Candidemia indicates poor outcome in patients with infected pancreatic necrosis

Prediction of survival in patients with infected pancreatic necrosis: a prospective cohort study

BACKGROUND

Infected pancreatic necrosis (IPN) is a severe complication of acute pancreatitis, with mortality rates ranging from 15 to 35%. However, limited studies exist to predict the survival of IPN patients and nomogram has never been built. This study aimed to identify predictors of mortality, estimate conditional survival (CS), and develop a CS nomogram and logistic regression nomogram for real-time prediction of survival in IPN patients.

METHODS

A prospective cohort study was performed in 335 IPN patients consecutively enrolled at a large Chinese tertiary hospital from January 2011 to December 2022. The random survival forest method was first employed to identify the most significant predictors and capture clinically relevant nonlinear threshold effects. Instantaneous death risk and CS was first utilized to reveal the dynamic changes in the survival of IPN patients. A Cox model-based nomogram incorporating CS and a logistic regression-based nomogram were first developed and internally validated with a bootstrap method.

RESULTS

The random survival forest model identified seven foremost predictors of mortality, including the number of organ failures, duration of organ failure, age, time from onset to first intervention, hemorrhage, bloodstream infection, and severity classification. Duration of organ failure and time from onset to first intervention showed distinct thresholds and nonlinear relationships with mortality. Instantaneous death risk reduced progressively within the first 30 days, and CS analysis indicated gradual improvement in real-time survival since diagnosis, with 90-day survival rates gradually increasing from 0.778 to 0.838, 0.881, 0.974, and 0.992 after surviving 15, 30, 45, 60, and 75 days, respectively. After further variables selection using step regression, five predictors (age, number of organ failures, hemorrhage, time from onset to first intervention, and bloodstream infection) were utilized to construct both the CS nomogram and logistic regression nomogram, both of which demonstrated excellent performance with 1000 bootstrap.

CONCLUSION

Number of organ failures, duration of organ failure, age, time from onset to first intervention, hemorrhage, bloodstream infection, and severity classification were the most crucial predictors of mortality of IPN patients. The CS nomogram and logistic regression nomogram constructed by these predictors could help clinicians to predict real-time survival and optimize clinical decisions.

Impact of multiple drug-resistant Gram-negative bacterial bacteraemia on infected pancreatic necrosis patients

Introduction

Multiple drug-resistant Gram-negative bacterial (MDR-GNB) bacteraemia poses a serious threat to patients in hospital. Infected pancreatic necrosis (IPN) patients are a vulnerable population to infectious complications during hospitalization. This study aims to evaluate the impact of MDR Gram-negative bacteraemia on IPN patients.

Methods

A case-control study was performed with data collected from 1 January 2016 to 1 July 2022 in a Chinese tertiary teaching hospital. Clinical data of the IPN patients with MDR-GNB bacteraemia were analyzed and compared to those of a matched control group without MDR-GNB bacteraemia (case-control ratio of 1:2). Comparisons were performed between with/without MDR-GNB bacteraemia and different severities of acute pancreatitis (AP). Independent predictors of overall mortality were identified via univariate and multivariate binary logistic regression analyses.

Results

MDR-GNB bacteraemia was related to a higher mortality rate (62.5% vs. 8.3%, p < 0.001). Severe AP combined with MDR-GNB bacteraemia further increased mortality up to 81.3% (p = 0.025). MDR-GNB bacteraemia (odds ratio (OR) = 8.976, 95% confidence interval (CI) = 1.805 -44.620, p = 0.007) and severe AP (OR = 9.414, 95% CI = 1.742 -50.873, p = 0.009) were independent predictors of overall mortality. MDR- Klebsiella pneumoniae was the most common causative pathogen.

Conclusion

A higher mortality rate in IPN patients was related to MDR-GNB bacteraemia and further increased in severe AP patients combined with MDR-GNB bacteraemia.

Early-onset emphysematous pancreatitis indicates poor outcomes in patients with infected pancreatic necrosis

BACKGROUND

Emphysematous pancreatitis (EP) is a subtype of infected pancreatic necrosis (IPN) characterized by presence of gas in (peri)pancreatic necrosis. However, the impacts of EP on outcomes of IPN are still controversial.

METHODS

A prospective database of consecutive patients with IPN in a tertiary hospital was post-hoc analyzed. Patients were assigned to EP and non-EP groups to perform a comprehensive comparison.

RESULTS

A total of 178 patients with IPN were enrolled and the overall mortality was 30.9%. EP accounted for 20.8% (n = 37) of cases and was significantly associated with higher incidences of Escherichia coli (45.9 versus 18.4%, P = 0.001) and Klebsiella pneumoniae (56.8 versus 33.3%, P = 0.009) infection. There was scarcely any disparity in clinical characteristics and outcomes between IPN patients with and without EP. However, patients with early-onset EP defined as air bubble signs occurring within 2 weeks from disease onset were significantly older and have higher prevalence of history of diabetes, and they were also associated with significantly higher mortality (57.1 versus 8.7%, P = 0.015) compared with late-onset patients.

CONCLUSIONS

The clinical outcomes of EP might be like those of non-emphysematous infection. However, when EP occurs within 2 weeks from disease onset, it is highly lethal.

Risk Factors for Mortality Among Critical Acute Pancreatitis Patients with Carbapenem-Resistant Organism Infections and Drug Resistance of Causative Pathogens

Introduction

Carbapenem-resistant organisms (CRO) have emerged as a major global public health threat, but their role in critical acute pancreatitis (CAP) is still not defined. Our study aims to investigate risk factors associated with mortality and drug resistance among CAP patients with CRO infection.

Methods

The clinical characteristics of CAP patients with CRO infection and drug resistance of causative pathogens from January 1, 2016, to October 1, 2021, were reviewed retrospectively. Independent risk factors for mortality were determined via univariate and multivariate analyses.

Result

Eighty-two CAP patients suffered from CRO infection, with mortality of 60.0%. The independent risk factors for mortality were procalcitonin > 5 ng/L (hazard ratio = 2.300, 95% confidence interval = 1.180–4.484, P = 0.014) and lactic acid > 2 mmol/L (hazard ratio = 2.101, 95% confidence interval = 1.151–3.836, P = 0.016). The pancreas was the main site of infection, followed by lung, bloodstream and urinary tract. Klebsiella pneumoniae and Acinetobacter baumannii were the main pathogenic bacteria of CRO strains with extensive antibiotic resistance (> 60%) to 6 of 8 common antibiotics, except sulfamethoxazole (56.3%) and tigecycline (33.2%).

Conclusion

CRO infection has become a serious threat for CAP patients, with high rates of mortality. Procalcitonin and lactic acid represent two independent risk factors for mortality in CAP patients with CRO infection. Klebsiella pneumoniae and Acinetobacter baumannii are the primary categories of CRO pathogens. Greater efforts are needed for early prevention and prompt treatment of CRO infections in CAP patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-022-00624-w.