TY - JOUR
T1 - Overuse and Misuse of Antibiotics and the Clinical Consequence in Necrotizing Pancreatitis
T2 - An Observational Multicenter Study
AU - Timmerhuis, Hester C.
AU - van den Berg, Fons F.
AU - Noorda, Paula C.
AU - van Dijk, Sven M.
AU - van Grinsven, Janneke
AU - Sperna Weiland, Christina J.
AU - Umans, Devica S.
AU - Mohamed, Yasmin A.
AU - Curvers, Wouter L.
AU - Bouwense, Stefan A. W.
AU - Hadithi, Muhammed
AU - Inderson, Akin
AU - Issa, Yama
AU - Jansen, Jeroen M.
AU - de Jonge, Pieter Jan F.
AU - Quispel, Rutger
AU - Schwartz, Matthijs P.
AU - Stommel, Martijn W. J.
AU - Tan, Adriaan C. I. T. L.
AU - Venneman, Niels G.
AU - Besselink, Marc G.
AU - Bruno, Marco J.
AU - Bollen, Thomas L.
AU - Sieswerda, Elske
AU - Verdonk, Robert C.
AU - Voermans, Rogier P.
AU - Dutch Pancreatitis Study Group
AU - van Santvoort, Hjalmar C.
N1 - Funding Information: This study is investigator-initiated (St. Antonius Hospital) and is supported by the Antonius Research Fund. The funder had no role in any part of the study design, conduct and analysis. Publisher Copyright: Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.
PY - 2023/10/1
Y1 - 2023/10/1
N2 - 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.
AB - 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.
KW - antibiotics
KW - antifungal
KW - antimicrobial
KW - microbiology
KW - necrotizing pancreatitis
UR - http://www.scopus.com/inward/record.url?scp=85170295179&partnerID=8YFLogxK
U2 - https://doi.org/10.1097/SLA.0000000000005790
DO - https://doi.org/10.1097/SLA.0000000000005790
M3 - Article
C2 - 36728517
SN - 0003-4932
VL - 278
SP - e812-e819
JO - Annals of surgery
JF - Annals of surgery
IS - 4
ER -