Revised Atlanta classification and determinant-based classification: Which one better at stratifying outcomes of patients with acute pancreatitis?

Characteristics and risk factors for infection and mortality caused by Klebsiella pneumoniae in patients with acute pancreatitis

Background

The purpose of this study is to investigate the risk factors for carbapenem-resistant Klebsiella pneumoniae (CRKP) infection and death of K. pneumoniae infections in acute pancreatitis (AP) patients.

Methods

This was a retrospective analysis of AP patients with K. pneumoniae infection between January 2019 and April 2024. Logistic regression model was used to determine the risk factors for acquisition of CRKP. Cox proportional hazards regression model was used to identify risk factors for mortality of K. pneumoniae infection.

Results

A total of 113 AP patients experienced K. pneumoniae infections, including 66 with CRKP infection and 47 with CSKP infection. The mortality rate of these patients was 36.3%, with a significantly higher mortality rate in the CRKP group than in the CSKP group (P < 0.001). Only mechanical ventilation (OR = 2.301; 95% CI 1.02-5.20; P = 0.045) was the independent risk factor for CRKP infection in patients with AP. Surgery (HR 0.38; 95% CI 0.20-0.75; P = 0.005) and mechanical ventilation (HR 2.93; 95% CI 1.10-7.82; P = 0.032) were the independent risk factors associated with mortality of K. pneumoniae infection in patients with AP.

Conclusion

Klebsiella pneumoniae infection has become a threat to patients with AP. Therefore, implementing preventive and control measures based on risk factors is crucial for the prognosis.

Moderately severe acute pancreatitis after snake bite: a case report from Southern China

Venomous snakebites are not rare worldwide, and this is also the situation in the mountainous regions of southern China, where they pose a serious health risk to the local population. Snake venom usually causes a variety of clinical symptoms, such as local pain and swelling, systemic coagulation system abnormalities, and shock, but rarely leads to acute pancreatitis. In this report, we presented a rare case of moderately severe acute pancreatitis caused by snake venom even after prompt antivenom treatment. The patient was relieved, obviously, with effective treatment of acute pancreatitis and was discharged without severe complications. Although acute pancreatitis after snake bite is a rarity, its serious complications and lethality still deserve our utmost attention, and timely and standardized treatment of acute pancreatitis is needed in addition to antivenom treatment.

Prognostic significance of organ failure and infected pancreatic necrosis in acute pancreatitis: An updated systematic review and meta-analysis

OBJECTIVES

In patients with acute pancreatitis (AP), minimally invasive treatment and the step-up approach have been widely used to deal with infected pancreatic necrosis (IPN) in the last decade. It is unclear whether IPN has become a less important determinant of mortality relative to organ failure (OF). We aimed to statistically aggregate recent evidence from published studies to determine the relative importance of IPN and OF as determinants of mortality in patients with AP (PROSPERO: CRD42020176989).

METHODS

Relevant studies were sourced from MEDLINE and EMBASE databases. Relative risk (RR) or weighted mean difference (WMD) was analyzed as outcomes. A two-sided P value of less than 0.05 was regarded as statistical significance.

RESULTS

Forty-three studies comprising 11 601 patients with AP were included. The mortality was 28% for OF patients and 24% for those with IPN. Patients with OF without IPN had a significantly higher risk of mortality compared to those with IPN but without OF (RR 3.72, P < 0.0001). However, patients with both OF and IPN faced the highest risk of mortality. Additionally, IPN increased length of stay in hospital for OF patients (WMD 28.75, P = 0.032).

CONCLUSION

Though IPN remains a significant concern, which leads to increased morbidity and longer hospital stay, it is a less critical mortality determinant compared to OF in AP.

Clinical characteristics and risk factors of organ failure and death in necrotizing pancreatitis

BACKGROUND

Organ failure (OF) and death are considered the most significant adverse outcomes in necrotizing pancreatitis (NP). However, there are few NP-related studies describing the clinical traits of OF and aggravated outcomes.

PURPOSE

An improved insight into the details of OF and death will be helpful to the management of NP. Thus, in our research, we addressed the risk factors of OF and death in NP patients.

METHODS

We performed a study of 432 NP patients from May 2017 to December 2021. All patients with NP were followed up for 36 months. The primary end-points were risk factors of OF and death in NP patients. The risk factors were evaluated by logistic regression analysis.

RESULTS

NP patients with OF or death patients were generally older, had a higher APACHE II score, longer hospital stay, longer ICU stay, as well as a higher incidence of severe acute pancreatitis (SAP), shock and pancreatic necrosis. Independent risk factors related to OF included BMI, APACHE II score and SAP (P < 0.05). Age, shock and APACHE II score (P < 0.05) were the most significant factors correlated with the risk of death in NP patients. Notably, increased mortality was linked to the number of failed organs.

CONCLUSIONS

NP is a potentially fatal disease with a long hospital or ICU stay. Our study indicated that the incidence of OF and death in NP patients was 69.9% and 10.2%, respectively. BMI, SAP, APACHE II score, age and shock are potential risk factors of OF and death in NP patients. Clinicians should focus on these factors for early diagnosis and appropriate therapy.

Role of Pancreatic Stone Protein as an Early Biomarker for Risk Stratification of Acute Pancreatitis

BACKGROUND

Early risk stratification of acute pancreatitis is crucial to improve clinical outcomes. The objective of this study was to evaluate the ability of pancreatic stone protein (PSP) to predict acute pancreatitis severity and to compare it with the biomarkers and severity scores currently used for that purpose.

PATIENTS AND METHODS

Prospective single-center observational study enrolling 268 adult patients with acute pancreatitis. Biomarkers including PSP were measured upon admission to the Emergency Department and severity scores as SOFA, PANC-3, and BISAP were computed. Patients were classified into mild-moderate (non-severe) and severe acute pancreatitis according to the Determinant-Based Classification Criteria. Area under the curve (AUC) and regression analysis were used to analyze the discrimination abilities and the association of biomarkers and scores with severity.

RESULTS

Two hundred and thirty-five patients (87.7%) were classified as non-severe and 33 (12.3%) as severe acute pancreatitis. Median [IQR] PSP was increased in patients with severe acute pancreatitis (890 μg/L [559-1142] vs. 279 μg/L [141-496]; p < 0.001) and it was the best predictor (ROC AUC: 0.827). In multivariate analysis, PSP and urea were the only independent predictors for severe acute pancreatitis and a model combining them both ("biomarker model") showed an AUC of 0.841 for prediction of severe acute pancreatitis, higher than the other severity scores.

CONCLUSIONS

PSP is a promising biomarker for predicting the severity of acute pancreatitis upon admission. A model combining PSP and urea might further constitute a potential tool for early risk stratification of this disease.

Clinical Characteristics of Acute Pancreatitis Patients with Multidrug-Resistant Bacterial Infection

Background

There are few published reports describing the clinical characteristics of acute pancreatitis (AP) patients with multidrug-resistant organism (MDRO) infection.

Methods

This was a retrospective analysis of AP patients with MDRO infection in West China Hospital between July 2015 and June 2020. Basic clinical data, disease progression states, and prognoses of the MDRO and non-MDRO infection groups were compared and analyzed. Logistic regression analysis was performed to explore the related risk factors for MDRO infection. The prognoses of different MDRO infection types were compared.

Results

In total, 9812 AP patients were included, 2436 (24.83%) of whom had healthcare-associated infections (641 [26.31%] MDRO infections and 1795 [73.69%] non-MDRO infections). The main MDRO strain was carbapenem-resistant Acinetobacter baumannii (CRAB) (400/62.40%). The rate of discharge against doctor’s advice, mortality, hospitalization expenses, and hospitalization days was higher in the MDRO infection group than in the noninfection group. By logistic regression analysis, the independent risk factors associated with MDRO infection included male sex (OR 1.36, 95% CI 1.09~1.70), severity (OR 1.40, 95% CI 1.10~1.78), ICU referral (OR 2.48, 95% CI 1.79~3.44), abdominal puncture (OR 2.78, 95% CI 1.93~4.02), fiberoptic bronchoscopy (OR 1.95, CI 1.35~2.81), and PICC/CVC placement (OR 1.48, CI 1.06~2.06). Compared with biliary and hypertriglyceridemia (HTG) (OR 0.94, 95% CI 0.73~1.23), alcohol (OR 0.30, 95% CI 0.19~0.47) and other etiologies (OR 0.58, 95% CI 0.41~0.81) conferred a lower risk of MDRO infection. The carbapenem-resistant Klebsiella pneumoniae (CRKP) infection rate was highest in the patients who died.

Conclusion

The CRAB proportion was highest in AP patients with MDRO infection. MDRO infection is related to many factors, has a poor prognosis, and increases the patient burden. CRKP infection is directly related to poor prognosis.

Synchronous organ failure and infected pancreatic necrosis define genuine critical acute pancreatitis

BACKGROUND

Critical acute pancreatitis (CAP) was supposed to be strongly associated with the highest risk of adverse outcomes. However, the definition of CAP needs to be further clarified.

METHODS

A prospective database with consecutive patients of infected pancreatic necrosis (IPN) at a tertiary hospital was post-hoc analyzed. Patients were assigned to IPN alone, Metachronous-CAP (MCAP) and Synchronous-CAP group (SCAP) according to presence or absence of organ failure (OF) and the crosstalk between OF and IPN. Clinical interventions and outcomes were compared among groups.

RESULTS

A total of 248 IPN patients were enrolled and the overall mortality was 25.8%. Compared with MCAP, SCAP was associated with higher mortality (66.2 versus 10.0%) and morbidity (41.2 versus 18.0%), longer duration of OF (median 35.5 versus 12.0 days), ICU length of stay (LOS) (median 28.0 versus 16.0 days) and hospital LOS (median 67.0 versus 60.0 days) (all P < 0.05). The IPN alone and MCAP had comparable mortality (10.8 versus 10.0%), morbidity and hospital LOS, except that MCAP patients were characterized with longer duration of OF and ICU LOS (P < 0.05).

CONCLUSIONS

SCAP, characterized with synchronous persistent OF and IPN, was associated with higher mortality and morbidity and should be defined as genuine CAP.

Immune Dysfunction is Associated with Readmission in Survivors of Sepsis Following Infected Pancreatic Necrosis

Objective

Immunosuppression is common in patients with infected pancreatic necrosis (IPN) and associated with morbidity and mortality. This study aimed to investigate the impact of immune status on mortality and readmission after hospital discharge in patients with IPN-related sepsis.

Methods

In this prospective observational study, eligible adult patients with IPN-related sepsis requiring ICU admission were included. Monocytic human leukocyte antigen DR (mHLA-DR), expression of regulatory T cells (Treg), and neutrophil CD88 (nCD88) were measured on the diagnosis of sepsis, ICU discharge, hospital discharge, and 15, 30, 60 days after hospital discharge. Logistic regression model was used to assess potential risk factors for readmission 60-days within the index discharge.

Results

A total of 53 patients were included, 13 died during hospitalization and one withdrew the consent soon after discharge. Among the survivors, a tendency of immune recovery was observed during the consecutive follow-ups, evidenced by the increased expression of mHLA-DR. Sixteen patients (41.03%) were readmitted within 60 days after the index discharge. In the multivariable regression model, APACHE II score when sepsis was diagnosed >9 and mHLA-DR at discharged <14,591 AB/C were found to be independent risk factors affecting readmission.

Conclusion

Immunosuppression is common in patients with IPN-related sepsis and can persist until two months after discharge. The compromised mHLA-DR level at discharge was associated with readmission within two months after discharge.

Impact of Different Patterns of Organ Failure on Mortality in Acute Necrotizing Pancreatitis

OBJECTIVES

Organ failure (OF) and infected necrosis (IN) are the most important predictors of mortality in necrotizing acute pancreatitis (AP). We studied the relationship between timing (onset and duration) and patterns of OF with mortality and the impact of IN on mortality.

METHODS

Consecutive patients with necrotizing AP between January 2017 and February 2020 were analyzed retrospectively for OF and its impact on outcome. Organ failure was divided as single OF, simultaneous multiple OF (SiMOF) and sequential multiple OF (SeMOF). Mortality was compared for timing of onset, total duration and patterns of OF.

RESULTS

Among 300 patients with necrotizing AP, 174 (58%) had OF. Mortality was not associated with onset of OF (P = 0.683) but with duration of OF (P = 0.006). Mortalities for single OF, SiMOF, and SeMOF were 11.8%, 30.4%, and 69.2% respectively (P < 0.001). On Cox proportional hazard analysis, adjusted hazard ratio of risk of mortality for OF with IN versus IN, SiMOF versus single OF and SeMOF versus single OF was 3.183, 2.878, and 8.956, respectively (P = 0.023, <0.030, and <0.001, respectively).

CONCLUSIONS

Duration of OF was associated with increased mortality and SeMOF had worse outcome than single OF and SiMOF.

Efficacy of probiotics for treatment of severe acute pancreatitis: A meta-analysis

BACKGROUND

In this study, we performed a meta-analysis to comprehensively evaluate both domestic and foreign randomized controlled trials (RCTs) related to the treatment of severe acute pancreatitis with probiotics published between 2005 and 2019 to clarify if probiotic treatment has a positive impact on patients' hospital stay, duration of abdominal pain, death, secondary infection, multiple organ failure, and other prognostic-related indicators.

AIM

To evaluate the clinical efficacy of probiotics in the treatment of SAP.

METHODS

RCTs evaluating the effectiveness of probiotic therapy in SAP patients were searched in databases such as CNKI, Wanfang Med Online, VIP, PubMed, and Cochrane. The quality of the included articles was assessed and possible biases among them were analyzed. We performed all statistical analyses with Revman 5.3 software.

RESULTS

A total of 14 trials with 921 patients were involved in the study. Meta-analysis showed that there were significant differences in secondary infection (P < 0.0001), mean hospital stay (P < 0.0001), mean time to abdominal pain relief (P < 0.0001), mortality (P = 0.03), and the incidence of secondary multiorgan failure (P = 0.01) between the study group and control group.

CONCLUSION

According to this meta-analysis, probiotic treatment could significantly shorten the length of hospital stay, alleviate abdominal pain, and reduce the risk of secondary infection, death, and secondary multiple organ failure.

Evaluation of 880 patients diagnosed with acute pancreatitis according to the Revised Atlanta Classification: A single-center experience

OBJECTIVE The Revised Atlanta Classification (RAC) is increasingly used in the evaluation of patients diagnosed with acute pancreatitis (AP). In our study, we aimed to evaluate the etiology, disease severity, and mortality rates of patients diagnosed with AP in our center in the previous 6 years. METHODS Patients diagnosed with AP between 2013 and 2018 were evaluated. AP etiology, demographic data, disease severity, and mortality rates according to the RAC were evaluated. RESULTS A total of 880 patients were included in the study. Five hundred and eighteen (59%) patients were female and 362 (41%) were male. Regarding the etiology, 474 (53.9%) patients had biliary AP (BAP), 71 (8.1%) had hyperlipidemic AP (HAP), and 44 (5%) had alcoholic AP (AAP). According to the RAC, 561 (63.7%) patients were considered to be in the mild AP group (MAP), 268 (30.5%) in the moderately severe AP (MSAP), and 51 (5.8%) in the severe AP (SAP). The mortality rate was 4.8% in the MSAP group and 49% in the SAP group. Mortality was 2.3 times in patients over 65 years old and 3.7 times higher in patients with ischemic heart disease. CONCLUSIONS In our country, BAP is still the main etiology of acute pancreatitis. Over the years, we have seen a decrease in BAP and idiopathic AP cases, while there was an increase in HAP cases due to factors such as lifestyle changes and fatty nutrition. We found that mortality was associated with disease severity, advanced age (> 65 y), hypertension, and ischemic heart disease regardless of the etiology.

Acute pancreatitis in Chile: A multicenter study on epidemiology, etiology and clinical outcome. Retrospective analysis of clinical files

BACKGROUND

Epidemiology of acute pancreatitis (AP) is variable in different geographical regions.

OBJECTIVES

To compare etiology and severity of AP to published data from South America and the rest of world, study impact of demographical factors and treatment on its outcome in Chilean hospitals.

METHODS

Multicenter observational study. Data of consecutive patients with AP were collected at the moment of discharge from 11 centers and retrospectively analyzed.

RESULTS

Data of 962 patients were included in the analysis, 447 men and 515 women. Mean age was 48,2 years. Biliary etiology was significantly more frequent in women (70%) than in men (52%). Conversely, alcohol was responsible for about 17% of AP in men but exceptional in women. Mild AP was seen in 73.4%, moderately severe in 14.1% and severe in 13%. The overall mortality was 2.5% (24 of 962): 0.3%, 3.1% and 15.1% in mild, moderately severe and severe cases, respectively. No difference was found in the mortality and severity of biliary versus alcoholic AP, while hypertriglyceridemia induced AP was more severe, without increased mortality. Severity and mortality increased with age. ERCP was performed in 16% of biliary pancreatitis. Adherence to main guidelines was heterogeneous: more than half of mild AP patients were admitted to critical care units and antibiotics were used in about 25% them.

CONCLUSION

This is the first multicenter study in Chile on AP. When compared to literature, we found similar severity distribution and an acceptably low mortality. Biliary etiology was dominant, but alcohol was also important in men.

New insights into acute pancreatitis

The incidence of acute pancreatitis continues to increase worldwide, and it is one of the most common gastrointestinal causes for hospital admission in the USA. In the past decade, substantial advancements have been made in our understanding of the pathophysiological mechanisms of acute pancreatitis. Studies have elucidated mechanisms of calcium-mediated acinar cell injury and death and the importance of store-operated calcium entry channels and mitochondrial permeability transition pores. The cytoprotective role of the unfolded protein response and autophagy in preventing sustained endoplasmic reticulum stress, apoptosis and necrosis has also been characterized, as has the central role of unsaturated fatty acids in causing pancreatic organ failure. Characterization of these pathways has led to the identification of potential molecular targets for future therapeutic trials. At the patient level, two classification systems have been developed to classify the severity of acute pancreatitis into prognostically meaningful groups, and several landmark clinical trials have informed management strategies in areas of nutritional support and interventions for infected pancreatic necrosis that have resulted in important changes to acute pancreatitis management paradigms. In this Review, we provide a summary of recent advances in acute pancreatitis with a special emphasis on pathophysiological mechanisms and clinical management of the disorder.

Impact of characteristics of organ failure and infected necrosis on mortality in necrotising pancreatitis

OBJECTIVE

In patients with pancreatitis, early persisting organ failure is believed to be the most important cause of mortality. This study investigates the relation between the timing (onset and duration) of organ failure and mortality and its association with infected pancreatic necrosis in patients with necrotising pancreatitis.

DESIGN

We performed a post hoc analysis of a prospective database of 639 patients with necrotising pancreatitis from 21 hospitals. We evaluated the onset, duration and type of organ failure (ie, respiratory, cardiovascular and renal failure) and its association with mortality and infected pancreatic necrosis.

RESULTS

In total, 240 of 639 (38%) patients with necrotising pancreatitis developed organ failure. Persistent organ failure (ie, any type or combination) started in the first week in 51% of patients with 42% mortality, in 13% during the second week with 46% mortality and in 36% after the second week with 29% mortality. Mortality in patients with persistent multiple organ failure lasting <1 week, 1-2 weeks, 2-3 weeks or longer than 3 weeks was 43%, 38%, 46% and 52%, respectively (p=0.68). Mortality was higher in patients with organ failure alone than in patients with organ failure and infected pancreatic necrosis (44% vs 29%, p=0.04). However, when excluding patients with very early mortality (within 10 days of admission), patients with organ failure with or without infected pancreatic necrosis had similar mortality rates (28% vs 34%, p=0.33).

CONCLUSION

In patients with necrotising pancreatitis, early persistent organ failure is not associated with increased mortality when compared with persistent organ failure which develops further on during the disease course. Furthermore, no association was found between the duration of organ failure and mortality.

Results of the modification of an acute pancreatitis management protocol in Intensive Care medicine

OBJECTIVE

To determine whether the implementation of a protocol for the management of patients with acute pancreatitis (AP) in an Intensive Care Unit (ICU) improves the clinical outcomes.

DESIGN

A retrospective, before-after observational case series study was carried out.

STUDY PERIOD

1 January 2001 to 31 December 2016, divided in 2 periods (pre-protocol 2001-2007, post-protocol 2008-2016).

SCOPE

An ICU with 48 beds and a recruitment population of 700,000 inhabitants.

PARTICIPANTS

AP patients admitted to the ICU, with no exclusion criteria.

INTERVENTIONS

The recommendations proposed in the 7th Consensus Conference of the SEMICYUC on AP (5 September 2007) were applied in the second period.

MAIN VARIABLES OF INTEREST

Patient age, sex, APACHE II, SOFA, study period, pre-ICU hospital stay, nutrition, surgery, antibiotic prophylaxis, hospital mortality, ICU length of stay, hospital length of stay, determinant-based classification.

RESULTS

The study comprised 286 patients (94 in the pre-protocol period, 192 in the post-protocol period), with a global in-hospital mortality rate of 23.1% (n=66). Application of the protocol decreased the pre-ICU hospital stay and the use of antibiotic prophylaxis, and increased the use of enteral nutrition. Hospital mortality decreased in the second period (35.1 vs. 17.18%; P=.001), with no significant changes in ICU and hospital stays. In the multivariate logistic regression analysis, the variable period of treatment remained as a variable of statistical significance in terms of hospital mortality (OR 0.34 for the period 2008-2016, 95% CI 0.15-0.74).

CONCLUSIONS

The implementation of a protocol could result in decreased mortality among AP patients admitted to the ICU.

Value of the revised Atlanta classification (RAC) and determinant-based classification (DBC) systems in the evaluation of acute pancreatitis

OBJECTIVE

Since increasing acute pancreatitis (AP) severity is significantly associated with mortality, accurate and rapid determination of severity is crucial for effective clinical management. This study investigated the value of the revised Atlanta classification (RAC) and the determinant-based classification (DBC) systems in stratifying severity of acute pancreatitis.

METHODS

This retrospective observational cohort study included 480 AP patients. Patient demographics and clinical characteristics were recorded. The primary outcome was mortality, and secondary outcomes were admission to intensive care unit (ICU), duration of ICU stay, and duration of hospital stay.

RESULTS

Based on the RAC classification, there were 295 patients with mild AP (MAP), 146 patients with moderate-to-severe AP (MSAP), and 39 patients with severe AP (SAP). Based on the DBC classification, there were 389 patients with MAP, 41 patients with MSAP, 32 patients with SAP, and 18 patients with critical AP (CAP). ROC curve analysis showed that the DBC system had a significantly higher accuracy at predicting organ failure compared to the RAC system (p < .001). Multivariate regression analysis showed that age and ICU stay were independent risk factors of mortality.

CONCLUSION

The DBC system had a higher accuracy at predicting organ failure. Age and ICU stay were significantly associated with risk of death in AP patients. A classification of CAP by the DBC system should warrant close attention, and rapid implementation of effective measures to reduce mortality.