Procalcitonin-based algorithm may guide antibiotic use in acute pancreatitis

Measurement of this peptide can help detect infections.

louis ochoa

August 01, 2022 | | Reading time: 5 minutes

Both chronic and acute pancreatitis can cause the pancreas to produce fewer enzymes than are needed to break down and process nutrients from food. Photo: Shutterstock.

According to the results of a randomized controlled trial, an algorithm based on the procalcitonin could safely reduce the unnecessary use of antibiotics in patients with acute pancreatitis.

The researchers wrote in The Lancet Gastroenterology & Hepatology, that “antibiotic overuse and the resulting emergence of multidrug-resistant microorganisms is a potent threat to the well-being of humanity in the 21st century.”

Additionally, lead author Ajith K. Siriwardena, MD, suggested that clinicians should consider incorporating the decision-making process into their daily practice.

Overuse of antibiotics is common in cases of acute pancreatitis, the researchers said, because clinical features are often insufficient to distinguish between inflammation and infection. Although the measurement of procalcitonin may help detect infections, “bullet measurement” of the biomarker is not cost-effective, leading previous reviews and analyzes to conclude that more research is needed before widespread use can be recommended.

Siriwardena and colleagues attempted to fill this need by conducting a randomized controlled trial involving 260 patients hospitalized for acute pancreatitis.

Patients were randomized in a ratio close to 1:1. Both the intervention group and the control group received guideline-based care; however, in addition to the standard of care, the procalcitonin in the intervention group on days 0, 4 and 7 and weekly thereafter. Among these patients, antibiotics were stopped or not started when the procalcitonin was below 1.0 ng/mL, but antibiotics were started or continued when the procalcitonin was 1.0 ng/mL or more.

The primary outcome was the presence or absence of antibiotic use during the hospital stay. A range of secondary outcomes were also reported, including all-cause mortality, days of antibiotic use, infection rates, and endoscopic, radiological, or surgical intervention.

Significantly fewer patients in the group of procalcitonin received antibiotics during their stay, compared to the usual care group (45% vs. 63%), resulting in an adjusted risk difference of -15.6%. The patients in the group procalcitonin who received antibiotics received about 1 fewer days of antibiotic treatment.

“The algorithms based on procalcitonin to guide the use of antibiotics should be considered in the care of this group of patients and incorporated into future guidelines on the management of the disease. acute pancreatitis“, the researchers concluded.

Despite reduced antibiotic use, length of hospital stay was similar between groups, as were rates of clinical infection, hospital-acquired infection, death, and adverse events, suggesting that the algorithm safely reduced the use of antibiotics without negatively affecting clinical outcomes, according to researchers.

Dr. Aaron Sasson, MD, director of the cancer center of pancreas and co-leader of the gastrointestinal oncology team at Stony Brook (NY) Medicine, said the study is noteworthy because it addresses an important issue with a large prospective randomized trial; however, he pointed out some limitations.

“There are several problems with this trial. First, it included a large percentage of patients with acute pancreatitis mild, a group of patients for whom the use of antibiotics is not controversial. Second, the rate of infected pancreatic necrosis was 5% in both arms of the study, indicating a lack of severity in the patient cohort.”

Sasson said the algorithm “could be useful” in differentiating between inflammation and infection in patients with acute pancreatitis“but only as a complement to other clinical parameters”.

He suggested that the algorithm would be more useful if it could distinguish between pancreatic necrosis and infected pancreatic necrosis. “Unfortunately, this trial did not answer this question,” she said, noting that a similar trial involving “only patients with severe pancreatitis” would be needed.

Source consulted here.