Epidemiology and prognosis of anti-infective therapy in the ICU setting during acute pancreatitis: a cohort study

Abstract

BackgroundRecent international guidelines for acute pancreatitis (AP) recommend limiting anti-infective therapy (AIT) to cases of suspected necrotizing AP or nosocomial extrapancreatic infection. Limited data are available concerning empirical and documented AIT prescribing practices in patients admitted to the intensive care unit (ICU) for the management of AP.MethodsUsing a multicentre, retrospective (2009–2014), observational database of ICU patients admitted for AP, our primary objective was to assess the incidence of AIT prescribing practices during the first 30 days following admission. Secondary objectives were to assess the independent impact of centre characteristics on the incidence of AIT and to identify factors associated with crude hospital mortality in a logistic regression model.ResultsIn this cohort of 860 patients, 359 (42%) received AIT on admission. Before day 30, 340/359 (95%) AIT patients and 226/501 (45%) AIT-free patients on admission received additional AIT, mainly for intra-abdominal and lung infections. A large heterogeneity was observed between centres in terms of the incidence of infections, therapeutic management including AIT and prognosis. Administration of AIT on admission or until day 30 was not associated with an increased mortality rate. Patients receiving AIT on admission had increased rates of complications (septic shock, intra-abdominal and pulmonary infections), therapeutic (surgical, percutaneous, endoscopic) interventions and increased length of ICU stay compared to AIT-free patients. Patients receiving delayed AIT after admission and until day 30 had increased rates of complications (respiratory distress syndrome, intra-abdominal and pulmonary infections), therapeutic interventions and increased length of ICU stay compared to those receiving AIT on admission. Risk factors for hospital mortality assessed on admission were age (adjusted odds ratio [95% confidence interval] 1.03 [1.02–1.05]; p < 0.0001), Balthazar score E (2.26 [1.43–3.56]; p < 0.0001), oliguria/anuria (2.18 [1.82–4.33]; p < 0.0001), vasoactive support (2.83 [1.73–4.62]; p < 0.0001) and mechanical ventilation (1.90 [1.15–3.14]; p = 0.011), but not AIT (0.63 [0.40–1.01]; p = 0.057).ConclusionsHigh proportions of ICU patients admitted for AP receive AIT, both on admission and during their ICU stay. A large heterogeneity was observed between centres in terms of incidence of infections, AIT prescribing practices, therapeutic management and outcome. AIT reflects the initial severity and complications of AP, but is not a risk factor for death.

Predictors of Mortality and Drug Resistance Among Carbapenem-Resistant Enterobacteriaceae-Infected Pancreatic Necrosis Patients

“…Although only tigecycline kept a low resistance rate, we should also use these antibiotics with a microbiologic profile cautiously to preclude the occurrence of drug resistance according to our previous study [ 11 ]. Similar to Montravers et al, there was no significant difference between different antibiotic therapies in our cohort, indicating that anti-infective therapy was not related to mortality with a high risk of drug resistance [ 32 ]. In line with a previous study, carbapenem (high dose, extended infusion), piperacillin and quinolone may be recommended as anti-infective therapies for CRE IPN according to microbiology results because of effective penetration [ 13 ].…”

“…Referral, after 48 h of onset, was not associated with the mortality ( P = 0.526), which may suggest a 48-h delay could be an acceptable time because of increasing quality of therapy in lower-level hospitals. Most Chinese doctors, including those in our two centers, indiscriminately used antibiotic prophylaxis in the AP patients with ‘suspect’ infections, which may do harm in natural courses and lead to the occurrence of MDR bacterial IPN [ 13 , 32 ]. Recent guidelines also recommended not preventing IPN with antibiotic prophylaxis, but we could not analyze the impact of antibiotic prophylaxis on IPN because of the high referral rate and lack of important data before admission, which needs to be verified in the future [ 19 ].…”

Impact of prior antibiotics on infected pancreatic necrosis microbiology in ICU patients: a retrospective cohort study

“…Other patient outcomes in our study were comparable in the exposed and unexposed groups, except for a higher overall number of antibiotics in the exposed group. Similarly, in a 2019 retrospective cohort study of ICU patients with acute pancreatitis, mortality was not different between the groups with vs. without antibiotic therapy at ICU admission [46].…”

重症急性膵炎に対する予防的抗菌薬使用の現況 第49回日本救急医学会総会・学術集会より(Current status of prophylactic antimicrobial use for severe acute pancreatitis: in the 49th Annual Meeting of the Japanese Association for Acute Medicine)

“…このような世界的潮流があるにもかかわらず，現実の臨床では，PA投与は依然として広く行われている。1997年から2012年までに発表された世界各国におけるそれぞれのガイドラインへの遵守率を評価した研究のレビューでは，急性膵炎に対するPA使用率は41～88%と高い数値である 36)。日本でも同様の傾向が見られ，2016年の全国調査では，抗菌薬は軽症の2,151/2,275例（94.5%）と重症の695/704例（98.7%）に投与され，軽症・重症例ともにカルバペネムが最も多く使用されていた 1)。これに対し，フランスとベルギーの17のICUを含む多施設共同観察研究（研究期間2009～2014年）では，ICU入室時に42%（359/860例）は抗菌薬投与を受けていたが，予防的な抗菌薬投与を受けた患者はいなかったと報告されており，2001年のフランスコンセンサス勧告が影響しているのであろう，と考察されている 37)。これら疫学研究の研究期間は5年以上前に横断的に行われているものであり，ガイドライン内容が一般臨床医に広く認識されれば，その遵守率も上昇していく可能性があり，その指標としての疫学的な横断研究を繰り返していく必要性がある。…”