• Hester C Timmerhuis, Fons F van den Berg, Paula C Noorda, Sven M van Dijk, Janneke van Grinsven, Christina J Sperna Weiland, Devica S Umans, Yasmin A Mohamed, Wouter L Curvers, BouwenseStefan A WSAW0000-0002-7600-9429Department of Surgery, Maastricht University Medical Center+, Maastricht., Muhammed Hadithi, Akin Inderson, Yama Issa, Jeroen M Jansen, Pieter Jan F de Jonge, Rutger Quispel, Matthijs P Schwartz, StommelMartijn W JMWJ0000-0002-4257-5254Department of Surgery., TanAdriaan C I T LACITL0000-0002-7389-5437Department of Gastroenterology and Hepatology, Canisius Wilhelmina Hospital, Nijmegen., Niels G Venneman, Marc G Besselink, Marco J Bruno, Thomas L Bollen, Elske Sieswerda, Robert C Verdonk, Rogier P Voermans, Hjalmar C van Santvoort, and Dutch Pancreatitis Study Group.
• Departments of Surgery.
• Ann. Surg. 2023 Oct 1; 278 (4): e812e819e812-e819.

ObjectiveThe use and impact of antibiotics and the impact of causative pathogens on clinical outcomes in a large real-world cohort covering the entire clinical spectrum of necrotizing pancreatitis remain unknown.Summary Background DataInternational guidelines recommend broad-spectrum antibiotics in patients with suspected infected necrotizing pancreatitis. This recommendation is not based on high-level evidence and clinical effects are unknown.Materials And MethodsThis study is a post-hoc analysis of a nationwide prospective cohort of 401 patients with necrotizing pancreatitis in 15 Dutch centers (2010-2019). Across the patient population from the time of admission to 6 months postadmission, multivariable regression analyses were used to analyze (1) microbiological cultures and (2) antibiotic use.ResultsAntibiotics were started in 321/401 patients (80%) administered at a median of 5 days (P25-P75: 1-13) after admission. The median duration of antibiotics was 27 days (P25-P75: 15-48). In 221/321 patients (69%) infection was not proven by cultures at the time of initiation of antibiotics. Empirical antibiotics for infected necrosis provided insufficient coverage in 64/128 patients (50%) with a pancreatic culture. Prolonged antibiotic therapy was associated with Enterococcus infection (OR 1.08 [95% CI 1.03-1.16], P =0.01). Enterococcus infection was associated with new/persistent organ failure (OR 3.08 [95% CI 1.35-7.29], P <0.01) and mortality (OR 5.78 [95% CI 1.46-38.73], P =0.03). Yeast was found in 30/147 cultures (20%).DiscussionIn this nationwide study of patients with necrotizing pancreatitis, the vast majority received antibiotics, typically administered early in the disease course and without a proven infection. Empirical antibiotics were inappropriate based on pancreatic cultures in half the patients. Future clinical research and practice must consider antibiotic selective pressure due to prolonged therapy and coverage of Enterococcus and yeast. Improved guidelines on antimicrobial diagnostics and therapy could reduce inappropriate antibiotic use and improve clinical outcomes.Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

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