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Lin C, Li J, Liu B, Hong X, Luo T, Ye J, Yu Y, Peng X, Gou S, Tang H, Yuan T, Luo J, Yang M, Feng B, Zhao Z, Ning C, Sun Z, Zhu S, Chen L, Shen D, Huang G. Metagenomic next-generation sequencing, instead of procalcitonin, could guide antibiotic usage in patients with febrile acute necrotizing pancreatitis: a multicenter, prospective cohort study. Int J Surg 2024; 110:2721-2729. [PMID: 38348834 DOI: 10.1097/js9.0000000000001162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 01/26/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUNDS The effectiveness of procalcitonin-based algorithms in guiding antibiotic usage for febrile acute necrotizing pancreatitis (ANP) remains controversial. Metagenomic next-generation sequencing (mNGS) has been applied to diagnose infectious diseases. The authors aimed to evaluate the effectiveness of blood mNGS in guiding antibiotic stewardship for febrile ANP. MATERIALS AND METHODS The prospective multicenter clinical trial was conducted at seven hospitals in China. Blood samples were collected during fever (T ≥38.5°C) from ANP patients. The effectiveness of blood mNGS, procalcitonin, and blood culture in diagnosing pancreatic infection was evaluated and compared. Additionally, the real-world utilization of antibiotics and the potential mNGS-guided antimicrobial strategy in febrile ANP were also analyzed. RESULTS From May 2023 to October 2023, a total of 78 patients with febrile ANP were enrolled and 30 patients (38.5%) were confirmed infected pancreatic necrosis (IPN). Compared with procalcitonin and blood culture, mNGS showed a significantly higher sensitivity rate (86.7% vs. 56.7% vs. 26.7%, P <0.001). Moreover, mNGS outperformed procalcitonin (89.5 vs. 61.4%, P <0.01) and blood culture (89.5 vs. 69.0%, P <0.01) in terms of negative predictive value. Blood mNGS exhibited the highest accuracy (85.7%) in diagnosing IPN and sterile pancreatic necrosis, significantly superior to both procalcitonin (65.7%) and blood culture (61.4%). In the multivariate analysis, positive blood mNGS (OR=60.2, P <0.001) and lower fibrinogen level (OR=2.0, P <0.05) were identified as independent predictors associated with IPN, whereas procalcitonin was not associated with IPN, but with increased mortality (Odds ratio=11.7, P =0.006). Overall, the rate of correct use of antibiotics in the cohort was only 18.6% (13/70) and would be improved to 81.4% (57/70) if adjusted according to the mNGS results. CONCLUSION Blood mNGS represents important progress in the early diagnosis of IPN, with particular importance in guiding antibiotic usage for patients with febrile ANP.
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Affiliation(s)
- Chiayen Lin
- Department of Pancreatic Surgery, General Surgery
- Department of Hernia and Abdominal Wall Surgery
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha
| | - Jiarong Li
- Department of Pancreatic Surgery, General Surgery
- Department of Hernia and Abdominal Wall Surgery
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha
| | - Baiqi Liu
- Department of Pancreatic Surgery, General Surgery
- Department of Hernia and Abdominal Wall Surgery
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha
| | - Xiaoyue Hong
- Department of Pancreatic Surgery, General Surgery
- Department of Hernia and Abdominal Wall Surgery
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha
| | - Tao Luo
- Department of General Surgery, Changde Hospital, Xiangya School of Medicine, Central South University, Changde
| | - Jinsong Ye
- Department of General Surgery, Changde Hospital, Xiangya School of Medicine, Central South University, Changde
| | - Yi Yu
- Department of Hepatobiliary Surgery, General Surgery, The First People's Hospital of Chenzhou City, Chenzhou
| | - Xinran Peng
- Department of Hepatobiliary Surgery, General Surgery, The First People's Hospital of Chenzhou City, Chenzhou
| | - Shanmiao Gou
- Department of Pancreatic Surgery, General Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan
| | - Huayong Tang
- Department of General Surgery, The First Affiliated Hospital of Hunan Traditional Chinese Medical College
| | - Tongli Yuan
- Department of General Surgery, The First Affiliated Hospital of Hunan Traditional Chinese Medical College
| | - Jianguan Luo
- Department of Hepatobiliary Surgery, General Surgery, Liuyang People's Hospital, Changsha
| | - Ming Yang
- Department of Hepatobiliary Surgery, General Surgery, Liuyang People's Hospital, Changsha
| | - Bin Feng
- Center of Hepatobiliary and Pancreatic Surgery, Zhuzhou Hospital Affiliated to Xiangya School of Medicine, Central South University, Zhuzhou, Hunan Province, People's Republic of China
| | - Zhijian Zhao
- Center of Hepatobiliary and Pancreatic Surgery, Zhuzhou Hospital Affiliated to Xiangya School of Medicine, Central South University, Zhuzhou, Hunan Province, People's Republic of China
| | - Caihong Ning
- Department of Pancreatic Surgery, General Surgery
- Department of Hernia and Abdominal Wall Surgery
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha
| | - Zefang Sun
- Department of Pancreatic Surgery, General Surgery
- Department of Hernia and Abdominal Wall Surgery
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha
| | - Shuai Zhu
- Department of Pancreatic Surgery, General Surgery
- Department of Hernia and Abdominal Wall Surgery
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha
| | - Lu Chen
- Department of Pancreatic Surgery, General Surgery
- Department of Hernia and Abdominal Wall Surgery
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha
| | - Dingcheng Shen
- Department of Pancreatic Surgery, General Surgery
- Department of Hernia and Abdominal Wall Surgery
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha
| | - Gengwen Huang
- Department of Pancreatic Surgery, General Surgery
- Department of Hernia and Abdominal Wall Surgery
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha
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Abstract
Necrotizing or severe pancreatitis represents approximately 10%-20% of acute pancreatitis. 30%-40% of patients with acute necrotizing pancreatitis (ANP) will develop debris infection through translocation of intestinal microbial flora. Infected ANP constitutes a serious clinical condition and is complicated by severe sepsis with high mortality rates of up to 40% despite progress in current intensive care. The timely detection of sepsis is crucial. The Quick Sequential Organ Failure Assessment score, procalcitonin levels > 1.8 ng/mL and increased lactates > 2 mmol/L (> 18 mg/dL), indicate the need for urgent management. The escalated step-by-step management protocol starts with broad-spectrum antibiotics, percutaneous drainage or endoscopic management, and ends with surgical management if needed. The latter includes necrosectomy (either laparoscopic or traditional open surgery), peritoneal lavage and extensive drainage. This management protocol increases the chance of survival to approximately 60% in patients with otherwise fatal cases. Any treatment choice must be individualized, and the timing is critical.
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Affiliation(s)
- Efstathios T Pavlidis
- Second Propedeutic Department of Surgery, Hippocration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Theodoros E Pavlidis
- Second Propedeutic Department of Surgery, Hippocration Hospital, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
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