Procalcitonin-guided care can minimize antibiotic use in patients with acute pancreatitis: Study

UK: In acute pancreatitis, procalcitonin-guided care may be helpful to minimize antibiotic use without increasing the risk of infection or harm to patients, reports PROCAP trial data published in The Lancet Gastroenterology & Hepatology. The PROCAP was a single-center, patient-blinded, randomized controlled trial.

"The findings imply that in the care of this group of patients, procalcitonin-based algorithms to guide antibiotic use should be considered and incorporated into future guidelines on the management of acute pancreatitis," the researchers wrote in their study. 

Acute pancreatitis is very common and is the leading cause of hospitalization among gastrointestinal disorders. It can make the pancreas vulnerable to bacteria and infection, which may lead to clinical deterioration, lengthy recovery time, and mortality. Antibiotics are initiated on earliest suspicion to treat infected severe acute pancreatitis. However, differentiating inflammation from a bacterial infection in patients with acute pancreatitis can be difficult.

Clinicians have been using procalcitonin (PCT), a biomarker released in response to bacterial infections, to distinguish infection from inflammation. Algorithms based on procalcitonin measurement can differentiate bacterial sepsis from a systemic inflammatory response and help in the conservative use of antibiotics.

Prof Ajith K. Siriwardena, Manchester Royal Infirmary, UK, and his research team conducted a trial to test the hypothesis that a procalcitonin-based algorithm to guide the initiation, continuation, and discontinuation of antibiotics could lead to reduced antibiotic use without an adverse effect on outcomes in acute pancreatitis.

Researchers enrolled 260 participants with a clinical diagnosis of acute pancreatitis (aged 18 years or older) and randomly assigned them (1:1) to procalcitonin-guided care (n-132) or usual care (n-128). In the procalcitonin-guided care group, procalcitonin testing was conducted on days 0, 4, 7, and weekly thereafter. Guidance was to stop or not start antibiotics following a test value of less than 1•0 ng/mL and to start or continue antibiotics following a test value of 1•0 ng/mL or more. In the intervention group, any empirical clinical decision to use antibiotics was preceded by measurement of procalcitonin. Otherwise, both groups received standard care. The primary outcome was the use of antibiotics during the index admission to the hospital. All analyses were done in the intention-to-treat population.

Key findings of the trial,

• 45% of the patients in the procalcitonin-guided care group were prescribed antibiotics compared to 63% in the usual care group (adjusted risk difference –15•6%).

• The odds ratio for the treatment effect was 0•49.

• There was no significant difference in terms of the number of clinical infections or hospital-acquired infections per patient between the groups.

• Deaths were reported in 3% of the patients in the procalcitonin-guided care group and 2% in the usual care group; which were related to underlying severe pancreatitis

• There was no difference in adverse events between the groups.

The authors conclude that procalcitonin-guided care can reduce antibiotic use without increasing infection or harm in patients with acute pancreatitis. Procalcitonin-based algorithms to guide antibiotic use should be considered in the care of these patients and be incorporated into future guidelines on the management of acute pancreatitis.

Reference:

Siriwardena AK, Jegatheeswaran S, Mason JM; PROCAP investigators. A procalcitonin-based algorithm to guide antibiotic use in patients with acute pancreatitis (PROCAP): a single-centre, patient-blinded, randomised controlled trial. Lancet Gastroenterol Hepatol. 2022 Jul 18:S2468-1253(22)00212-6. doi: 10.1016/S2468-1253(22)00212-6. Epub ahead of print. PMID: 35863358.