Pancreatic candidiasis in a cat

Case summary An 11-year-old female spayed Maine Coon cat was referred for assessment of hyporexia, weight loss, vomiting and diarrhoea. An abdominal ultrasound revealed an enlarged and hypoechoic pancreas containing two large fluid-filled structures. Fine-needle aspiration of the cyst-like structures was performed, and cytology revealed moderate-to-marked predominantly suppurative inflammation with yeast cells. Candida glabrata was cultured from the fluid. The patient was treated with oral itraconazole and the clinical signs resolved, although repeat abdominal ultrasound and cytology revealed persistence of the infected cyst-like structures. The patient remained asymptomatic for 8 months after the discontinuation of antifungal medications, despite the persistence of the pancreatic infection with C glabrata. Relevance and novel information To our knowledge, this is the first report of pancreatic infection with Candida species in a cat, followed by a chronic subclinical infection persisting for at least 8 months after treatment discontinuation.

EXTRAPANCREATIC INFECTION AS A RISK FACTOR FOR ANTIBIOTIC RESISTANCE OF PANCREATIC INFECTIOUS AGENTS IN PATIENTS WITH ACUTE NECROTIZING PANCREATITIS

Aim of the study To determine the effect of extrapancreatic infection (EPI) on antibacterial resistance of pancreatic infectious agents in patients with acute infected necrotic pancreatitis Materials and Methods A longitudinal retrospective case-control study was conducted. The Object of the study were the patients with infected acute necrotizing pancreatitis (ANP). The subject of the study was the acquired AMR of pancreatic infection (PI) agents in patients with ANP. The control group included 27 patients who had a positive bacterial culture from sources of PI. 21 patients were included in the risk group, in which the additional source of EPI was recorded. Bacteriological monitoring was conducted in two stages: the primary identification of the agent of PI and the completion of inpatient treatment. Microbiological identification of the pathogen of EPI was performed before the primary determination of the pathogen of PI, and in the interval between stages I and II of the study. According to the results of the resistance profile of PI to AMR, all patients were divided into four clusters: I - patients who identified only antibiotic-sensitive bacterial strains (AMR"-"), II - patients with defined MDR-bacteria (multidrug-resistant), III - patients with XDR-bacteria (extensively drug-resistant), IV - patients with PDR bacteria (pandrug-resistant). Results The presence of EPI in patients with ANP influences the development of AMRs of PI toward increasing XDR and PDR strains (p=0.008 and p=0.04, respectively). In patients with infected ANP with the EPI, the risk of developing XDR infection was 2.4 times higher than the risk of developing this level of AMR in patients with no EPI (RR-2.4 (95% CI-1.16-4.91), p=0.03). EPI increases the risk of PDR PI by 8 times (RR-8.0 (95% CI-1.04-61.5) p=0.04). For each patient with infected ANP with signs of EPI, the risk of developing XDR strains was 36%, and PDR strains - 25%. Conclusions The presence of extrapancreatic sources of infection is a risk factor for development of AMR strains of microorganisms that persist in the sources of pancreatic infection. In this category of patients the risk of identification of extensively resistant strains was increased by 2.4-fold (p=0.03) and PDR strains by 8-fold (p=0.04), compared with patients with infected ANP without EPI.

TAXONOMIC STRUCTURE OF PANCREATIC INFECTIOUS AGENTS IN PATIENTS WITH ACUTE NECROTIC PANCREATITIS

The article describes the change in the level of antimicrobial resistance of infectious agents of acute infected necrotizing pancreatitis in patients in the dynamics of the disease and the treatment, classified the data according to the sensitivity of microorganisms. The main purpose of the prospective cohort study is to determine the taxonomic structure of pathogens of pancreatic infection in patients with acute necrotizing pancreatitis in the dynamics The relevance of the study of this pathology is the importance of the phenomenon of increasing the level of antibiotic resistance during long-term antibiotic therapy, which is shown to patients with pancreatic infection. The methodology of the study consisted of three-stage bacteriological monitoring and subsequent qualitative and quantitative evaluation of microbial agents and antibiotic resistance characteristics according to the stratified classification of the European Center for Disease Control ( Magiorakos et al., 2012): the taxonomic structure of pancreatic pathogens in 123 microbial isolates identified during the study was evaluated using antibioticogram results. The duration of the study was the entire duration of the diagnosed infectious process and averaged 33.4 days. The object of the study was selected microbial isolates, which were isolated in the above terms from the biological material of patients: aspirate parapancreatic fluid clusters in the initial stage, removed pancreatic sequesters in the second stage, and isolation from the drainage of the bursa omentalis and retroperitoneum in the third stage. The study empirically confirms and theoretically proves that the qualitative component of microbial pathogens of acute infected necrotic pancreatitis is characterized by time dependence: the level of classified resistance is higher in the third stage of the study compared with the obtained characteristics of the microorganisms in the first stage and, accordingly, in the second stage of the study; a consistent bacteriological characteristic indicates a transition from mono- to mixed infection (р< 0,001) with the inclusion of all members of the 'ESKAPE'-group in the second stage and the predominance of the gram-negative flora at each stage. The fungal component of the microorganisms is represented by the sole pathogen since the second stage of the study in the group with bacteria only. The results of the study may be useful in predicting the success of antibiotic therapy at different stages of the disease and the expected bacteriological characteristics in successive bacteriological crops of biological material of patients during the acute infected necrotizing pancreatitis.

Thymosin alpha 1 in the prevention of pancreatic infection following acute necrotizing pancreatitis (TRACE trial)

Abstract Background: IPN and its related septic complications are the major causes of death in patients with ANP. Therefore, prevention of pancreatic infection is of great clinical value in the treatment of ANP. This study aimed to evaluate the role of Thymosin Alpha 1 in treating ANP. Methods: Eligible patients were randomised to the treatment group(Thymosin alpha 1 group) or the control group. Occurrence of IPN will serve as the primary outcome measure of the TRACE trial. Occurrence of new-onset organ failure and persistent organ failure; CRP, HLA-DR, WBC day0, day 7 and day14; other related pancreatic complications and prognosis of the patients were also calculated. Discussion: The TRACE trial is designed to test the effect of a new therapy focusing on the immune system in preventing secondary infection following ANP, which is a potentially lethal complication causing substantial morbidity and mortality. We also aimed to prospectively investigate the effect of immunomodulatory treatment with thymosin alpha 1 in patients with different severity of diseases with predefined subgroup analysis. The results of the TRACE trial would potentially provide a novel therapeutic option in the early management of ANP and identify the patient population who may benefit most from immunomodulation. The trial was registered on the June 16, 2015 in the CT.gov register (NCT02473406)

Surgical and intervention treatment of secondary pancreatic infections

Introduction. Many experimental and clinical studies have improved our understanding of the pathophysiology of acute pancreatitis. Today, there are no disagreements over the timing and basic indications for surgery in this disease, but there are still various surgical approaches. Methods. A retrospective and prospective twocenter controlled study was conducted in 582 patients with acute pancreatitis treated in 2004–2018. Age of patients was 53 ± 12,5 years. The classification of the disease was used according to the recommendations of the International Consensus 2012. Patients included in the study were treated in accordance with the IAP/APA (2013) recommendations adapted to local resources and procedures. Of 582 patients, 387 (66,5%) patients with mild to moderate heaviness performed complex treatment, including 89 patients undergoing surgery. According to the goals and objectives of the study, other patients were divided into two groups: the main group – 103 patients with secondary pancreatic infection, who used the tactic of treatment «step-up approach»; а comparison group – 92 patients with open surgical intervention. Results. In the comparison group were used open necrosectomy and drainage. Postoperative complications have arisen in 52 (56,2%) patients. After surgery died 26 patients (28,3%), 19 had a 30-day mortality and 7 had a 90-daymortalityof them. In the main group 62 (60,2%) patients were treated by percutaneous controlled ultrasound intervention, 26 (25,2%) by videolaparoscopic necrosectomy and drainage and at 5 (4,9%) drainage through the wall of the stomach or duodenum. In 10 (9,7%) open operations were performed (minilumbotomy, upper medial, left or right-winged minilaparotomy with formation of mini-bursostomy) with pancreatic necrosectomy, including at 5 decompressive VAC-laparostomy local access. Postoperative complications have arisen in 33 (32%) patients. After surgery died 15 patients (14,6%), 6 had a 30-day mortality and 9 had a 90-day mortality of them. When comparing the two strategies of the treatment-tactical approach, the number of postoperative complications and mortality were lower than in the group of patients who performed only open surgical interventions (x2 = 6,976, p = 0,011). Conclusion. The our research showed that an individualized approach to patients with secondary pancreatic infection using the step-up approach provides a reduction in the number of laparotomic pancreatic necrosectomies and allows postponing «open» surgical interventions for a period after the 4th week from the onset of the disease and reducing the number of postoperative complications and mortality (x2 = 6,976, р = 0,031). Keywords: acute pancreatitis, secondary pancreatic infection, diagnostics, tactics «step-up approach», surgical treatment.