Antibiotic use in acute pancreatitis : an audit of current practice in a tertiary centre

Introduction: Intravenous antibiotic prophylaxis is not recommended in acute pancreatitis. According to current international guidelines antibiotics together with further intervention should be considered in the setting of infected necrosis. Appropriate antibiotic therapy particularly avoiding over-prescription is important. This study examines antibiotic use in acute pancreatitis in a tertiary centre using the current IAP/APA guidelines for reference. Methods: Data were collected on a consecutive series of patients admitted with acute pancreatitis over a 12 month period. Data were dichotomized by patients admitted directly to the centre and tertiary transfers. Information was collected on clinical course with specific reference to antibiotic use, episode severity, intervention and outcome. Results: 111 consecutive episodes of acute pancreatitis constitute the reported population. 31 (28%) were tertiary transfers. Overall 65 (58.5%) patients received antibiotics. Significantly more tertiary transfer patients received antibiotics. Mean person-days of antibiotic use was 23.9 (sd 29.7) days in the overall study group but there was significantly more use in the tertiary transfer group as compared to patients having their index admission to the centre (40.9 sd 37.1 vs 10.2 sd 8.9; P < 0.005). Thirty four (44%) of patients with clinically mild acute pancreatitis received antibiotics. Conclusions: There is substantial use of antibiotics in acute pancreatitis, in particular in patients with severe disease. Over-use is seen in mild acute pancreatitis. Better consideration must be given to identification of prophylaxis or therapy as indication. In relation to repeated courses of antibiotics in severe disease there must be clear indications for use

The practical management of chronic pancreatitis:A Multidisciplinary Symposium Held at the Annual Meeting of the Pancreatic Society of Great Britain and Ireland, Manchester 2016

Aim: This study is about a questionnaire survey of delegates attending the chronic pancreatitis symposium at the 2016 meeting of the Pancreatic Society of Great Britain and Ireland and seeks a multidisciplinary “snapshot” overview of practice. Methods: A questionnaire was developed with multidisciplinary input. Questions on access to specialist care, methods of diagnosis and treatment including specific scenarios were incorporated. Eighty-three (66%) of 125 delegates effectively participated in this survey. Results: Twenty-four (29%) had neither a chronic pancreatitis MDT in their hospital nor a chronic pancreatitis referral MDT. Most frequently utilised diagnostic modalities were CT, MR and EUS with no respondents utilising duodenal intubation tests. Initial treatment was provided through non-opiate analgesia by 69 (93%), through the use of opiates by 56 (76%) and through the use of co-analgesics by 49 (66%). Fifty two (68%) routinely referred patients with alcohol-related disease for counselling. Preferred treatment for large duct disease without mass was endoscopic therapy. In older patients with a mass, pancreaticoduodenectomy was preferred. Conclusion: This is a small study likely to be skewed by sampling bias but is thought to be the first multidisciplinary survey of the management of chronic pancreatitis in the United Kingdom and Ireland. The results show a need for comprehensive access to specialist pancreatitis MDT care and there remains substantial variation in management

The multi-societal European consensus on the terminology, diagnosis and management of patients with synchronous colorectal cancer and liver metastases:an E-AHPBA consensus in partnership with ESSO, ESCP, ESGAR, and CIRSE

Background: Contemporary management of patients with synchronous colorectal cancer and liver metastases is complex. The aim of this project was to provide a practical framework for care of patients with synchronous colorectal cancer and liver metastases with a focus on terminology, diagnosis and management. Methods: This project was a multi-organisational, multidisciplinary consensus. The consensus group produced statements which focused on terminology, diagnosis and management. Statements were refined during an online Delphi process and those with 70% agreement or above were reviewed at a final meeting. Iterations of the report were shared by electronic mail to arrive at a final agreed document comprising twelve key statements. Results: Synchronous liver metastases are those detected at the time of presentation of the primary tumour. The term “early metachronous metastases” applies to those absent at presentation but detected within 12 months of diagnosis of the primary tumour with “late metachronous metastases” applied to those detected after 12 months. Disappearing metastases applies to lesions which are no longer detectable on MR scan after systemic chemotherapy. Guidance was provided on the recommended composition of tumour boards and clinical assessment in emergency and elective settings. The consensus focused on treatment pathways including systemic chemotherapy, synchronous surgery and the staged approach with either colorectal or liver-directed surgery as first step. Management of pulmonary metastases and the role of minimally invasive surgery was discussed. Conclusions: The recommendations of this contemporary consensus provide information of practical value to clinicians managing patients with synchronous colorectal cancer and liver metastases

Management of colorectal cancer presenting with synchronous liver metastases

Up to a fifth of patients with colorectal cancer (CRC) present with synchronous hepatic metastases. In patients with CRC who present without intestinal obstruction or perforation and in whom comprehensive whole-body imaging confirms the absence of extrahepatic disease, evidence indicates a state of equipoise between several different management pathways, none of which has demonstrated superiority. Neoadjuvant systemic chemotherapy is advocated by current guidelines, but must be integrated with surgical management in order to remove the primary tumour and liver metastatic burden. Surgery for CRC with synchronous liver metastases can take a number of forms: the 'classic' approach, involving initial colorectal resection, interval chemotherapy and liver resection as the final step; simultaneous removal of the liver and bowel tumours with neoadjuvant or adjuvant chemotherapy; or a 'liver-first' approach (before or after systemic chemotherapy) with removal of the colorectal tumour as the final procedure. In patients with rectal primary tumours, the liver-first approach can potentially avoid rectal surgery in patients with a complete response to chemoradiotherapy. We overview the importance of precise nomenclature, the influence of clinical presentation on treatment options, and the need for accurate, up-to-date surgical terminology, staging tests and contemporary management options in CRC and synchronous hepatic metastatic disease, with an emphasis on multidisciplinary care

A procalcitonin-based algorithm to guide antibiotic use in patients with acute pancreatitis (PROCAP) : a single-centre, patient-blinded, randomised controlled trial

Background: Differentiating inflammation from bacterial infection in acute pancreatitis can be difficult. Procalcitonin (PCT) can distinguish infection from inflammation and algorithms based on PCT measurement can differentiate bacterial sepsis from a systemic inflammatory response. The PROCalcitonin-based algorithm for antibiotic use in Acute Pancreatitis (PROCAP) randomized trial tests the hypothesis that a PCT-based algorithm to guide initiation, continuation and discontinuation of antibiotics will lead to reduced antibiotic use without an adverse effect on outcome. Methods: PROCAP is a single-centre randomised controlled trial of patients with acute pancreatitis assigned to procalcitonin-guided care or usual care. The primary outcome was use of antibiotics during the index admission. Secondary outcomes included mortality (safety endpoint), days of antibiotic use, infections, interventions, length of stay, readmission, health-related quality of life (QoL) and cost up to 90 days. Findings: From 29th July 2018 to 13th November 2020, 260 patients were recruited. 132 received procalcitonin-guided care and 128 usual care. Antibiotics were used during the index admission in 44.7% patients assigned to procalcitonin-guided care and in 61.7% assigned to usual care; risk difference (adjusted): -15.6% (95%CI: -27.0% to -4.2%), p=0.007. Treatment effect odds ratio is 0.49 (95%CI: 0.29 to 0.83), p=0.008. Procalcitonin-guided care reduced the average number of days of antibiotic use per patient from 5.8 to 4.5 days, mean difference (adjusted): ‑1.16, (95%CI: -2.10 to -0.22), p=0.015. There were no differences in mortality, infections, adverse events, length of stay, QoL or cost. Interpretation: This trial found that procalcitonin-guided care reduced antibiotic use without increasing infection or harm in patients with acute pancreatitis. ISRCTN 50584992. Funding: There was no external funding for this study

Procalcitonin-guided use of antibiotics in acute pancreatitis – Authors' reply

We thank Bilal Ahmad Mir and colleagues and Jayanta Samanta and Jahnvi Dhar for their interest in our study. 1 First, in relation to whether to restrict the procalcitonin assay to patients with moderate or severe acute pancreatitis, there is evidence of misuse of antibiotics regardless of disease severity and globally across health-care systems. 2 Furthermore, current definitions of severe disease require persistent organ dysfunction after 48 h of treatment and final allocated severity might not be apparent at presentation. 3 Thus, an effective algorithm should be evaluated at all severities of acute pancreatitis and from the point of hospital admission. Additionally, tertiary centres admit patients with severe disease who would have initially been admitted to smaller hospitals. These patients are often receiving antibiotics and applying the algorithm is logical so that those without proven infection and with a low procalcitonin can stop antibiotic therapy