Do we need to re-evaluate the role of fine-needle aspiration in infected necrotizing pancreatitis in the post-POINTER era?

Aims Infected necrotizing pancreatitis is increasingly managed with delayed invasive intervention and conservative antibiotic therapy. In this context, fine needle aspiration (FNA) could play a crucial role by facilitating targeted, culture-based antimicrobial treatment. Our study aimed to assess the clinical value of FNA and its potential impact on antimicrobial therapy in a large cohort of patients with acute necrotizing pancreatitis.

Methods We performed a post-hoc analysis of a Dutch prospective cohort of 618 patients with acute necrotizing pancreatitis (CTSI≥3) from 17 hospitals between 2010 and 2020. A fisher exact test was used for descriptive analysis.

Results Of 618 patients with acute necrotizing pancreatitis, 72 patients (12%) underwent a total of 73 FNA procedures. Of the 73 procedures, 11 (15%) were endoscopic ultrasound-guided FNAs (EUS-FNA) and 62 (85%) were percutaneous FNAs. 58/73 (81%) FNA cultures were positive for bacteria and/or yeast, of which 40% were polymicrobial. 9/11 (82%) who underwent EUS-FNA had positive culture results and all were polymicrobial, as compared to 14/49 (29%) with percutaenous FNA (p<0.001). Enterobacteriaceae (72%) and fungi (55%) were more frequently cultured in EUS-FNA compared to percutaneous FNA (30%, p=0.002, 11%, p=0.015). No post-procedural complications were observed. 53/72 (74%) patients underwent subsequent (peri-)pancreatic drainage. Median time between FNA and drainage culture was 13 days (IQR 4-23). Level of agreement between FNA and drainage in terms of species identification was on average 40% (IQR100). Of 66 patients (92%) with available antimicrobial treatment data, 32 (48%) received antibiotics at the time of FNA. Differences in culture results were observed between patients who received antibiotics for 1 day or longer the week before FNA and those who did not. In 14/56 (25%) of the positive FNA cultures, the micro-organisms were resistant to three commonly administered empiric antibiotic regimes, of which 13/14 (93%) was due to Enterococcus Faecium.

Conclusions FNA is a safe procedure for diagnosing infected necrotizing pancreatitis and guiding antimicrobial therapy. Poorly covered microbes by empirical therapy (i.e. Enterococcus, Candida) were frequently found. EUS-FNA cultures were often polymicrobial, likely due to peri-procedural contamination, and should be omitted. The long interval and in-between antibiotics seems to heavily impact the agreement between FNA and subsequent drainage cultures. Although large prospective studies are first needed, the role of FNA needs reconsideration, as it has the potential to optimize conservative treatment of infected necrotizing pancreatitis and help curb antimicrobial resistance.

Conflicts of Interest

Authors do not have any conflict of interest to disclose.

Publikationsverlauf

Artikel online veröffentlicht:
27. März 2025