calibration curve showed good consistency between the actual and prediction probability. Decision curve analysis showed that the dynamic nomogram has excellent clinical value.

CONCLUSION

This dynamic nomogram helps with the early identification and screening of high-risk patients with POF in ABP.

Guidelines for the management of patients with severe acute pancreatitis, 2021

OBJECTIVE

To provide guidelines for the management of the intensive care patient with severe acute pancreatitis.

DESIGN

A consensus committee of 22 experts was convened. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guideline construction process was conducted independently of any industrial funding (i.e. pharmaceutical, medical devices). The authors were required to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised.

METHODS

The most recent SFAR and SNFGE guidelines on the management of the patient with severe pancreatitis were published in 2001. The literature now is sufficient for an update. The committee studied 14 questions within 3 fields. Each question was formulated in a PICO (Patients Intervention Comparison Outcome) format and the relevant evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and their application of the GRADE® method resulted in 24 recommendations. Among the formalised recommendations, 8 have high levels of evidence (GRADE 1+/-) and 12 have moderate levels of evidence (GRADE 2+/-). For 4 recommendations, the GRADE method could not be applied, resulting in expert opinions. Four questions did not find any response in the literature. After one round of scoring, strong agreement was reached for all the recommendations.

CONCLUSIONS

There was strong agreement among experts for 24 recommendations to improve practices for the management of intensive care patients with severe acute pancreatitis.

Prognostic factors associated with development of infected necrosis in patients with acute necrotizing or severe pancreatitis-A systematic review and meta-analysis

PURPOSE

Acute pancreatitis is a potentially life-threatening condition with a wide spectrum of clinical presentation and illness severity. An infection of pancreatic necrosis (IPN) results in a more than twofold increase in mortality risk as compared with patients with sterile necrosis. We sought to identify prognostic factors for the development of IPN among adult patients with severe or necrotizing pancreatitis.

METHODS

We conducted this prognostic review in accordance with systematic review methodology guidelines. We searched six databases from inception through March 21, 2021. We included English language studies describing prognostic factors associated with the development of IPN. We pooled unadjusted odds ratio (uOR) and adjusted odds ratios (aOR) for prognostic factors using a random-effects model. We assessed risk of bias using the Quality in Prognosis Studies tool and certainty of evidence using the GRADE approach.

RESULTS

We included 31 observational studies involving 5,210 patients. Factors with moderate or higher certainty of association with increased IPN risk include older age (uOR, 2.19; 95% confidence interval [CI], 1.39-3.45, moderate certainty), gallstone etiology (aOR, 2.35; 95% CI, 1.36-4.04, high certainty), greater than 50% necrosis of the pancreas (aOR, 3.61; 95% CI, 2.15-6.04, high certainty), delayed enteral nutrition (aOR, 2.09; 95% CI, 1.26-3.47, moderate certainty), multiple or persistent organ failure (aOR, 11.71; 95% CI, 4.97-27.56, high certainty), and invasive mechanical ventilation (uOR, 12.24; 95% CI, 2.28-65.67, high certainty).

CONCLUSION

This meta-analysis confirms the association between several clinical early prognostic factors and the risk of IPN development among patients with severe or necrotizing pancreatitis. These findings provide the foundation for the development of an IPN risk stratification tool to guide more targeted clinical trials for prevention or early intervention strategies.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, Level IV.

Revolution in the diagnosis and management of hepatitis C virus infection in current era

Chronic hepatitis C virus (HCV) infection is a major global public health problem, particularly in developing part of the world. Significant advances have been made in the early diagnosis and treatment of the disease. Its management has been particularly revolutionized during the past two decades. In this review, we summarize the major advances in the diagnostic and management armamentarium for chronic HCV infection. The focus of the present review is on the newer directly acting anti-viral agents, which have revolutionized the management of chronic HCV infection. Management of uncomplicated chronic HCV infection and of specific complications and special at-risk populations of patients will be covered in detail. Despite the advent and approval of highly effective and well tolerable oral agents, still many challenges remain, particularly the affordability, the equitable distribution and access to later drugs. The World Health Organization aims to eliminate viral hepatitis including HCV by 2030 since its poses a major public health threat. There is an urgent need to ensure uniform and early access to diagnostic and therapeutic facilities throughout the world if the later goal has to be realized.

JPN clinical practice guidelines 2021 with easy-to-understand explanations for the management of acute pancreatitis

BACKGROUND

In preparing the Japanese (JPN) guidelines for the management of acute pancreatitis 2021, the committee focused the issues raised by the results of nationwide epidemiological survey in 2016 in Japan METHOD: In addition to a systematic search using the previous JPN guidelines, papers published from January 2014 to September 2019 were searched for the contents to be covered by the guidelines based on the concept of GRADE system.

RESULTS

Thirty-six clinical questions (CQ) were prepared in 15 subject areas. Base on the facts that patients diagnosed with severe disease by both Japanese prognostic factor score and contrast-enhanced CT grade had a high fatality rate and that little prognosis improvement after 2 weeks of disease onset was not obtained, we emphasized the importance of Pancreatitis Bundles, which was shown to be effective in improving prognosis, and the CQ sections for local pancreatic complications had been expanded to ensure adoption of a step-up approach. Furthermore, on the facts that enteral nutrition for severe acute pancreatitis was not started early within 48 hours of admission and that unnecessary prophylactic antibiotics was used in almost all cases, we emphasized early enteral nutrition in small amounts even if gastric feeding is used and no prophylactic antibiotics in mild pancreatitis.

CONCLUSION

All the members of the committee have put a lot of effort into preparing the extensively revised guidelines in the hope that more people will have a common understanding and that better medical care will be spread.

[Etiology and pathogenesis of infected pancreatic necrosis]

Modern literature data confirm the central role of intestinal barrier complex not only as a target in acute necrotizing pancreatitis, but also as a trigger for septic complications. Intra-abdominal hypertension, endothelial dysfunction and gut microbiome changes following necrotizing pancreatitis might have an independent impact on acute intestinal distress syndrome and bacterial translocation. Monitoring of these conditions and early target therapy can improve the outcomes in patients with severe acute pancreatitis. Adverse outcomes of infected pancreatic necrosis including high mortality and morbidity are largely due to the prevalence of multidrug-resistant bacterial pathogens.

Association Between Procalcitonin and Post-hepatectomy Liver Failure in Hepatocellular Carcinoma Patients

Objectives: Procalcitonin (PCT) has long been proved as an early diagnostic signal for postoperative outcomes. The purpose of this study is to explore the value of serum procalcitonin levels in predicting post-hepatectomy liver failure (PHLF), and further to declarethe relationship between postoperative PCT and short-term prognosis in patients after hepatectomy.

Methods: Clinical data of patients with hepatocellular carcinoma (HCC) who underwent hepatectomy from June 1st, 2019 to September 31st, 2020 at Shanghai Eastern Hepatobiliary Surgery Hospital had been retrospectively analyzed. Logistic regression analysis was used to evaluate the risk factors related to PHLF. The Kaplan-Meier method was used to calculate the PHLF rate and 30-day survival after surgery.

Results: A total of 885 patients with complete data were finally included in analysis, 311 of them with elevated serum PCT (≥1 ng/ml). Results of the logistic regression analysis suggested a significant association between PCT and PHLF [HR, 95%CI; 3.801 (1.825, 7.917), p < 0.001]. Other significant risk factors for PHLF included portal hypertension, portal blocking time (>30 min) and blood transfusion (>200 ml). Kaplan-Meier analysis also suggested a higher PHLF rate in elevated PCT patients [9.0% (95% CI, 7.3 to 12.8 VS. 1.9% (95% CI, 1.1–4.3)); p < 0.001]. For secondary outcomes, elevated PCT was also highly associated with postoperative sepsis, ICU admission, 30-day mortality and 3-month mortality.

Conclusion: Elevated procalcitonin level in patients after hepatectomy is related to higher PHLF rate, with lower 30-day survival and poor short-term postoperative outcomes.

The value of serum procalcitonin in the anti-infection therapy of acute stroke patients

Objectives:

To investigate the value of dynamic monitoring of serum procalcitonin (PCT) in anti-infective therapy of patients with acute stroke.

Methods:

This is a case control retrospective study of acute stroke patients conducted from July 2016 to October 2018, in the Department of Neurology, Affiliated Hospital of Hebei University, who who reached within twenty four hours. They, were selected as the study subjects who were divided into infection group and non-infection group according to the inclusion and exclusion criteria. The serum PCT and CRP levels were compared between the two groups at 24 hours, 48 hours and 72 hours. In order to judge the changes of PCT level and the infection of stroke patients, different kinds of antibiotics were used for corresponding treatment. Retrospective analysis of the cases that did not monitor PCT anti infective treatment before July 2016 were compared with the cases that monitored PCT to guide anti infective treatment after July 2016, and compared the efficacy of antibiotics.

Results:

The serum PCT level of patients in the infection group was significantly higher than that of patients in the noninfection group (P<0.001). For the patients whose PCT<0.5 ng/ml within 72 hour, anti-infective therapy was not administered. However, for those patients whose PCT<0.5 ng/ml and CRP rose significantly, WBC, body temperature and chest CT were closely monitored. For the patients whose PCT increased slightly (0.5 ng/ml<PCT<2.0 ng/ml), first-generation and second-generation cephalosporin or semisynthetic penicillin, such as mezlocillin, were administered. For the patients whose PCT increased moderately (5 ng/ml>PCT>2 ng/ml), mezlocillin/ sulbactam or ceftriaxone/ tazobactam was administered. For patients whose PCT increased significantly (PCT>5 ng/ml), carbapenem antibiotic or a combination of two antibiotics was administered.

Conclusion:

Dynamic detection of serum PCT concentration can make accurate judgment on the severity of bacterial infection in patients with acute stroke and guide the rational application of antibiotics.

Use of antibiotics in acute pancreatitis: ten major concerns

Acute pancreatitis is one of the most common gastrointestinal causes for hospitalization. In 15-20% it evolves into severe necrotizing pancreatitis. Recent studies have shown no association between the initiation of antibiotic therapy in acute pancreatitis and severe outcomes such as organ failure, infection of pancreatic necrosis, extrapancreatic infections or mortality. Specific subgroups with predicted severe acute pancreatitis or both extensive sterile necrosis and persistent organ failure may benefit from prophylactic antibiotics. Local infection develops in 30% of patients with pancreatic necrosis and results in morbidity and mortality. Contrast enhanced computed tomography should be performed in all patients with acute pancreatitis who develop sepsis, organ failure or fail to improve. C-reactive protein is an independent predictor of severe acute pancreatitis. Procalcitonin is the most sensitive laboratory test for detection of pancreatic infection. Antibiotics do however play a large role in patients with suspected or confirmed infected pancreatic necrosis and extrapancreatic infections. In clinical practice most clinicians prescribe antibiotics in the first 3 days of acute pancreatitis which in turns lead to excessive, unjustified use of antibiotics. Deep knowledge of the recent guidelines combined with an individualized management based on right clinical judgment is a rationale approach of patients with acute pancreatitis.

Infection recurrence following minimally invasive treatment in patients with infectious pancreatic necrosis

BACKGROUND

In recent decades, an increasing number of patients have received minimally invasive intervention for infected pancreatic necrosis (IPN) because of the benefits in reducing postoperative multiple organ failure and mortality. However, there are limited published data regarding infection recurrence after treatment of this patient population.

AIM

To investigate the incidence and prediction of infection recurrence following successful minimally invasive treatment in IPN patients.

METHODS

Medical records for 193 IPN patients, who underwent minimally invasive treatment between February 2014 and October 2018, were retrospectively reviewed. Patients, who survived after the treatment, were divided into two groups: one group with infection after drainage catheter removal and another group without infection. The morphological and clinical data were compared between the two groups. Significantly different variables were introduced into the correlation and multivariate logistic analysis to identify independent predictors for infection recurrence. Sensitivity and specificity for diagnostic performance were determined.

RESULTS

Of the 193 IPN patients, 178 were recruited into the study. Of them, 9 (5.06%) patients died and 169 patients survived but infection recurred in 13 of 178 patients (7.30%) at 7 (4-10) d after drainage catheters were removed. White blood cell (WBC) count, serum C-reactive protein (CRP), interleukin-6, and procalcitonin levels measured at the time of catheter removal were significantly higher in patients with infection than in those without (all P < 0.05). In addition, drainage duration and length of the catheter measured by computerized tomography scan were significantly longer in patients with infection (P = 0.025 and P < 0.0001, respectively). Although these parameters all correlated positively with the incidence of infection (all P < 0.05), only WBC, CRP, procalcitonin levels, and catheter length were identified as independent predictors for infection recurrence. The sensitivity and specificity for infection prediction were high in WBC count (≥ 9.95 × 10⁹/L) and serum procalcitonin level (≥ 0.05 ng/mL) but moderate in serum CRP level (cut-off point ≥ 7.37 mg/L). The catheter length (cut-off value ≥ 8.05 cm) had a high sensitivity but low specificity to predict the infection recurrence.

CONCLUSION

WBC count, serum procalcitonin, and CRP levels may be valuable for predicting infection recurrence following minimally invasive intervention in IPN patients. These biomarkers should be considered before removing the drainage catheters.

A 2020 review on the role of procalcitonin in different clinical settings: an update conducted with the tools of the Evidence Based Laboratory Medicine

Biomarkers to guide antibiotic treatment decisions have been proposed as an effective way to enhancing a more appropriate use of antibiotics. As a biomarker, procalcitonin (PCT) has been found to have good specificity to distinguish bacterial from non-bacterial inflammations. Decisions regarding antibiotic use in an individual patient are complex and should be based on the pre-test probability for bacterial infection, the severity of presentation and the results of PCT serum concentration. In the context of a high pre-test probability for bacterial infections and/or a high-risk patient with sepsis, monitoring of PCT over time helps to track the resolution of infection and decisions regarding early stop of antibiotic treatment. As outlined by the Evidence Based Laboratory Medicine (EBLM), not only the pre-test probability but also the positive likelihood ratio influence the performance of a test do be really diagnostic. This aspect should be taken into account in the interpretation of the results of clinical trials evaluating the performance of PCT in guiding antibiotic therapy.

Risk factors for mortality in emphysematous pancreatitis

Objective: To investigate the difference in the characteristics between patients with emphysematous pancreatitis (EP) who survived and those who died. Methods: PubMed search was performed to gather EP cases from March 1959 to February 2019. Forty-two articles with 58 EP cases were identified and met the study's inclusion criteria. The elderly were defined as individuals aged >65 years. Data on patients' demographics, clinical symptoms, laboratory results, treatments, outcomes, and mortality were collected and analyzed by chi-square test and Student's t-test. p-Value <.05 (2-tailed) was set as the significance level. Results: Forty-seven men and eleven women aged 61.3 ± 15.9 (mean ± standard deviation) years were included. The elderly accounted for 43.1% (n = 25) of cases. There were 20 mortality cases, and 38 cases survived, with an overall mortality rate of 34.5%. Sex, underlying diseases, etiologies, and laboratory results were not significantly related to mortality. Older age was significantly related to mortality (p = .001). The shock was more commonly seen in the mortality group (100%) than in the survival group (21%) (p < .001). In contrast, fever was less frequent in the mortality group than in the survival group (25 vs. 71%, p = .002). Conclusions: EP patients have a high mortality rate (34.5%). Older age, afebrile status, and presence of shock are associated with high mortality. To improve the survival of this aggressive group, a further prospective investigation involving a larger sample size is necessary.

Risk factors for mortality in emphysematous pancreatitis

Objective: To investigate the difference in the characteristics between patients with emphysematous pancreatitis (EP) who survived and those who died. Methods: PubMed search was performed to gather EP cases from March 1959 to February 2019. Forty-two articles with 58 EP cases were identified and met the study's inclusion criteria. The elderly were defined as individuals aged >65 years. Data on patients' demographics, clinical symptoms, laboratory results, treatments, outcomes, and mortality were collected and analyzed by chi-square test and Student's t-test. p-Value <.05 (2-tailed) was set as the significance level. Results: Forty-seven men and eleven women aged 61.3 ± 15.9 (mean ± standard deviation) years were included. The elderly accounted for 43.1% (n = 25) of cases. There were 20 mortality cases, and 38 cases survived, with an overall mortality rate of 34.5%. Sex, underlying diseases, etiologies, and laboratory results were not significantly related to mortality. Older age was significantly related to mortality (p = .001). The shock was more commonly seen in the mortality group (100%) than in the survival group (21%) (p < .001). In contrast, fever was less frequent in the mortality group than in the survival group (25 vs. 71%, p = .002). Conclusions: EP patients have a high mortality rate (34.5%). Older age, afebrile status, and presence of shock are associated with high mortality. To improve the survival of this aggressive group, a further prospective investigation involving a larger sample size is necessary.

Antibacterial and Antifungal Therapy for Patients with Acute Pancreatitis at High Risk of Pancreatogenic Sepsis (Review)

Controlling infection is crucial in treating patients with acute pancreatitis (AP). The infectious process in AP often predisposes to subsequent sepsis by damaging not only the pancreas, but retroperitoneal tissues as well. Among other AP-associated factors, are the rapidly developing immune imbalance, the poor penetration of antimicrobial agents into necrotic tissue, and the impossibility of a single surgical debridement. Antibacterial and antifungal therapy for patients with infected necrosis and AP-associated extra-pancreatic infections remains a complex and largely unresolved problem, partially due to the high occurrence of multiresistant pathogens. The preventive use of antimicrobial agents has been discussed in the literature; however, the lack of consistent results makes it difficult to develop a unified strategy and clinical guidelines on this specific issue. Recent meta-analyses provide no conclusive evidence that antibacterial prophylaxis reduces the infection rate, mortality, or the need for surgical treatment in patients with necrotizing pancreatitis. We found only two studies indicating the benefits of using carbapenems for prophylactic purposes and one meta-analysis indicating a reduction in mortality under antibiotic treatment started no later than 72 h after the onset of the attack. Selective bowel decontamination is considered as one of the preventive anti-infection measures, although the available data may not be fully reliable. The main indications for antibacterial therapy in patients with AP are confirmed infected necrosis or extra-pancreatic infection, as well as clinical symptoms of suspected infection. Intra-arterial administration or local treatment with antibiotics can increase the efficacy of antibacterial therapy. No randomized studies on antifungal prophylaxis in AP are available; some reports though recommend using such therapy among patients at high risk of invasive candidiasis.

Parecoxib Improves the Outcomes of Acute Mild and Moderate Pancreatitis: A 3-Year Matched Cohort Study Based on a Prospective Database

OBJECTIVES

The aim of this study was to evaluate the role of parecoxib in patients with different severities of acute pancreatitis (AP).

METHODS

A total of 772 eligible patients with AP were divided into 4 groups: mild and moderately AP (MAP) treated with parecoxib (group A, n = 236), MAP without parecoxib treatment (group B, n = 453), severe AP (SAP) treated with parecoxib (group C, n = 28), and SAP without parecoxib treatment (group D, n = 55). Patients in group A were exactly matched with patients in group B by propensity score matching, similar to the matching between group C and group D.

RESULTS

The morbidity of abdominal infection in group A was significantly lower as compared with that in group B (P < 0.050). The progression of MAP to SAP significantly decreased in group A than group B (P < 0.050). No significant differences were observed between group C and group D. The risk factors independently related to the progression of MAP included alcoholic/high-fat dietary (P = 0.028) and parecoxib administration (P = 0.011).

CONCLUSIONS

Early administration of parecoxib could reduce the morbidity of complications among patients with MAP. Parecoxib may prevent the progression of MAP to SAP and improve its outcomes.

Impaired thiol/disulfide homeostasis in patients with mild acute pancreatitis

BACKGROUND/AIMS

The aim of this study was to compare the dynamic thiol/disulfide (SS) homeostasis and ischemia-modified albumin (IMA) concentration between healthy subjects and patients with mild acute pancreatitis (AP).

MATERIALS AND METHODS

A total of 28 patients with AP (AP group) and 35 age- and sex-matched healthy individuals (control group) were included in this study. Serum thiols/SS and IMA concentrations were measured and compared between the two groups.

RESULTS

The mean serum native thiol (SH) and total thiol (TT) levels were significantly lower in the AP group than in the control group (224.7±80.3 μmol/L vs. 314.66±87.5 μmol/L, p<0.001 and 273.3±76.8 vs. 346.9±79 μmol/L, p<0.001, respectively). SS levels were significantly higher in the AP group than in the control group (24.2±11.1 μmol/L vs. 16.1±9.9 μmol/L, p<0.054). There were no differences in the IMA concentration and the mean IMA/albumin ratio (IMAR) between both the groups.

CONCLUSION

We found that mild AP may affect serum thiol and SS levels, and cause impaired thiol/SS homeostasis.

2019 WSES guidelines for the management of severe acute pancreatitis

Although most patients with acute pancreatitis have the mild form of the disease, about 20-30% develops a severe form, often associated with single or multiple organ dysfunction requiring intensive care. Identifying the severe form early is one of the major challenges in managing severe acute pancreatitis. Infection of the pancreatic and peripancreatic necrosis occurs in about 20-40% of patients with severe acute pancreatitis, and is associated with worsening organ dysfunctions. While most patients with sterile necrosis can be managed nonoperatively, patients with infected necrosis usually require an intervention that can be percutaneous, endoscopic, or open surgical. These guidelines present evidence-based international consensus statements on the management of severe acute pancreatitis from collaboration of a panel of experts meeting during the World Congress of Emergency Surgery in June 27-30, 2018 in Bertinoro, Italy. The main topics of these guidelines fall under the following topics: Diagnosis, Antibiotic treatment, Management in the Intensive Care Unit, Surgical and operative management, and Open abdomen.

Severity stratification and prognostic prediction of patients with acute pancreatitis at early phase: A retrospective study

Severity stratification and prognostic prediction at early stage is crucial for reducing the rates of mortality of patients with acute pancreatitis (AP). We aim to investigate the predicting performance of neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and red-cell distribution width (RDW) combined with severity scores (sequential organ failure assessment [SOFA], bed-side index for severity of AP [BISAP], Ranson criteria, and acute physiology and chronic health evaluation II [APACHE II]) for severe AP (SAP) and mortality.A total of 406 patients diagnosed with AP admitted in a tertiary teaching hospital were enrolled. Demographic information and clinical parameters were retrospectively collected and analyzed. NLR, PLR, RDW, blood urea nitrogen (BUN), and AP severity scores (SOFA, BISAP, Ranson, and APACHE II) were compared between different severity groups and the survival and death group. Receiver-operating characteristic (ROC) curves for SAP and 28-day mortality were calculated for each predictor using cut-off values. Area under the curve (AUC) analysis and logistic regression models were performed to compare the performance of laboratory biomarkers and severity scores.Our results showed that NLR, PLR, RDW, glucose, and BUN level of the SAP group were significantly increased compared to the mild acute pancreatitis (MAP) group on admission (P < .001). The severity of AP increased as the NLR, SOFA, BISAP, and Ranson increased (P < .01). The AUC values of NLR, PLR, RDW, BUN, SOFA, BISAP, Ranson, and APACHE II to predict SAP were 0.722, 0.621, 0.787, 0.677, 0.806, 0.841, 0.806, and 0.752, respectively, while their AUC values to predict 28-day mortality were 0.851, 0.693, 0.885, 0.765, 0.968, 0.929, 0.812, and 0.867, respectively. BISAP achieved the highest AUC, sensitivity and NPV in predicting SAP, while SOFA is the most superior in predicting mortality. The combination of BISAP + RDW achieved the highest AUC (0.872) in predicting SAP and the combination of SOFA + RDW achieved the highest AUC (0.976) in predicting mortality. RDW (OR = 1.739), SOFA (OR = 1.554), BISAP (OR = 2.145), and Ranson (OR = 1.434) were all independent risk factors for predicting SAP, while RDW (OR = 7.361) and hematocrit (OR = 0.329) were independent risk factors for predicting mortality by logistic regression model.NLR, PLR, RDW, and BUN indicated good predictive value for SAP and mortality, while RDW had the highest discriminatory capacity. RDW is a convenient and reliable indicator for prediction not only SAP, but also mortality.