Gastrointestinal Enterococcus colonization was associated with subsequent infected necrosis in acute necrotizing pancreatitis, typically preceding clinical diagnosis by 3 weeks, and early antibiotic use was associated with both Enterococcus colonization and infected necrosis.
Key Findings
Results
Rectal Enterococcus colonization was associated with subsequent development of infected necrosis in necrotizing pancreatitis.
Adjusted hazard ratio for rectal Enterococcus colonization and infected necrosis was 4.48 (95% CI 1.51–13.28)
Adjustment was made for baseline disease severity, biliary etiology, and prior antibiotic exposure
Results were similar when adjusting for early extra-pancreatic infection instead of disease severity
Study included 57 patients with necrotizing pancreatitis from the POEMA cohort across 20 Dutch hospitals
Results
Salivary Enterococcus colonization was also associated with subsequent infected necrosis, with a higher hazard ratio than rectal colonization.
Adjusted hazard ratio for salivary Enterococcus colonization and infected necrosis was 5.37 (95% CI 1.72–16.79)
Both rectal and salivary sampling were performed twice weekly for 30 days
Samples were analyzed using 16S rRNA sequencing
The salivary association was similarly adjusted for baseline disease severity, biliary etiology, and prior antibiotic exposure
Results
Enterococcus colonization typically preceded clinical diagnosis of infected necrosis by approximately 3 weeks.
The lead time between Enterococcus colonization and clinical diagnosis of infected necrosis was typically 3 weeks
20 of 57 patients (35%) with necrotizing pancreatitis developed infected necrosis
Colonization developed during admission rather than being present at baseline
Colonization occurred predominantly in the first 2 weeks of admission
Results
Early antibiotic use was associated with Enterococcus colonization in the gastrointestinal tract.
Early antibiotic use was associated with Enterococcus colonization with an adjusted HR of 4.99 (95% CI 1.57–15.80)
40% of early antibiotic use occurred without a documented infection
Early antibiotic use was also associated with reduced butyrate-producer abundance in the gut microbiota
These associations suggest a potential mechanism linking antibiotic-driven dysbiosis to subsequent infection
Results
Early antibiotic use was associated with subsequent development of infected necrosis.
Adjusted hazard ratio for early antibiotic use and infected necrosis was 3.56 (95% CI 1.23–10.28)
40% of patients receiving early antibiotics had no documented infection at the time of antibiotic administration
The authors note that whether this relationship is causal warrants further investigation
Authors suggest that if confirmed, findings would warrant a more restrictive antibiotic policy in early acute pancreatitis
Background
Infected necrosis complicated 35% of necrotizing pancreatitis cases in this cohort, consistent with known epidemiology.
20 of 57 patients with necrotizing pancreatitis developed infected necrosis (35%)
The broader literature cited in the abstract reports infected necrosis complicates 30% of necrotizing pancreatitis cases
The POEMA cohort comprised 276 patients with acute pancreatitis across 20 Dutch hospitals, of whom 57 had necrotizing pancreatitis
Intestinal bacterial translocation is described as the presumed mechanism for infected necrosis
Methods
The study design involved prospective twice-weekly microbiota sampling from rectal and salivary sites for 30 days using 16S rRNA sequencing.
This was a predefined subgroup analysis of the POEMA cohort, a prospective multicenter microbiota study
Sampling was performed twice weekly for 30 days
Both rectal and salivary samples were collected to capture gut and upper gastrointestinal microbiota
16S rRNA sequencing was used for microbiota analysis
Study spanned 20 Dutch hospitals
What This Means
This research suggests that a specific type of bacteria called Enterococcus, when it expands in the gut and mouth of patients with severe pancreatitis, is a warning sign that a dangerous complication called infected pancreatic necrosis may be developing. In patients whose pancreas tissue was dying (necrotizing pancreatitis), those who developed high levels of Enterococcus bacteria in their gut or saliva were roughly 4–5 times more likely to later develop infected necrosis — and this bacterial overgrowth appeared about 3 weeks before doctors could diagnose the infection clinically. Notably, this bacterial expansion was not present when patients first arrived at the hospital but developed during their stay, mostly in the first two weeks.
The study also found that giving antibiotics early in the course of pancreatitis — which happened without any confirmed infection in 40% of cases — was strongly linked to both the rise of Enterococcus in the gut and the later development of infected necrosis. Early antibiotic use was also associated with a drop in beneficial bacteria that produce butyrate, a compound important for gut health. This suggests that antibiotics may disrupt the normal gut bacterial community in ways that allow harmful Enterococcus bacteria to take over, potentially increasing the risk of serious infection.
This research suggests that routine early use of antibiotics in pancreatitis patients without confirmed infection may do more harm than good by disrupting the gut microbiome and potentially promoting dangerous bacterial overgrowth. The authors caution that while these associations are striking, it remains to be proven that antibiotic use directly causes these outcomes, and they call for a more cautious approach to prescribing antibiotics early in acute pancreatitis until further research confirms these findings.
van den Berg F, Pauw H, Timmerhuis H, Besselink M, Issa Y, Bruno M, et al.. (2026). Antibiotic-associated Enterococcus expansion in the gastrointestinal tract precedes infected necrosis in acute necrotizing pancreatitis.. Gut microbes. https://doi.org/10.1080/19490976.2026.2670039