Review for 10.1186/s12876-023-03070-1 (2023)

Title: Effect of early antibiotic treatment strategy on prognosis of acute pancreatitis
Version: 1 Date: 30 Sep 2023
Reviewer's report:
Comments to Editor
This original article is relevant since it explores the impact of ATB over AP studied by type
of etiology, and more evidence is needed regarding the role of ATB prophylaxis in AP of
biliary etiology in order to diminish the rate of complications, including infectous complications.
Ramdomized controlled trials are focused in preventing infection of pancreatic necrosis, or
global complications/ infections without perform stratification by groups of biliary AP or not.
**Comments to Authors:**
Infectious complications encompass a wide spectrum of issues. Authors should specify whether
they are discussing this in a general (pancreatic) or extrapancreatic context.
Extrapancreatic infections (EPI) are both relevant and common. Additionally, biliary infections
related to acute pancreatitis (AP) hold significance. In some instances, antibiotics (ATB)
are administered due to suspicion of EPI. This concept should be considered (10.1016/
j.pan.2018.05.481) and also outlined in the results section.
The introduction should also focus on the role of antibiotics (ATB) in preventing necrosis
infection or extrapancreatic infections as documented in the literature. It should address the
pertinent evidence supporting or opposing the use of ATB.
Regarding exclusion criteria: Were patients with concurrent acute cholangitis or cholecystitis
excluded? Did the authors consider including only pure pancreatitis patients? We understand that
distinguishing between cholangitis and AP, or cholecystitis and AP, can be challenging, leading
to an increased rate of infections incorrectly attributed to AP. Other authors have considered
including only "pure acute pancreatitis confirmed by radiological findings" patients for studying
infections related to AP (https://doi.org/10.1016/j.hpb.2021.10.016).
Was a routine CT scan performed? There is no evidence justifying routine CT scans in patients
with AP, especially in cases of mild AP.
Authors must outline the management protocol of their institution, including criteria for
initiating ATB treatment, the preferred type of ATB, and definitions for suspected pancreatic
infections, suspected extrapancreatic infections, and each specific infection analyzed. How
did they define infection of pancreatic necrosis? Was a positive culture required in all cases?
The definition of "early antibiotic administration" is missing in the methods section (<24hrs?,
<72hrs?).
Please enumerate the indications for ATB therapy in the cohort: empirical, infected pancreatic
necrosis, suspected pancreatic necrosis, extrapancreatic infections, etc.
What were the indications for performing laparotomy? Did the centre employ endoscopic
treatment for infected pancreatic necrosis? Recent randomized controlled trials from the Dutch
Pancreatitis group have demonstrated that endoscopic approaches are effective in managing
necrosis infections.
Is it possible to conduct a logistic regression analysis on factors related to worse outcomes (well-
known factors such as % of necrosis) while including ATB (and/or type of ATB) as one of the
factors analyzed?
In section 3.5 of the results, the authors incorporated personal opinions, which is not appropriate.
For example, "Based on the above results, we believe…"
In the discussion section, I suggest that the authors should commence by commenting on their
results in the first paragraph.
Discussion - Line 388: However, in some high-risk populations, such as those with gallstones,
there may be complications of infection. The authors need to reference studies that demonstrate
biliary AP's susceptibility to more infectious complications.
Please add a reference to line 397.
Line 408: Regarding the small sample size in each etiological group, it is challenging to
recommend guiding ATB prescriptions. The study's conclusions regarding the lower incidence
of exploratory laparotomy in the biliary AP plus ATB group may not be applicable in current
clinical practice due to the introduction of interventional endoscopy and minimally invasive
procedures. This aspect must be discussed.