Risk factors and outcomes of infected pancreatic necrosis: Retrospective cohort of 148 patients admitted to the ICU for acute pancreatitis

Abstract

Objective: The primary objective of this article is to identify risk factors for infected pancreatic necrosis (IPN) in patients admitted to the intensive care unit (ICU) for severe acute pancreatitis. We also described outcomes of IPN. Background: Acute pancreatitis is common and associated with multiple, potentially life-threatening complications. Over the last decade, minimally invasive procedures have been developed to treat IPN. Methods: We retrospectively studied consecutive patients admitted for severe acute pancreatitis to the ICUs of the Nantes University Hospital in France, between 2012 and 2015. Logistic regression was used to evaluate potential associations linking IPN to baseline patient characteristics and outcomes. Results: Of the 148 included patients, 26 (17.6%) died. IPN developed in 62 (43%) patients and consistently required radiological, endoscopic, and/or surgical intervention. By multivariate analysis, factors associated with IPN were number of organ failure (OF) (for ! 3: OR, 28.67 (6.23-131.96), p < 0.001) and portosplenomesenteric venous thrombosis (OR, )).Conclusion: IPN occurred in nearly half our ICU patients with acute pancreatitis and consistently required interventional therapy. Number of OFs and portosplenomesenteric venous thrombosis were significantly associated with IPN. Early management of OF may reduce IPN incidence, and management of portosplenomesenteric venous thrombosis should be investigated. KeywordsSevere acute pancreatitis, infected pancreatic necrosis, risk factors, intensive care, portosplenomesenteric venous thrombosis Received: 6 November 2017; accepted: 10 February 2018 Key summaryInfected pancreatic necrosis (IPN) increases the already high morbidity and mortality rates in severe acute pancreatitis. Whereas the step-up approach is now advocated for management of IPN, few clinical risk factors are known.Half the patients in a retrospective cohort developed IPN. Independent risk factors of IPN were portosplenomesenteric venous thrombosis and multiple organ failure. Anticoagulation for portosplenomesenteric venous thrombosis did not protect from the development of cavernoma.

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

“…CT showed gas bubbles within necrotic collections in 14 (25%) patients. The median number of pancreatic samples per patient was 2 [1][2][3] and the total number of samples in the 56 patients was 137. The sample cultures were positive in 48 (85.7%) patients, and 8 patients (14.3%), IPN was considered as possible.…”

“…Finally, the patient characteristics before the first sample collection were not significantly different between the exposed and unexposed groups. Organ failure is common in patients with IPN [34]. The recommendation when following the step-up strategy is to wait at least 4 weeks if possible before performing a Table 1 Baseline features of the study patients overall and in the antibiotic-exposed and unexposed groups a IPN infected pancreatic necrosis, IQR interquartile range, BMI body mass index, SAPS II Simplified Acute Physiology Score version II, CTSI Computed Tomography Severity Index, ICU intensive care unit a Exposure was defined as patients who were started on antibiotics more than 24 h before the first pancreatic sample was collected b Other causes of pancreatitis: hypertriglyceridemia, drugs, endoscopic retrograde cholangiopancreatography, and unknown c The SAPS II can range from 0 (least severe) to 163 (most severe, with a 100% predicted risk of death); patients with a score of 50 have a 46.1% predicted risk of death d The CTSI can range from 0 to 10; the predicted risk of death is 6% for values in the 4-6 range and 17% for values in the 7-10 range e Organ failure was defined as a modified Marshall score (Supplemental Digital Content 1) ≥ 2 for the renal, respiratory, or cardiovascular system f Multidrug-resistant bacteria were defined as bacteria with acquired non-susceptibility to at least one agent in three or more antimicrobial categories g Extensively drug-resistant bacteria were defined as non-susceptibility to at least one agent in all but two or fewer antimicrobial categories pancreatic procedure.…”

“…In the 33 patients in the exposed group, the reasons for previous antibiotic exposure were suspected IPN without shock (n = 10, 30%), suspected IPN with septic shock (n = 10, 30%), and extra-abdominal infection (n = 13, 39%; 6 for pneumonia, 3 for catheter-related infection, and 1 for urinary tract infection). The median time on antibiotics before sampling was 7 [3][4][5][6][7][8][9][10] days. The antibiotics used before sampling were broad-spectrum penicillins in half the patients ( Table 2).…”

“…The antibiotics used before sampling were broad-spectrum penicillins in half the patients ( Table 2). The median duration of overall antimicrobial therapy in the ICU was 47 days, and the number of antibiotics received overall in the ICU was significantly higher in the exposed group (5 [4][5][6][7][8] days versus 3 [2][3][4][5] days, p = 0.002).Of the 137 samples, 91 (66.4%) were from exposed patients. Of the 91 samples from exposed patients, 74 (81.3%) were positive, and of the 41 samples from unexposed patients, 32 (78%) were positive.…”

“…rates [1,2]. Infected pancreatic necrosis (IPN) develops in about one-third of patients, who are then at increased risk for death [3]. International guidelines about the management of IPN [4][5][6][7][8] recommend a step-up strategy, based on findings from randomized controlled trials [9,10].…”