Introduction

Previous studies have demonstrated that infected pancreatic fluid collections are associated with worse clinical outcomes¹.

Aims & Methods

In light of the global rise in antibiotic resistance, this study investigates the impact of the spectrum of infecting microorganisms on the effectiveness of endosonography (EUS)-guided drainage for these conditions. Data on EUS-guided drainage of pancreatic fluid collections performed between 2018 and 2022 at three endoscopy units of Charité Berlin, regardless of the etiology, were reviewed and analyzed. The primary- endpoints were the duration of hospital stay and clinical success of the therapeutic EUS, defined as (1) the resolution of the collection to <50% within 1-3 months as observed in follow-up imaging and (2) clinical improvement. The secondary endpoints were the duration of ICU stay, mortality, and the total number of required interventions to achieve treatment success, including the initial intervention, removal and replacement of stents, and additional procedures, e.g., necrosectomy or therapy of complications during 12 months follow-up. The infection of the fluid collection was diagnosed based on microbiological evidence obtained from EUS-guided fine needle aspiration or positive blood culture, after excluding other sources of infection, along with clinical presentation and elevated inflammatory markers. The microorganisms were categorized based on microscopic appearance, Gram staining, and the number of germs in a collection. Patients with sterile necrotic collections undergoing the same therapeutic modality were used as a control group to compare the outcomes.

Results

A total of 102 patients (71.6% male, mean age 55.9±13.9 years) were included in the final analysis. In 91 of the 102 cases (89.2%), double pigtail plastic stents were utilized (46.1% were multiple), and in 38 (37.3%) patients, a transmural endoscopic necrosectomy was performed. In 29.5% of cases, penicillin; 18.2%, carbapenems; 13.6%, cephalosporins; 6.8%, metronidazole; 6.8%, vancomycin; and 18.2%, other antibiotics were administered. Compared to the control group, Gram-positive germs were associated with a significantly longer hospital stay (32 vs. 21 days, p < 0.001 ) and a greater need for ICU services (49 vs. 2 days, p < 0.001). Endoscopic therapy was less successful for Candida glabrata infections compared to those caused by Candida albicans (45.5% vs. 85.4%). While both were associated with a significantly prolonged hospital stay, infections with Enterococcus faecium (including 4 cases of vancomycin-resistant Enterococcus faecium, VRE) resulted in significantly higher mortality (29.4% vs. 4.5%, p < 0.05), and infections with Enterococcus faecalis were associated with significantly worse clinical outcomes as defined by the resolution of the collection in follow-up assessments (33.3% vs. 88%, p < 0.05). These correlations remained significant in the multivariate regression analysis, with Enterococcus faecium showing an odds ratio (OR) of 8.1 (95% CI: 1.4–47.4) for higher mortality.

Conclusion

The type of infecting organism significantly impacts clinical outcomes in patients undergoing EUS-guided drainage for infected peripancreatic fluid collections. Enterococcus faecalis and faecium infections were associated with poorer clinical outcomes, highlighting the need for targeted therapeutic strategies.

References

1. Werge M, Novovic S, Schmidt PN, Gluud LL. Infection increases mortality in necrotizing pancreatitis: A systematic review and meta-analysis. Pancreatology. 2016 Sep-Oct;16(5):698-707.

Disclosure

No conflict of interest.