Primary studies included in this broad synthesis

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Estudio primario

No clasificado

Adverse clinical outcomes associated with multidrug-resistant organisms in patients with infected pancreatic necrosis.

Autores Ning C , Huang G , Shen D , Bonsu AAFK , Ji L , Lin C , Cao X , Li J
Revista Pancreatology : official journal of the International Association of Pancreatology (IAP) ... [et al.]
Año 2019
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BACKGROUND: Multidrug-resistant organisms (MDROs) is becoming a serious worldwide threat to public health. However, the impact of MDROs on the outcomes of the patients with infected pancreatic necrosis (IPN) remains unclear. This study aims to evaluate the roles of MDROs in IPN. METHODS: A prospectively maintained database of 188 patients with IPN between January 2010 and May 2019 was analyzed. The microbiology profile of organisms isolated from wall-off necrosis (WON) was specifically investigated to correlate with the outcomes of the patients. RESULTS: Of the 188 patients with IPN, 108 patients (57.4%) had MDROs detected in aspirates from WON. Carbapenem-resistant Klebsiella pneumoniae (CRKP) accounted for 43.5% of the MDROs isolated (60/138), followed by Carbapenem-resistant Acinetobacter baumanii (CRAB) (34.8%, 48/138) and Escherichia coli producing an extended-spectrum beta-lactamase (ESBLp) (6.5%, 9/138). MDROs infection was associated with higher mortality (35.2% vs 11.3%, P < 0.001), higher rate of hemorrhage (36.1% vs 11.3%, P < 0.001), longer intensive care unit (ICU) stay (23 vs 12 days, P < 0.001), longer hospital stay (68 vs 51 days, P = 0.001) and more hospitalization expenses (45,190 ± 31,680 vs 26,965 ± 17,167 $, P < 0.001). Multivariate analysis of predictors of mortality indicated that MDROs infection (OR = 2.6; 95% confidence interval [CI], 1.0-6.5; P = 0.042), age ≥ 50 years (OR = 2.6; 95% CI, 1.2-5.8; P = 0.016), severe category (OR = 2.9; 95% CI, 1.1-8.0; P = 0.035), bloodstream infection (OR = 3.4; 95% CI, 1.5-7.6; P = 0.049), step-down surgical approach (OR = 2.7; 95% CI, 1.1-6.2; P = 0.023) were significant factors. CONCLUSIONS: MDROs infection was prevalent among patients with IPN and associated with adverse clinical outcomes and increased mortality.

Estudio primario

No clasificado

2019 WSES guidelines for the management of severe acute pancreatitis.

Revista World Journal of Emergency Surgery
Año 2019
Enlaces Pubmed DOI PubMed Central https://doi.org/10.1186/s13017-019-0247-0

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Although most patients with acute pancreatitis have the mild form of the disease, about 20-30% develops a severe form, often associated with single or multiple organ dysfunction requiring intensive care. Identifying the severe form early is one of the major challenges in managing severe acute pancreatitis. Infection of the pancreatic and peripancreatic necrosis occurs in about 20-40% of patients with severe acute pancreatitis, and is associated with worsening organ dysfunctions. While most patients with sterile necrosis can be managed nonoperatively, patients with infected necrosis usually require an intervention that can be percutaneous, endoscopic, or open surgical. These guidelines present evidence-based international consensus statements on the management of severe acute pancreatitis from collaboration of a panel of experts meeting during the World Congress of Emergency Surgery in June 27-30, 2018 in Bertinoro, Italy. The main topics of these guidelines fall under the following topics: Diagnosis, Antibiotic treatment, Management in the Intensive Care Unit, Surgical and operative management, and Open abdomen.

Estudio primario

No clasificado

Impact of Antibiotic-Resistant Bacterial and Fungal Infections in Outcome of Acute Pancreatitis.

Revista Pancreas
Año 2018
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OBJECTIVES: The knowledge about pathogens and their antibiotic susceptibility patterns is essential to select an appropriate antibiotic. METHODS: We investigated the microbiological profile in pancreatic and extrapancreatic infections, and antibiotic sensitivity pattern in patients with acute pancreatitis. RESULTS: Of 556 patients with acute pancreatitis, only 189 developed bacterial infection; however, bacteremia was present in 42 patients (7.6%). Culture-proven infected pancreatic necrotic collection was present in 161 patients (29%). Escherichia coli and Klebsiella pneumoniae were the most common organisms. Among the bacterial infection cohort, 164 patients developed multidrug-resistant bacterial infection. Infection with multidrug-resistant bacteria, especially at multiple sites, increased mortality. Nearly 50% of patients (n = 94) acquired extremely drug-resistant bacterial infection at some time and emerged as key reason for prolonged hospital and intensive care unit stay. Colistin resistance and tigecycline resistance were documented in 2.1% and 17.2% of the specimens at admission and in 4.6% and 21% of specimens during the hospital stay. Of 556 patients, 102 patients developed fungal infection and 28 patients had only fungal infection without bacterial infection. CONCLUSIONS: Colistin and tigecycline are best reserved as last-resort antibiotics. Fungal infection was found to be associated with increased mortality, median hospital stay, and intensive care unit stay.

Estudio primario

No clasificado

Infected Pancreatic Necrosis due to Multidrug-Resistant Organisms and Persistent Organ failure Predict Mortality in Acute Pancreatitis.

Revista Clinical and translational gastroenterology
Año 2018
Enlaces Pubmed DOI PubMed Central

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BACKGROUND: Organ failure determines outcome in acute pancreatitis (AP). It is controversial if infected pancreatic necrosis (IPN) is also an independent determinant of mortality. We hypothesized that the predictors of mortality in AP might have changed with advances in management and consequent decline in mortality over the past decades. Our objective was to study the predictors of mortality in patients with AP. METHODS: Consecutive patients with a first episode of AP hospitalized from January 2015 to December 2016 were included in an observational study. Patients with IPN were treated with a conservative first approach followed by intervention. Necrosectomy, if required, was delayed beyond 4 weeks and done primarily employing minimally invasive techniques. The primary outcome measure was independent predictors of in-hospital mortality. RESULTS: Of 209 patients with AP, 81 (39%) had persistent organ failure (OF) and 108 (52%) developed IPN. Overall, 46/209 (22%) patients died. Independent predictors of mortality were OF (odds ratio [OR]19; 95% CI: 6.1-58.8), and IPN due to infection with multidrug resistant (MDR) organisms (OR: 8.4; 95% CI:3.1-22.5). Infected pancreatic necrosis by itself was not found to be a significant predictor of mortality (OR 2; 95% CI: 0.4-9.5). CONCLUSION: Persistent OF and complicated IPN due to MDR infection were independent predictors of mortality in patients with AP. Renewed efforts to prevent MDR infection with antibiotic stewardship and strategies for early control of sepsis are urgently required.

Estudio primario

No clasificado

Natural history of gas configurations and encapsulation in necrotic collections during necrotizing pancreatitis

Revista Journal of Gastrointestinal Surgery
Año 2018

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Estudio primario

No clasificado

Emergence of antimicrobial resistance to Pseudomonas aeruginosa in the intensive care unit: association with the duration of antibiotic exposure and mode of administration.

Revista Annals of intensive care
Año 2017
Enlaces Pubmed DOI PubMed Central

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BACKGROUND: Antibiotics are frequently used in intensive care units (ICUs), and their use is associated with the emergence of bacterial resistance to antibiotics. The aim of this study was to investigate the association between the emergence of Pseudomonas aeruginosa resistance and the duration of antibiotic exposure or mode of administration in an ICU unit. METHODS: A 4-year cohort study of intensive care unit was performed in patients with P. aeruginosa isolates from clinical specimens, initially susceptible to the investigated antibiotics (piperacillin/tazobactam, ceftazidime, ciprofloxacin, meropenem and amikacin). Odds ratios (ORs) with 95% confidence interval (95% CI) of emergence of resistance were calculated using logistic regression analysis for various exposure periods to antibiotics (1-3, 4-7, 8-15 and >15 days) relative to no exposure with adjustment for age, sex, Simplified Acute Physiology Score 3 (SAPS 3) and length of stay. ORs on the emergence of P. aeruginosa resistance were also calculated for the various modes of administration. RESULTS: Included were 187 patients [mean age 61 years, 69% male, mean SAPS 3 score (SD): 59 (12.3)]. None of the antibiotics investigated showed the emergence of resistance within 1-3 days. Significant meropenem resistance emerged within 8-15 days [OR 79.1 (14.9-421.0)] after antibiotic exposure unlike other antibiotics (>15 days). No difference was observed between intermittent and extended administration of meropenem and between beta-lactam mono- or combined therapy. CONCLUSIONS: Use of meropenem was associated with the emergence of resistance as soon as 8 days after exposure to the antibiotic.

Estudio primario

No clasificado

The Surgical Infection Society Revised Guidelines on the Management of Intra-Abdominal Infection.

Revista Surgical infections
Año 2017
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BACKGROUND: Previous evidence-based guidelines on the management of intra-abdominal infection (IAI) were published by the Surgical Infection Society (SIS) in 1992, 2002, and 2010. At the time the most recent guideline was released, the plan was to update the guideline every five years to ensure the timeliness and appropriateness of the recommendations. METHODS: Based on the previous guidelines, the task force outlined a number of topics related to the treatment of patients with IAI and then developed key questions on these various topics. All questions were approached using general and specific literature searches, focusing on articles and other information published since 2008. These publications and additional materials published before 2008 were reviewed by the task force as a whole or by individual subgroups as to relevance to individual questions. Recommendations were developed by a process of iterative consensus, with all task force members voting to accept or reject each recommendation. Grading was based on the GRADE (Grades of Recommendation Assessment, Development, and Evaluation) system; the quality of the evidence was graded as high, moderate, or weak, and the strength of the recommendation was graded as strong or weak. Review of the document was performed by members of the SIS who were not on the task force. After responses were made to all critiques, the document was approved as an official guideline of the SIS by the Executive Council. RESULTS: This guideline summarizes the current recommendations developed by the task force on the treatment of patients who have IAI. Evidence-based recommendations have been made regarding risk assessment in individual patients; source control; the timing, selection, and duration of antimicrobial therapy; and suggested approaches to patients who fail initial therapy. Additional recommendations related to the treatment of pediatric patients with IAI have been included. SUMMARY: The current recommendations of the SIS regarding the treatment of patients with IAI are provided in this guideline.

Estudio primario

No clasificado

Penetration of piperacillin-tazobactam into human prostate tissue and dosing considerations for prostatitis based on site-specific pharmacokinetics and pharmacodynamics.

Revista Journal of infection and chemotherapy : official journal of the Japan Society of Chemotherapy
Año 2015
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This study aimed to investigate the penetration of PIPC-TAZ into human prostate, and to assess effectiveness of PIPC-TAZ against prostatitis by evaluating site-specific PK-PD. Patients with prostatic hypertrophy (n = 47) prophylactically received a 0.5 h infusion of PIPC-TAZ (8:1.2-0.25 g or 4-0.5 g) before transurethral resection of the prostate. PIPC-TAZ concentrations in plasma (0.5-5 h) and prostate tissue (0.5-1.5 h) were analyzed with a three-compartment PK model. The estimated model parameters were, then used to estimate the drug exposure time above the minimum inhibitory concentration for bacteria (T > MIC, the PD indicator for antibacterial effects) in prostate tissue for six PIPC-TAZ regimens (2.25 or 4.5 g; once, twice, three times or four times daily; 0.5 h infusions). Prostate tissue/plasma ratio of PIPC was about 36% both for the maximum drug concentration (Cmax) and the area under the drug concentration-time curve (AUC). Against MIC distributions for isolates of Escherichia coli, Klebsiella species and Proteus species, regimens of 4.5 g twice daily and 2.25 g three times daily achieved a >90% probability of attaining the bacteriostatic target for PIPC (30% T > MIC) in prostate tissue; regimens of 4.5 g three times daily and 2.25 g four times daily achieved a >90% probability of attaining the bactericidal target for PIPC (50% T > MIC) in prostate tissue. However, against Pseudomonas aeruginosa isolates, none of the tested regimens achieved a >90% probability. PIPC-TAZ is appropriate for the treatment of prostatitis from the site-specific PK-PD perspective.

Estudio primario

No clasificado

Emergence of multidrug resistant infection in patients with severe acute pancreatitis.

Autores Lee HS , Lee SK , Park DH , Lee SS , Seo DW , Kim MH , Chong YP
Revista Pancreatology : official journal of the International Association of Pancreatology (IAP) ... [et al.]
Año 2014
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BACKGROUND/OBJECTIVES: Infection is the most important risk factor contributing to death in severe acute pancreatitis. Multidrug resistant (MDR) bacterial infections are an emerging problem in severe acute pancreatitis. METHODS: From January 2009 to December 2011 the medical records of 46 patients with infected severe acute pancreatitis were reviewed retrospectively to identify risk factors for the development of MDR bacterial infection and assess the related outcomes. RESULTS: The mean age of the 46 patients was 55 years; 38 were males. Thirty-six patients (78.3%) had necrotizing pancreatitis and all of enrolled 46 patients had suspected or proven pancreatic infection. MDR microorganisms was found in 29 (63%) of the 46 patients. A total of 51 episodes of MDR infection were collected from 11 cases of infected pancreatic pseudocysts, 36 cases of infected necrosis/infected walled-off necrosis and 4 cases of bacteremia. The most frequent MDR bacteria was methicillin-resistant Staphylococcus aureus (n = 15). Transferred patients had a higher incidence of MDR infections than primarily admitted patients (72% vs. 35%, P = .015). The mean intensive care unit stay was significantly longer in patients with MDR bacterial infections (20 vs. 2 days, P = .001). Mortality was not significantly different in the patients with MDR infections vs. those without it (14% vs. 6%, P = .411). CONCLUSIONS: Clinicians should be aware of the high incidence of MDR bacterial infections in patients with severe acute pancreatitis, especially referred patients. Empiric therapy directed at these pathogens may be used in patients where severe sepsis persists, until definitive culture results are obtained.

Estudio primario

No clasificado

farmacocinética clínicos de meropenem en el jugo pancreático y específica de sitio logro objetivo farmacodinámico contra las bacterias Gram-negativas: consideraciones de la dosificación.

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Revista Pancreatology : official journal of the International Association of Pancreatology (IAP) ... [et al.]
Año 2014
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FUNDAMENTO Y OBJETIVO: Muy pocos estudios han puesto de manifiesto la dinámica de penetración de meropenem en el páncreas o el jugo pancreático en los seres humanos. Este estudio de la farmacocinética y la farmacodinámica clínicos de meropenem en el jugo pancreático humano se realizó para establecer una base para la validación de los regímenes de dosificación para las infecciones pancreáticas. Métodos: Diez pacientes con drenaje naso-pancreática endoscópica recibieron 500 mg de meropenem lo largo de 0,5 h en perfusión intravenosa. La sangre venosa y muestras de jugo pancreático se recogieron después de la infusión de hasta 5,0 horas y se utilizan para obtener medidas de la concentración de meropenem. La probabilidad de alcanzar el objetivo farmacodinámico (40% del tiempo por encima de la concentración mínima inhibitoria [MIC]) en el jugo pancreático en contra de distribución de la CMI para los aislados clínicos de bacterias Gram-negativas se determinó usando una simulación de Monte Carlo. RESULTADOS: La concentración media máxima de meropenem en el jugo pancreático fue de 2,08 ± 0,94 mg / ml a 1,025 ± 0,18 h. La relación jugo / de plasma de páncreas fue 0,055 ± 0,028. Un 0,5-h infusión de 500 mg de meropenem cada 8 h logra una probabilidad del 99,4% de cumplimiento de metas contra Escherichia coli, 96,4% frente a especies de Klebsiella, 94,3% frente a especies de Enterobacter y 96,2% frente a especies de Proteus, pero sólo el 41,3% frente a Pseudomonas aeruginosa . CONCLUSIÓN: meropenem intravenoso muestra una baja penetrancia en el jugo pancreático. Sin embargo, un régimen de dosificación de 500 mg de meropenem (0,5-h de infusión) cada 8 h proporciona suficiente tiempo de exposición de drogas en el jugo pancreático en contra de los cuatro Gram-negativas las poblaciones de bacterias comunes.