Favourable pancreatitis outcomes with procalcitonin-based algorithm to guide antibiotic use

In a single-centre, patient-blinded, randomised-controlled trial, a procalcitonin-based algorithm was successful in sparing both antibiotic use and days of antibiotic use in patients with acute pancreatitis. Despite the markedly reduced use of antibiotics, there was no increase in hospital-acquired infections or harm in patients with acute pancreatitis compared with usual care.

Acute pancreatitis is an inflammatory condition of the pancreas, most commonly caused by bile stones or excessive use of alcohol. In most patients, the disease takes a mild course, but in 20–30% it is a life-threatening disease with considerable mortality [1]. International guidelines do not recommend the use of antibiotics in acute pancreatitis in the absence of specific infections [1]. Yet, globally, there is an overuse of antibiotics in all forms of acute pancreatitis, mainly because of the difficulty in clinically distinguishing between a systemic inflammatory response and infection.

Normal physiologic levels of procalcitonin are low, but they rise rapidly in response to infection and fall after eradication. Thus, procalcitonin is a biomarker to distinguish infection from inflammation, and algorithms based on procalcitonin measurement can differentiate bacterial sepsis from a systemic inflammatory response. Therefore, Prof. Ajith Siriwardena (Manchester Royal Infirmary, UK) and his team tested whether a procalcitonin-based algorithm to guide initiation, continuation, and discontinuation of antibiotics can reduce antibiotic use in patients with acute pancreatitis without an adverse effect on outcomes [2].

The PROCAP trial (ISRCTN50584992) included 260 adult patients with acute pancreatitis randomised to either a procalcitonin-based algorithm guiding antibiotic use in addition to usual care (n=132) or usual care only (n=128). Participants had to have at least 2 of the following 3 features: abdominal pain consistent with acute pancreatitis, serum lipase activity (or amylase activity) at least 3 times greater than the upper limit of normal activity, and characteristic findings of acute pancreatitis on contrast-enhanced CT or MRI. Moreover, patients were stratified according to disease severity (mild versus moderately-severe or severe) and admission pathway (either direct admission to the Manchester Royal Infirmary or tertiary transfer from another hospital). If the clinicians wanted to use antibiotics and the procalcitonin level was <1.0 µg/L in the intervention group, it was recommended that no antibiotics were started or patients already treated with antimicrobial therapy should stop it. Only for patients with procalcitonin level ≥1.0 µg/L, an antibiotic intervention was recommended.

Significantly fewer participants in the intervention group used antibiotics compared with the control group (45% vs 62%; P=0.0077). In addition, there were fewer days of antibiotic use in the intervention arm compared with usual care. Regarding the number of clinical infections or hospital-acquired infections, no significant difference was observed between the 2 groups. In addition, mild and severe disease and admission pathways did not influence the results. Overall, costs were markedly reduced by applying the procalcitonin-based algorithm.

“Our findings suggest that procalcitonin-guided care can reduce antibiotic use without increasing infection or harm in patients with acute pancreatitis,” Prof. Siriwardena concluded. Therefore, a procalcitonin-based algorithm should be considered in the care of patients with acute pancreatitis and be incorporated into future guidelines.

1. Leppäniemi A, et al. World J Emerg Surg. 2019;14:27.
2. Siriwardena A, et al. A Procalcitonin-based algorithm to guide antibiotic use in patients with acute pancreatitis: The final results of the PROCAP randomized controlled trial. LB04, UEG Week 2022, 8–11 October, Vienna, Austria.

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Posted on 2 December, 2022