by Philippe Montravers, Elie Kantor, Jean-Michel Constantin,
Jean-Yves Lefrant, Thomas Lescot, Nicolas Nesseler, Catherine Paugam, Matthieu
Jabaudon and Hervé Dupont
Critical Care volume 23,
Article number: 393 (2019)
Background:
Recent international guidelines for acute pancreatitis (AP)
recommend limiting anti-infective therapy (AIT) to cases of suspected
necrotizing AP or nosocomial extrapancreatic infection. Limited data are
available concerning empirical and documented AIT prescribing practices in
patients admitted to the intensive care unit (ICU) for the management of AP.
Methods:
Using a multicentre, retrospective (2009–2014),
observational database of ICU patients admitted for AP, our primary objective
was to assess the incidence of AIT prescribing practices during the first 30 days
following admission. Secondary objectives were to assess the independent impact
of centre characteristics on the incidence of AIT and to identify factors
associated with crude hospital mortality in a logistic regression model.
Results:
In this cohort of 860 patients, 359 (42%) received AIT on
admission. Before day 30, 340/359 (95%) AIT patients and 226/501 (45%) AIT-free
patients on admission received additional AIT, mainly for intra-abdominal and
lung infections. A large heterogeneity was observed between centres in terms of
the incidence of infections, therapeutic management including AIT and
prognosis. Administration of AIT on admission or until day 30 was not
associated with an increased mortality rate. Patients receiving AIT on
admission had increased rates of complications (septic shock, intra-abdominal
and pulmonary infections), therapeutic (surgical, percutaneous, endoscopic)
interventions and increased length of ICU stay compared to AIT-free patients.
Patients receiving delayed AIT after admission and until day 30 had increased
rates of complications (respiratory distress syndrome, intra-abdominal and
pulmonary infections), therapeutic interventions and increased length of ICU
stay compared to those receiving AIT on admission. Risk factors for hospital
mortality assessed on admission were age (adjusted odds ratio [95% confidence
interval] 1.03 [1.02–1.05]; p < 0.0001), Balthazar score E (2.26
[1.43–3.56]; p < 0.0001), oliguria/anuria (2.18 [1.82–4.33]; p < 0.0001),
vasoactive support (2.83 [1.73–4.62]; p < 0.0001) and mechanical
ventilation (1.90 [1.15–3.14]; p = 0.011), but not AIT (0.63 [0.40–1.01]; p = 0.057).
Conclusions:
High proportions of ICU patients admitted for AP receive
AIT, both on admission and during their ICU stay. A large heterogeneity was
observed between centres in terms of incidence of infections, AIT prescribing
practices, therapeutic management and outcome. AIT reflects the initial
severity and complications of AP, but is not a risk factor for death.
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