International guidelines do not recommend the use of antibiotics in acute pancreatitis in the absence of specific infections1. However, globally, there is an overuse of antibiotics in all forms of acute pancreatitis, mainly because of the difficulty in distinguishing between a systemic inflammatory response and infection.
Normal physiologic levels of procalcitonin (PCT) are low, but they rise rapidly in response to infection and fall after eradication. Thus, PCT can distinguish infection from inflammation, and algorithms based on procalcitonin measurement can differentiate bacterial sepsis from a systemic inflammatory response. Therefore, Prof. Ajith Siriwardena (Manchester Royal Infirmary, UK) and his team tested in the PROCAP trial (ISRCTN50584992), whether a procalcitonin-based algorithm to guide initiation, continuation, and discontinuation of antibiotics can reduce antibiotic use in patients with acute pancreatitis, without an adverse effect on outcome.
In the single-centre, patient-blinded, randomised-controlled trial, adult patients with acute pancreatitis were included and randomly assigned to either a procalcitonin-based algorithm guiding antibiotic use in addition to usual care or to usual care only. Moreover, patients were stratified according to disease severity (mild versus moderately-severe or severe) and admission pathway (either direct admission to the Manchester Royal Infirmary or tertiary transfer from another hospital).
In total, 260 patients were randomised, 132 to PCT-guided treatment and 128 to standard-of-care. If the clinicians wanted to use antibiotics and the PCT result was <1.0 µg/L in the intervention group, it was recommended that no antibiotics were started, or patients already treated with antimicrobial therapy should stop it. Only in patients with PCT result ≥1.0 µg/L, an antibiotic intervention was recommended.
Significantly fewer participants in the intervention group used antibiotics compared with the control group (45% vs 62%; P=0.0077). In addition, there were fewer days of antibiotic use in the intervention arm compared with usual care. Regarding the number of clinical infections or hospital-acquired infections, there was no significant difference between the 2 groups. In addition, mild and severe disease and admission pathway did not influence the results. Costs were markedly reduced by applying the PCT-based algorithm.
“Our findings suggest that procalcitonin-guided care can reduce antibiotic use without increasing infection or harm in patients with acute pancreatitis,” Prof. Siriwardena concluded. Therefore, a PCT-based algorithm should be considered in the care of patients with acute pancreatitis and be incorporated into future guidelines.