Infected Necrotizing Pancreatitis Research Articles

Efficacy and Safety of Anhydrous Ethanol-Assisted Endoscopic Ultrasound-Guided Transluminal Necrosectomy in Infected Necrotizing Pancreatitis.

Endoscopic necrosectomy has become the first-line treatment option for infectious necrotizing pancreatitis (INP), especially walled-off necrosis. However, the problems, including operation-related adverse events (AEs) and the need for multiple endoscopic procedures, have not been effectively addressed. We sought to evaluate the clinical safety and efficacy of anhydrous ethanol-assisted endoscopic ultrasound (EUS)-guided transluminal necrosectomy in INP. A single-center observational cohortstudy of INP patients was conducted in a tertiaryendoscopic center. Anhydrous ethanol-assisted EUS-guided transluminal necrosectomy (modified group) and conventional endoscopic necrosectomy (conventional group) were retrospectively compared in INP patients. The technical and clinical success rates, operation time, perioperative AEs, postoperative hospital stay, and recurrent INP rates were analyzed, respectively. Atotalof55patientswereenrolled. No statistically significant differences were observed between the two groups regarding baseline characteristics. Compared to patients in the conventional group, patients in the modified group demonstrated significantly reduced times of endoscopic transluminal necrosectomies (1.96 ± 0.89 vs. 2.73 ± 0.98; P = 0.004) and comparable perioperative AEs (P = 0.35). Meanwhile, no statistically significant differences were observed in the technical and clinical success rates (P = 0.92), operation time (P = 0.59), postoperative hospital stay (P = 0.36), and recurrent INP rates (P = 1.00) between the two groups. Anhydrous ethanol-assisted EUS-guided transluminal necrosectomy seemed safe and effective in treating INP. Compared with conventional endoscopic transluminal necrosectomy, its advantage was mainlyin reducing the number of endoscopic necrosectomies without increasing perioperative AEs.

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.

P02 Evaluating antibiotic prescribing in pancreatitis: a single-centre retrospective case series

Abstract Background Procalcitonin (PCT) has been shown to safely reduce antibiotic use in respiratory tract infections but there is little evidence for other potentially infected body systems. A recent randomized controlled trial (RCT) demonstrated the safety and efficacy of PCT in reducing antibiotic use in patients with pancreatitis. Objectives We aimed to review antibiotic prescribing in patients with pancreatitis and to estimate the potential impact of PCT on rates of antibiotic prescribing at the Royal Cornwall Hospital Trust (RCHT). Methods Patient care episodes for pancreatitis between June 2022 and May 2023 were identified using pancreatitis ICD-10 codes. An audit tool was developed using the inclusion criteria used in the RCT. Electronic notes systems were used to collect the following: patient demographics, whether diagnostic criteria for pancreatitis were met, clinical specialty, pancreatitis severity, presence of necrosis, indications for antibiotics and course lengths. Results 121 patient care episodes were identified, of which 76 (63%) were analysed. Of these, 61 (80.3%) met the diagnostic criteria for pancreatitis and analysed; median age 57 (IQR 26), 28 (45.9%) female, 51 (83.6%) managed under surgeons and 10 (16.4%) under medicine. 15 (19.7%) patient episodes were excluded: 14 did not meet diagnostic criteria for pancreatitis and 1 on long term immunosuppression. 30 (49.2%) patients with a clinical diagnosis of pancreatitis were prescribed antibiotics; 5 (16.7%) for pancreatitis and 16 (53.3%) for extra-pancreatic indications: respiratory tract 3 (18.8%), cholecystitis 7 (43.8%), suspected cholangitis 1 (6.3%), other intra-abdominal infection 5 (31.3%). The indication for antibiotics was unclear in 9 episodes (30.0%). Of those prescribed antibiotics for pancreatitis, 4 (80%) were appropriately prescribed for suspected infected necrotic pancreatitis (patients with pancreatic or extra-pancreatic necrosis who deteriorate (physiologically or blood results) or fail to improve after 7-10 days), 1 (20%) was inappropriate. The overall rate of antibiotic prescribing in the PROCAP study were 31% in the PCT group and 47% in the usual care group (non-PCT); the rate of antibiotic prescribing in the usual care group was found to be comparable to our data (47.0% verses 49.2%). However, the majority of antibiotic prescriptions in our cohort were for extra-pancreatic infections, not pancreatitis. It is not possible to determine the proportion of antibiotics prescribed for pancreatitis in the PROCAP study and therefore we are unable to compare our findings. Conclusions Rates of antibiotic prescribing for patients at RCHT with pancreatitis are comparable to those in the PROCAP non-PCT guided treatment group which might suggest that adoption of PCT in our hospital could reduce antibiotic prescribing, as per the findings of the PROCAP study. Rates of antibiotic prescribing for pancreatitis at RCHT are low, with the majority of prescribing for extra-pancreatic indications, although the indication was unclear in approximately one third of episodes. The PROCAP study does not report rates of prescribing for pancreatitis which prevents estimating the impact of PCT on antimicrobial prescribing for pancreatitis at RCHT. Whether PCT has a role in reducing antimicrobial prescribing for patients with pancreatitis at RCHT is unclear.

Etiological differences in demographics, clinical course and consequences of acute pancreatitis: a retrospective study.

Aim: The study is intended to consider acute pancreatitis from the point of view of its etiological structure, as well as demographic description, features of the clinical course, distribution of morphological forms, severity and consequences of the disease in different etiological variants. Materials and Methods: The work was based on a retrospective analysis of the medical records of 677 patients with acute pancreatitis who underwent inpatient treatment from 2017 to 2022 in an emergency hospital and a tertiary regional hospital in Vinnytsia, Ukraine. Results: The etiological structure of the general sample was as follows: the alimentary factors - 37,5% of cases, biliary - 18,6%, alcohol - 14,0% and postoperative - 7,8%, respectively. The oldest patients were observed in the group with biliary AP (age [median, interquartile range] 61 [46-72] years), the youngest - in the group with alcoholic AP (age [median, interquartile range] 40 [35-47] years). Men significantly predominated in the groups with alimentary and alcoholic AP. A significant predominance of women was observed in the group with biliary AP (62,7% vs. 37,3%, p=0,0003). The highest mortality was in the alcoholic AP group (22,1%), also here was a significantly lower rate of inpatient bed days (6,0). Edematous AP was dominant in all etiological variants. While infected necrotic pancreatitis was significantly more often found in patients with alcoholic genesis (7,4%). Conclusions: The etiologic variations of acute pancreatitis differ by demographic and clinical indicators and require more detailed study to understand its prognosis, management, and development of effective prevention and treatment strategies.

Endoscopic versus minimally invasive surgical approach for infected necrotizing pancreatitis: a systematic review and meta-analysis of randomized controlled trials

Background/Aims Acute pancreatitis is a common condition of the digestive system, but sometimes it develops into severe cases. In about 10–20% of patients, necrosis of the pancreas or its periphery occurs. Although most have aseptic necrosis, 30% of cases will develop infectious necrotizing pancreatitis. Infected necrotizing pancreatitis (INP) requires a critical treatment approach. Minimally invasive surgical approach (MIS) and endoscopy are the management methods. This meta-analysis compares the outcomes of MIS and endoscopic treatments. Methods We searched a medical database until December 2022 to compare the results of endoscopic and MIS procedures for INP. We selected eligible randomized controlled trials (RCTs) that reported treatment complications for the meta-analysis. Results Five RCTs comparing a total of 284 patients were included in the meta-analysis. Among them, 139 patients underwent MIS, while 145 underwent endoscopic procedures. The results showed significant differences (p < 0.05) in the risk ratios (RRs) for major complications (RR: 0.69, 95% confidence interval (CI): 0.49–0.97), new onset of organ failure (RR: 0.29, 95% CI: 0.11–0.82), surgical site infection (RR: 0.26, 95% CI: 0.07–0.92), fistula or perforation (RR: 0.27, 95% CI: 0.12–0.64), and pancreatic fistula (RR: 0.14, 95% CI: 0.05–0.45). The hospital stay was significantly shorter for the endoscopic group compared to the MIS group, with a mean difference of 6.74 days (95% CI: −12.94 to −0.54). There were no significant differences (p > 0.05) in the RR for death, bleeding, incisional hernia, percutaneous drainage, pancreatic endocrine deficiency, pancreatic exocrine deficiency, or the need for enzyme use. Conclusions Endoscopic management of INP performs better compared to surgical treatment due to its lower complication rate and higher patient life quality.

Elevated CK-MB levels are associated with adverse clinical outcomes in acute pancreatitis: a propensity score-matched study.

Cardiac injury, reflected by the measured concentrations of chemicals released from injured cardiac muscle, is common in acute pancreatitis (AP). However, there is no adequate evidence assessing the impact of cardiac injury on AP-related outcomes. Creatine kinase-myocardial band (CK-MB) mainly exists in the myocardium. Therefore, we sought to evaluate the relationship between the increase in CK-MB and the adverse clinical outcomes of AP. This propensity score-matched study analyzed AP patients admitted to the Department of Gastroenterology in the First Affiliated Hospital of Nanchang University from June 2017 to July 2022. Propensity score matching and multivariate logistic regression analysis were used to explore the relationship between CK-MB elevation and AP outcome variables. A total of 5,944 patients were screened for eligibility, of whom 4,802 were ultimately enrolled. Overall, 896 (18.66%) of AP patients had elevated (>24 U/ml) CK-MB levels, and 895 (99.89%) were paired with controls using propensity score matching. The propensity score-matched cohort analysis demonstrated that mortality (OR, 5.87; 95% CI, 3.89-8.84; P < 0.001), severe acute pancreatitis (SAP) (OR, 2.74; 95% CI, 2.23-3.35; P < 0.001), and infected necrotizing pancreatitis (INP) (OR, 3.40; 95% CI, 2.34-4.94; P < 0.001) were more frequent in the elevated CK-MB (>24 U/ml) group than in the normal CK-MB (≤ 24 U/ml) group. Using the multivariate logistic regression analysis, elevated CK-MB levels were independently associated with increased mortality (OR, 2.753, 95% CI, 2.095-3.617, P < 0.001), SAP incidence (OR, 2.223, CI, 1.870-2.643, P < 0.001), and INP incidence (OR, 1.913, 95% CI, 1.467-2.494, P < 0.001). CK-MB elevation was an independent risk factor for adverse clinical outcomes in AP patients. CK-MB elevation was significantly related to adverse outcomes in AP patients, which makes it a potentially useful laboratory parameter for predicting adverse clinical outcomes of AP.

A Risk Score for Predicting the Necessity of Surgical Necrosectomy in the Treatment of Infected Necrotizing Pancreatitis

BackgroundFor infected necrotizing pancreatitis (INP), percutaneous catheter drainage (PCD) is now widely acknowledged as the initial intervention in a step-up approach, followed, if necessary, by minimally invasive necrosectomy or even open pancreatic necrosectomy. However, an overemphasis on PCD may cause a patient’s condition to deteriorate, leading to missed surgical opportunities or even death. This study aimed to develop a simple and convenient scoring tool for assessing the need for surgery in INP patients who received PCD procedures. MethodsIn an observational study conducted between April 2015 and December 2020, PCD was utilized as the initial step to treat 143 consecutive INP patients. A surgical necrosectomy was performed when the patient failed to respond. Risk factors of PCD failure (i.e., need for surgical necrosectomy) were identified by multivariate logistic regression models. An integer-based risk scoring tool was developed using the β coefficients derived from the logistic regression model. ResultsIn 62 (43.4%) patients, PCD was successful, while the remaining 81 (56.6%) individuals required subsequent surgical necrosectomy. In the multivariate model, organ failure, percentage of pancreatic necrosis, extrapancreatic necrosis volume, and mean CT density of extrapancreatic necrosis volume were associated with a need for surgical necrosectomy. A predictive scoring tool based on these four factors demonstrated an area under the receiver operating characteristic curve (AUC) of 0.893. Under the scoring tool, a total score of 4 or more indicates a high possibility of surgical necrosectomy being required (at least 80%). Using the coordinates of the receiver operating characteristic curve (ROC), the sensitivity and specificity at this threshold are 0.802 and 0.903, respectively. ConclusionsA risk score model integrating organ failure, percentage of pancreatic necrosis, extrapancreatic necrosis volume, and mean CT density of extrapancreatic necrosis volume can identify INP patients at high risk for necrosectomy. The straightforward risk assessment tool assists clinicians in stratifying INP patients and making more judicious medical decisions.

Nomogram development and validation for predicting minimally invasive step-up approach failure in infected necrotizing pancreatitis patents: a retrospective cohort study.

Previous studies have shown that minimally invasive treatment for infected necrotizing pancreatitis (INP) may be safer and more effective than open necrosectomy (ON), but ON is still irreplaceable in a portion of INP patients. Furthermore, there is a lack of tools to identify INP patients at risk of minimally invasive step-up approach failure (eventually received ON or died), which may enable appropriate treatment for them. Our study aims to identify risk factors that can predict minimally invasive step-up approach failure in INP patients and to develop a nomogram for early prediction. Multivariate logistic regression was performed to evaluate the association between minimally invasive step-up approach failure and factors regarding demographics, disease severity, laboratory index and the location of extrapancreatic necrotic collections. A novel nomogram was developed, and its performance was validated both internally and externally by its discrimination, calibration, and clinical usefulness. There were 267, 89, and 107 patients in the training, internal and external validation cohorts, respectively. Multivariate logistic regression demonstrated that the CT severity index (CTSI) greater than 8 points, Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 16 points or more, early spontaneous bleeding, fungi infection, granulocyte and platelet decrease within 30 days of acute pancreatitis onset, and extrapancreatic necrosis collection located in small bowel mesentery were independent risk factors for minimally invasive step-up approach failure. The area under the curve and coefficient of determination (R2) of the nomogram constructed from the above these factors were 0.920 and 0.644, respectively. The Hosmer-Lemeshow test showed that the model had a good fitness (P=0.206). In addition, the nomogram performed well in both the internal and external validation cohorts. The nomogram had a good performance in predicting minimally invasive step-up approach failure, which may help clinicians early distinguish INP patients at risk of minimally invasive step-up approach failure.

Endoscopic transluminal drainage and necrosectomy for infected necrotizing pancreatitis: Progress and challenges.

Infected necrotizing pancreatitis (INP) represents a severe condition in patients with acute pancreatitis. Invasive interventions are recommended in symptomatic INP. Growing evidence has suggested interventional strategies of INP evolving from traditional surgery to minimally invasive step-up endoscopic procedures. However, there is still no standardized protocol for endoscopic interventions. Recently, various studies have been published about the endoscopic management of INP. This article reviews published articles and guidelines to present the progress and challenges of endoscopic transluminal drainage and necrosectomy in INP.

Invasive intervention timing for infected necrotizing pancreatitis: Late invasive intervention is not late for collection.

With the advance of invasive interventions, the treatment model for infected necrotizing pancreatitis (INP) has shifted from open surgery to the step-up minimally invasive treatment. Late intervention, originating from the open surgery era, has been questioned in the minimally invasive period. With the emergence of new high-quality evidence about the timing for intervention, it seems to be increasingly apparent that, even in the age of minimal invasiveness, “late intervention” waiting for the necrotic collections to be encapsulated is still necessary. This opinion review mainly discusses the intervention timing for INP.

Interventional strategies in infected necrotizing pancreatitis: Indications, timing, and outcomes.

Acute pancreatitis (AP) is one of the most common gastrointestinal diseases and remains a life-threatening condition. Although AP resolves to restitutio ad integrum in approximately 80% of patients, it can progress to necrotizing pancreatitis (NP). NP is associated with superinfection in a third of patients, leading to an increase in mortality rate of up to 40%. Accurate and early diagnosis of NP and associated complications, as well as state-of-the-art therapy are essential to improve patient prognoses. The emerging role of endoscopy and recent trials on multidisciplinary management of NP established the “step-up approach”. This approach starts with endoscopic interventions and can be escalated to other interventional and ultimately surgical procedures if required. Studies showed that this approach decreases the incidence of new multiple-organ failure as well as the risk of interventional complications. However, the optimal interventional sequence and timing of interventional procedures remain controversial. This review aims to summarize the indications, timing, and treatment outcomes for infected NP and to provide guidance on multidisciplinary decision-making.

Cost-effectiveness analysis of infected necrotizing pancreatitis management in an academic setting

Background and aimsTraditional management for infected necrotizing pancreatitis (INP) often utilizes open necrosectomy, which carries high morbidity and complication rates. Thus, minimally invasive strategies have gained favor, specifically step-up approaches utilizing endoscopic or minimally-invasive surgery (MIS); however, the ideal management modality for INP has not been identified. MethodsA decision tree model was designed to analyze costs and survival associated with open necrosectomy, endoscopic step-up, and MIS step-up protocols for management of INP after 4 weeks of necrosis development with adequate retroperitoneal access. Costs were based on a third-party payer perspective using Medicare reimbursement rates. The model's effectiveness was represented by quality-adjusted life-years (QALYs). Sensitivity analyses were performed to validate results. ResultsEndoscopic step-up was the dominant economic strategy with 7.92 QALYs for $90,864.09. Surgical step-up resulted in a decrease of 0.09 QALYs and a cost increase of $10,067.89 while open necrosectomy resulted in a decrease of 0.4 QALYs and an increased cost of $18,407.52 over endoscopic step-up. In 100,000 random-sampling simulations, 65.5% of simulations favored endoscopic step-up. MIS step-up was favored when MIS acute mortality rates fell and when MIS drainage success rates rose. ConclusionsIn our simulated patients with INP, the most cost-effective management strategy is endoscopic step-up. Cost-effectiveness varies with changes in acute mortality and drainage success, which will depend on local expertise.

Delayed Drainage of Infected Pancreatic Necrosis Is Safe

The current American Gastroenterological Association guidelines recommend strong consideration of catheter drainage of infected necrotic pancreatitis

Rethinking Carbapenems: A Pharmacokinetic Approach for Antimicrobial Selection in Infected Necrotizing Pancreatitis.

To provide an overview of pathophysiological changes to the pancreas during infected necrotizing pancreatitis (INP), optimal drug properties needed to penetrate the pancreas, human and animal studies supporting the use of antimicrobials, and carbapenem-sparing strategies in INP. A literature analysis of PubMed/MEDLINE was performed (from 1960 to September 2020) using the following key terms: infected necrotizing pancreatitis, necrotizing acute pancreatitis, and infected pancreatitis antimicrobial concentration. Individual antimicrobials were investigated with these search terms. All relevant studies describing the management of INP, and human and animal pharmacokinetic (PK) data supporting antimicrobial use in the pancreas were reviewed for possible inclusion regardless of sample size or study design. Piperacillin/tazobactam and cefepime achieve adequate pancreatic tissue concentrations in INP studies. A majority of the literature supporting carbapenem use in INP involves imipenem, and meropenem Monte Carlo simulations suggest that standard dosing regimens of meropenem may not achieve PK targets to eradicate Pseudomonas aeruginosa. Carbapenems are often utilized for INP treatment based on guideline recommendations. This review discusses PK data, the history of carbapenem use in INP, and the pathophysiology of pancreatitis to suggest carbapenem-sparing strategies and provides stewardship tactics such as when to start antimicrobials, which empirical antimicrobial to use, and when to discontinue antimicrobials in the INP setting. Noncarbapenem antipseudomonals, such as piperacillin/tazobactam and cefepime, are appropriate carbapenem-sparing options in INP, based on PK data, spectrum of activity, and risk of collateral damage.

EXTRAPANCREATIC INFECTION AS A RISK FACTOR FOR ANTIBIOTIC RESISTANCE OF PANCREATIC INFECTIOUS AGENTS IN PATIENTS WITH ACUTE NECROTIZING PANCREATITIS

Aim of the study To determine the effect of extrapancreatic infection (EPI) on antibacterial resistance of pancreatic infectious agents in patients with acute infected necrotic pancreatitis&#x0D; Materials and Methods A longitudinal retrospective case-control study was conducted. The Object of the study were the patients with infected acute necrotizing pancreatitis (ANP). The subject of the study was the acquired AMR of pancreatic infection (PI) agents in patients with ANP. The control group included 27 patients who had a positive bacterial culture from sources of PI. 21 patients were included in the risk group, in which the additional source of EPI was recorded. Bacteriological monitoring was conducted in two stages: the primary identification of the agent of PI and the completion of inpatient treatment. Microbiological identification of the pathogen of EPI was performed before the primary determination of the pathogen of PI, and in the interval between stages I and II of the study. According to the results of the resistance profile of PI to AMR, all patients were divided into four clusters: I - patients who identified only antibiotic-sensitive bacterial strains (AMR"-"), II - patients with defined MDR-bacteria (multidrug-resistant), III - patients with XDR-bacteria (extensively drug-resistant), IV - patients with PDR bacteria (pandrug-resistant).&#x0D; Results The presence of EPI in patients with ANP influences the development of AMRs of PI toward increasing XDR and PDR strains (p=0.008 and p=0.04, respectively). In patients with infected ANP with the EPI, the risk of developing XDR infection was 2.4 times higher than the risk of developing this level of AMR in patients with no EPI (RR-2.4 (95% CI-1.16-4.91), p=0.03). EPI increases the risk of PDR PI by 8 times (RR-8.0 (95% CI-1.04-61.5) p=0.04). For each patient with infected ANP with signs of EPI, the risk of developing XDR strains was 36%, and PDR strains - 25%.&#x0D; Conclusions The presence of extrapancreatic sources of infection is a risk factor for development of AMR strains of microorganisms that persist in the sources of pancreatic infection. In this category of patients the risk of identification of extensively resistant strains was increased by 2.4-fold (p=0.03) and PDR strains by 8-fold (p=0.04), compared with patients with infected ANP without EPI.

Knowledge, Perception, and Antibiotic Prescribing Practice in the Intensive Care Unit: Findings from the Malaysian Public Setting.

ABSTRACTIntroduction:Approach to managing infection in the intensive care unit (ICU) often varies between institutions and not many readily adapt to available local guidelines despite it was constructed to suite local clinical scenario. Malaysia already has two published guidelines on managing infection in the ICU but data on its compliance are largely unknown.Objectives:A cross-sectional survey was carried out and sent to a total of 868 specialists working primarily in the ICU. The aim of this study was to explore knowledge, perception, and the antibiotic prescribing practice among specialists and advanced trainees in Malaysian ICU.Materials and Methods:A cross-sectional survey was used, consisted of three sections: knowledge, perception, and antibiotic prescribing practice in ICU. Three case vignettes on hospital-acquired pneumonia (HAP), infected necrotizing pancreatitis (INP), and catheter-related bloodstream infection (CRBSI) were used to explore antibiotic prescribing practice.Results:A total of 868 eligible subjects were approached with 104 responded to the survey. Three hundred eighty-nine antibiotics were chosen from seven different classes in the case vignettes. All respondents acknowledged the importance of pharmacokinetic/pharmacodynamic (PK/PD) in antibiotic optimization and majority (97.2%) perceived that current dosing is inadequate to achieve optimal PK/PD target in ICU patients. Majority (85.6%) believed that antibiotic dose should be streamlined to the organisms’ minimum inhibitory concentration (MIC). In terms of knowledge, only 64.4% provided the correct correlations between antibiotics and their respective PK/PD targets. Compliance rates in terms of antibiotic choices were at 79.8%, 77.8%, and 27.9% for HAI, INP, and CRBSI, respectively.Conclusion:Malaysian physicians are receptive to use PK/PD approach to optimize antibiotic dosing in ICU patients. Nonetheless, there are still gaps in the knowledge of antibiotic PK/PD as well as its application in the critically ill, especially for β-lactams.

ТАКСОНОМІЧНА СТРУКТУРА ЗБУДНИКІВ ПАНКРЕАТИЧНОЇ ІНФЕКЦІЇ У ПАЦІЄНТІВ НА ГОСТРИЙ НЕКРОТИЧНИЙ ПАНКРЕАТИТ

У статті висвітлено зміну рівня антимікробної резистентностіінфекційних агентів при гострому інфікованому некротичному панкреатиті упацієнтів в динаміці захворювання та проведеного лікування, класифікованоотримані дані згідно з чутливістю мікроорганізмів. Основною метою проведеногопроспективного когортного дослідження є визначення таксономічної структуризбудників панкреатичної інфекції у пацієнтів на гострий некротичний панкреатиту динаміці. Актуальність дослідження даної патології полягає у значущостіфеномену підвищення рівня антибіотикорезистентності впродовж тривалоїантибіотикотерапії, що показана пацієнтам з панкреатичною інфекцією.Методика проведення дослідження полягала в трьохетапному біктеріологічномумоніторингу та наступній якісній та кількісній оцінці мікробних агентів тахарактеристикою антибіотикорезистентності згідно з стратифікованоюкласифікацією European Centre for Disease Control (Magiorakos et al., 2012): у 123мікробних ізолятах, які були ідентифіковані під час дослідження, за результатамиантибіотикограм оцінено таксономічну структуру збудників панкреатичноїінфекції. Тривалість дослідження становила весь термін діагностованогоінфекційного процесу і в середньому склала 33,4 доби. Об’єктом дослідження обраномікробні ізоляти, які було виділено у вищеназвані терміни з біологічного матеріалупацієнтів: аспірату парапанкреатичних рідинних скупчень на початковому етапі,видалених панкреатичних секвестрів на другому етапі та виділення з дренажівсальникової сумки та заочеревинної клітковини на третьому етапі. Дослідженняемпірично підтверджує та теоретично доводить, що якісна складова мікробнихзбудників гострого інфікованого некротичного панкреатиту характеризуєтьсячасозалежністю: рівень класифікованої резистентності вище на третьому етапідослідження порівняно з отриманими характеристиками мікроорганізмів напершому та, відповідно, другому етапах дослідження, послідовна бактеріологічнахарактеристика вказує на перехід з моно- до міксінфекції. (р&amp;lt; 0,001) з включеннямвже на другому етапі всіх членів ‘ESKAPE’-групи та переважанням грамнегативноїфлори на кожному з етапів. Грибкова складова отриманих мікроорганізмів,починаючи з другого етапу дослідження представлена єдиним збудником тавиключно в групі з бактеріями. Результати проведеного дослідження можуть бути корисними при прогнозі успішності антибіотикотерапії на різних етапахпротікання даного захворювання та очікуваної бактеріологічної характеристикипри послідовних бактеріологічних посівах біологічного матеріалу пацієнтіввпродовж перебігу гострого інфікованого некротичного панкреатиту.

The effect of technical details of percutaneous catheter drainage on the clinical outcomes of infected necrotizing pancreatitis patients

Background/aim This study aimed to investigate the effect of technical details of percutaneous catheter drainage (PCD) on the clinical outcomes of patients with infected necrotizing pancreatitis (INP).Materials and methods A total of 44 INP patients treated in our hospital from October 2013 to October 2015 were included. The correlations of the first PCD treatment data and the clinical outcomes were analyzed.Results The number of catheters was positively correlated with hospital readmission (r = 0.335, P = 0.032). Receiver operating characteristic curve analysis showed that patients with ≥ 3 catheters were more likely to have hospital readmission. Patients with pleural effusion undergoing thoracentesis were more likely to have new intensive care unit admission (P = 0.025) and bleeding in need of intervention (P = 0.032). Patients with more effusion regions had higher incidences of mortality (P = 0.012) and new intensive care unit admissions (2.44 ± 1.03 vs. 1.88 ± 0.80; P = 0.059). Patients with PCD only were less likely to have new intensive care unit admissions (22.22% vs. 54.55%; P = 0.038) than those with PCD + small incision or/and videoscopic assisted retroperitoneal debridement. Conclusion Number of catheters greater than three was associated with unfavorable outcomes of PCD treatment in INP patients. Patients that received PCD treatment only had better outcomes.

Outcomes from different minimally invasive approaches for infected necrotizing pancreatitis.

Infected necrotizing pancreatitis (INP), the leading cause of mortality in the late phase of acute pancreatitis, nearly always requires intervention. In recent years minimal invasive surgery is becoming more and more popular for the management of INP, but few studies compared different minimally invasive strategies. The objective of this observation study was to evaluate the safety and effectiveness with several minimal invasive treatment.We retrospectively reviewed cases of percutaneous catheter drainage (PCD), minimal access retroperitoneal pancreatic necrosectomy (MARPN), small incision pancreatic necrosectom (SIPN), single-incision access port retroperitoneoscopic debridement (SIAPRD) for INP between January 2013 and October 2018. Data were analyzed for the primary endpoints as well as secondary endpoints.Eighty-one patients with INP were treated by minimally invasive procedures including PCD (n = 32), MARPN (n = 18), SIPN (n = 16), and SIAPRD (n = 15). Overall mortality was greatest after PCD 34% (MARPN 11% vs SIPN 6% vs SIRLD6%). Problems after initial surgery were ongoing sepsis (PCD 56% vs MARPN 50% vs SIPN 31% vs SIAPRD13%; P < .05). There was a significant difference in number of interventions (median, 6 vs 5 vs 3 vs 2; P < .05). Time from onset of symptoms to recovery was less for SIAPRD than for PCD, MARPN, or SIPN (median, 45 vs 102 vs 80 vs 67 days; P < .05).SIAPRD remedy evidently improved outcomes, including systemic inflammatory response syndrome, number of interventions, length of hospital stay and overall cost. It is technically feasible, safe, and effective for INP, in contrast to others, and can achieve the best clinical results with the least cost. Furthermore, relevant multicentre randomized controlled trials are eager to prove these findings.

Step-up approach for acute infected necrotizing pancreatitis

Purpose of the study. The role of interventional methods of the treatment of acute infected necrotic pancreatitis depending on the morphological characteristics of the disease was determined.&#x0D; Material and methods. In present prospective cohort study, we included 96 patients with acute infected necrotizing pancreatitis. All patients were stratified according to morphologic features. Stepup approach with following steps of interventions was applied: percutaneous drainage of infected fluid collections, increasing of drainages diameter and number of it and open or minimally invasive necrosectomy. Clinical, laboratory, and instrumental monitoring were the defining indicators for the stopping of the treatment or for the passing to the next step of the treatment.&#x0D; Results. At the first step 7 of 96 patients with superficial focal necrosis, a necrosis index of 2 points and a category D were successfully treated. Other 89 patients were passed to the second step of treatment, of which 23 patients with superficial subtotal necrosis, necrosis index of 2 points and category E were successfully treated. Another 66 patients had undergone a third step of treatment. A multivariate regression analysis was conducted that allowed to identify predictive factors of inefficiency of using of percutaneous drainage interventions (stages I and II) as a final stage of treatment: transmural subtotal or total necrotizing pancreatitis (OR = 1,58; 95% CI 1,03–3,88; p = 0,033); Necrosis index of 4 or more points (OR = 3.19, 95% CI 1.57–8.37; p = 0,003); heterogeneous peripancreatic fluid collection (OR = 4,15, 95% CI 1,49–5.19; p = 0,001); The CT-index of severity of acute pancreatitis of 7 or more points (OR = 1,89, 95% CI: 1,03–3,43; p = 0,029).&#x0D; Conclusion. Step-up approach showed following results: 7,3% patients were treated at the first step, 24% – at the second step. Third step of treatment was applied in 68,7% of patients, of witch 12,5% was treated with laparoscopic necrosectomy. Predictors of ineffectiveness of ultrasound guided percutaneous drainage as the final treatment method are: necrosis index of 4 or more, heterogeneous paripancreatic fluid collections, subtotal and transmural necrotizing pancreatitis.