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van den Berg FF, Besselink MG, van Santvoort H. Short-chain fatty acids in patients with severe acute pancreatitis: friend or foe? Gut 2024:gutjnl-2024-332129. [PMID: 38360070 DOI: 10.1136/gutjnl-2024-332129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 02/17/2024]
Affiliation(s)
- Fons F van den Berg
- Department of Medical Microbiology and Infection Prevention, Amsterdam UMC Locatie AMC, Amsterdam, Noord-Holland, Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC Locatie VUmc, Amsterdam, Noord-Holland, Netherlands
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Timmerhuis HC, van den Berg FF, Noorda PC, van Dijk SM, van Grinsven J, Sperna Weiland CJ, Umans DS, Mohamed YA, Curvers WL, Bouwense SAW, Hadithi M, Inderson A, Issa Y, Jansen JM, de Jonge PJF, Quispel R, Schwartz MP, Stommel MWJ, Tan ACITL, Venneman NG, Besselink MG, Bruno MJ, Bollen TL, Sieswerda E, Verdonk RC, Voermans RP, van Santvoort HC. Overuse and Misuse of Antibiotics and the Clinical Consequence in Necrotizing Pancreatitis: An Observational Multicenter Study. Ann Surg 2023; 278:e812-e819. [PMID: 36728517 DOI: 10.1097/sla.0000000000005790] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The use and impact of antibiotics and the impact of causative pathogens on clinical outcomes in a large real-world cohort covering the entire clinical spectrum of necrotizing pancreatitis remain unknown. SUMMARY BACKGROUND DATA International guidelines recommend broad-spectrum antibiotics in patients with suspected infected necrotizing pancreatitis. This recommendation is not based on high-level evidence and clinical effects are unknown. MATERIALS AND METHODS This study is a post-hoc analysis of a nationwide prospective cohort of 401 patients with necrotizing pancreatitis in 15 Dutch centers (2010-2019). Across the patient population from the time of admission to 6 months postadmission, multivariable regression analyses were used to analyze (1) microbiological cultures and (2) antibiotic use. RESULTS Antibiotics were started in 321/401 patients (80%) administered at a median of 5 days (P25-P75: 1-13) after admission. The median duration of antibiotics was 27 days (P25-P75: 15-48). In 221/321 patients (69%) infection was not proven by cultures at the time of initiation of antibiotics. Empirical antibiotics for infected necrosis provided insufficient coverage in 64/128 patients (50%) with a pancreatic culture. Prolonged antibiotic therapy was associated with Enterococcus infection (OR 1.08 [95% CI 1.03-1.16], P =0.01). Enterococcus infection was associated with new/persistent organ failure (OR 3.08 [95% CI 1.35-7.29], P <0.01) and mortality (OR 5.78 [95% CI 1.46-38.73], P =0.03). Yeast was found in 30/147 cultures (20%). DISCUSSION In this nationwide study of patients with necrotizing pancreatitis, the vast majority received antibiotics, typically administered early in the disease course and without a proven infection. Empirical antibiotics were inappropriate based on pancreatic cultures in half the patients. Future clinical research and practice must consider antibiotic selective pressure due to prolonged therapy and coverage of Enterococcus and yeast. Improved guidelines on antimicrobial diagnostics and therapy could reduce inappropriate antibiotic use and improve clinical outcomes.
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Affiliation(s)
| | - Fons F van den Berg
- Department of Surgery, Amsterdam UMC, location University of Amsterdam
- Amsterdam Gastroenterology Endocrinology Metabolism
| | | | - Sven M van Dijk
- Department of Surgery, Amsterdam UMC, location University of Amsterdam
- Amsterdam Gastroenterology Endocrinology Metabolism
| | - Janneke van Grinsven
- Department of Surgery, Amsterdam UMC, location University of Amsterdam
- Amsterdam Gastroenterology Endocrinology Metabolism
| | | | - Devica S Umans
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam
| | | | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven
| | | | - Muhammed Hadithi
- Department of Gastroenterology and Hepatology, Maasstad Hospital
| | - Akin Inderson
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden
| | - Yama Issa
- Department of Surgery, Amsterdam UMC, location University of Amsterdam
- Department of Surgery, Gelre Hospital, Apeldoorn
| | - Jeroen M Jansen
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam
| | | | - Rutger Quispel
- Department of Gastroenterology and Hepatology, Reinier de Graaf Gasthuis, Delft
| | - Matthijs P Schwartz
- Department of Gastroenterology and Hepatology, Meander Medical Center, Amersfoort
| | | | - Adriaan C I T L Tan
- Department of Gastroenterology and Hepatology, Canisius Wilhelmina Hospital, Nijmegen
| | - Niels G Venneman
- Department of Gastroenterology and Hepatology, Medical Spectrum Twente, Enschede
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, location University of Amsterdam
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam
| | | | - Elske Sieswerda
- Department of Medical Microbiology
- Julius Center for Health Sciences and Primary Care, Utrecht University
| | - Robert C Verdonk
- Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein
| | - Rogier P Voermans
- Amsterdam Gastroenterology Endocrinology Metabolism
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location University of Amsterdam
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van den Berg FF, Boermeester MA. Update on the management of acute pancreatitis. Curr Opin Crit Care 2023; 29:145-151. [PMID: 36727757 PMCID: PMC9994841 DOI: 10.1097/mcc.0000000000001017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW This review provides insight into the recent advancements in the management of acute pancreatitis. RECENT FINDINGS Moderate fluid resuscitation and Ringer's lactate has advantages above aggressive fluid resuscitation and normal saline, respectively. A normal "on-demand" diet has a positive effect on recovery from acute pancreatitis and length of hospital stay. A multimodal pain management approach including epidural analgesia might reduce unwarranted effects of opiate use. A more targeted use of antibiotics is starting to emerge. Markers such as procalcitonin may be used to limit unwarranted antibiotic use. Conversely, many patients with infected necrotizing pancreatitis can be treated with only antibiotics, although the optimal choice and duration is unclear. Delay of drainage as much as is possible is advised since it is associated with less procedures. If drainage is required, clinicians have an expanding arsenal of interventional options to their disposal such as the lumen-apposing metal stent for transgastric drainage and (repeated) necrosectomy. Immunomodulation using removal of systemic cytokines or anti-inflammatory drugs is an attractive idea, but up to now the results of clinical trials are disappointing. No additional preventive measures beside non-steroidal anti-inflammatory drugs (NSAIDs) can be recommended for post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. SUMMARY More treatment modalities that are less invasive became available and a trend towards less aggressive treatments (fluids, starvation, interventions, opiates) of acute pancreatitis is again emerging. Despite recent advancements, the pathophysiology of specific subgroup phenotypes is still poorly understood which reflects the disappointing results of pharmacological and immunomodulatory trials.
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Affiliation(s)
- Fons F. van den Berg
- Amsterdam UMC location University of Amsterdam, Medical Microbiology & Infection prevention
| | - Marja A. Boermeester
- Amsterdam UMC location University of Amsterdam, Department of Surgery, Meibergdreef 9
- Amsterdam institute for Infection and Immunity
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
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van den Berg FF, Issa Y, Vreijling JP, Lerch MM, Weiss FU, Besselink MG, Baas F, Boermeester MA, van Santvoort HC. Whole-exome Sequencing Identifies SLC52A1 and ZNF106 Variants as Novel Genetic Risk Factors for (Early) Multiple-organ Failure in Acute Pancreatitis. Ann Surg 2022; 275:e781-e788. [PMID: 33427755 DOI: 10.1097/sla.0000000000004312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The aim of this study was to identify genetic variants associated with early multiple organ failure (MOF) in acute pancreatitis. SUMMARY BACKGROUND DATA MOF is a life-threatening complication of acute pancreatitis, and risk factors are largely unknown, especially in early persistent MOF. Genetic risk factors are thought to enhance severity in complex diseases such as acute pancreatitis. METHODS A 2-phase study design was conducted. First, we exome sequenced 9 acute pancreatitis patients with early persistent MOF and 9 case-matched patients with mild edematous pancreatitis (phenotypic extremes) from our initial Dutch cohort of 387 patients. Secondly, 48 candidate variants that were overrepresented in MOF patients and 10 additional variants known from literature were genotyped in a replication cohort of 286 Dutch and German patients. RESULTS Exome sequencing resulted in 161,696 genetic variants, of which the 38,333 non-synonymous variants were selected for downstream analyses. Of these, 153 variants were overrepresented in patients with multiple-organ failure, as compared with patients with mild acute pancreatitis. In total, 58 candidate variants were genotyped in the joined Dutch and German replication cohort. We found the rs12440118 variant of ZNF106 to be overrepresented in patients with MOF (minor allele frequency 20.4% vs 11.6%, Padj=0.026). Additionally, SLC52A1 rs346821 was found to be overrepresented (minor allele frequency 48.0% vs 42.4%, Padj= 0.003) in early MOF. None of the variants known from literature were associated.Conclusions: This study indicates that SLC52A1, a riboflavin plasma membrane transporter, and ZNF106, a zinc finger protein, may be involved in disease progression toward (early) MOF in acute pancreatitis.
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Affiliation(s)
- Fons F van den Berg
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Yama Issa
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen P Vreijling
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Markus M Lerch
- Departments of Clinical Chemistry, Genetics and Pediatrics, Amsterdam Gastroenterology & Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Frank Ulrich Weiss
- Departments of Clinical Chemistry, Genetics and Pediatrics, Amsterdam Gastroenterology & Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Frank Baas
- Department of Medicine A, University Medicine Greifswald, Greifswald, Germany
| | - Marja A Boermeester
- Department of Surgery, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Clinical Genetics, Leiden University Medical Center, Leiden, The Netherlands
| | - Hjalmar C van Santvoort
- Department of Surgery, University Medical Center, Utrecht, The Netherlands; Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
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van den Berg FF, van Dalen D, Hyoju SK, van Santvoort HC, Besselink MG, Wiersinga WJ, Zaborina O, Boermeester MA, Alverdy J. Western-type diet influences mortality from necrotising pancreatitis and demonstrates a central role for butyrate. Gut 2021; 70:915-927. [PMID: 32873697 PMCID: PMC7917160 DOI: 10.1136/gutjnl-2019-320430] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 07/09/2020] [Accepted: 07/26/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The gut microbiota are the main source of infections in necrotising pancreatitis. We investigated the effect of disruption of the intestinal microbiota by a Western-type diet on mortality and bacterial dissemination in necrotising pancreatitis and its reversal by butyrate supplementation. DESIGN C57BL/6 mice were fed either standard chow or a Western-type diet for 4 weeks and were then subjected to taurocholate-induced necrotising pancreatitis. Blood and pancreas were collected for bacteriology and immune analysis. The cecum microbiota composition of mice was analysed using 16S rRNA gene amplicon sequencing and cecal content metabolites were analysed by targeted (ie, butyrate) and untargeted metabolomics. Prevention of necrotising pancreatitis in this model was compared between faecal microbiota transplantation (FMT) from healthy mice, antibiotic decontamination against Gram-negative bacteria and oral or systemic butyrate administration. Additionally, the faecal microbiota of patients with pancreatitis and healthy subjects were analysed. RESULTS Mortality, systemic inflammation and bacterial dissemination were increased in mice fed Western diet and their gut microbiota were characterised by a loss of diversity, a bloom of Escherichia coli and an altered metabolic profile with butyrate depletion. While antibiotic decontamination decreased mortality, Gram-positive dissemination was increased. Both oral and systemic butyrate supplementation decreased mortality, bacterial dissemination, and reversed the microbiota alterations. Paradoxically, mortality and bacterial dissemination were increased with FMT administration. Finally, patients with acute pancreatitis demonstrated an increase in Proteobacteria and a decrease of butyrate producers compared with healthy subjects. CONCLUSION Butyrate depletion and its repletion appear to play a central role in disease progression towards necrotising pancreatitis.
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Affiliation(s)
- Fons F van den Berg
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Demi van Dalen
- Department of Surgery, Radboudumc, Nijmegen, The Netherlands
| | - Sanjiv K Hyoju
- Department of Surgery, University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
| | - Hjalmar C van Santvoort
- Department of Surgery, Regional Academic Cancer Center Utrecht, UMC Utrecht Cancer Center, Utrecht, The Netherlands,Department of Surgery, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - Willem Joost Wiersinga
- Center for Experimental and Molecular Medicine, Department of Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Olga Zaborina
- Department of Surgery, University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
| | - Marja A Boermeester
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam, The Netherlands
| | - John Alverdy
- Department of Surgery, University of Chicago, Pritzker School of Medicine, Chicago, Illinois, USA
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