Scandinavian Journal of Gastroenterology

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Use of antibiotics in acute pancreatitis: ten major

concerns

Vasiliki Soulountsi & Theodoros Schizodimos

To cite this article: Vasiliki Soulountsi & Theodoros Schizodimos (2020): Use of antibiotics
in acute pancreatitis: ten major concerns, Scandinavian Journal of Gastroenterology, DOI:
10.1080/00365521.2020.1804995

To link to this article: https://doi.org/10.1080/00365521.2020.1804995

Published online: 17 Aug 2020.

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SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY
https://doi.org/10.1080/00365521.2020.1804995

REVIEW

Use of antibiotics in acute pancreatitis: ten major concerns

Vasiliki Soulountsia and Theodoros Schizodimosb
a
1st Department of Intensive Care Medicine, George Papanikolaou General Hospital, Thessaloniki, Greece; b2nd Department of Intensive
Care Medicine, George Papanikolaou General Hospital, Thessaloniki, Greece

ABSTRACT ARTICLE HISTORY

Acute pancreatitis is one of the most common gastrointestinal causes for hospitalization. In 15–20% it Received 24 June 2020
evolves into severe necrotizing pancreatitis. Recent studies have shown no association between the Revised 20 July 2020
initiation of antibiotic therapy in acute pancreatitis and severe outcomes such as organ failure, infec- Accepted 28 July 2020
tion of pancreatic necrosis, extrapancreatic infections or mortality. Specific subgroups with predicted
KEYWORDS
severe acute pancreatitis or both extensive sterile necrosis and persistent organ failure may benefit Acute pancreatitis;
from prophylactic antibiotics. Local infection develops in 30% of patients with pancreatic necrosis and pancreatic necrosis;
results in morbidity and mortality. Contrast enhanced computed tomography should be performed in antibiotics; procalcitonin;
all patients with acute pancreatitis who develop sepsis, organ failure or fail to improve. C-reactive pro- C-reactive protein
tein is an independent predictor of severe acute pancreatitis. Procalcitonin is the most sensitive labora-
tory test for detection of pancreatic infection. Antibiotics do however play a large role in patients with
suspected or confirmed infected pancreatic necrosis and extrapancreatic infections. In clinical practice
most clinicians prescribe antibiotics in the first 3 days of acute pancreatitis which in turns lead to
excessive, unjustified use of antibiotics. Deep knowledge of the recent guidelines combined with an
individualized management based on right clinical judgment is a rationale approach of patients with
acute pancreatitis.

Introduction pancreatitis (ANP) with permanent organ failure, at a rate of

Acute pancreatitis (AP) is one of the most common indica-
tions for inpatient hospital care in the US, with an annual
incidence of 13–45 cases per 100,000 people [1,2]. In Europe,
recent epidemiological data from 17 countries reported that
the incidence of AP ranged from 4.6 to 100 per 100,000
population, with the highest rates recorded in the eastern
and northern regions [3]. AP, as it is known, in 80% of cases
is a self-limiting disease with a need, usually, of short-term
inpatient hospitalization [4]. According to recent epidemio-
logical data, there is an increase in the incidence of pancrea-
titis [5] both as a diagnosis in the emergency department as
well as a diagnosis of admission in the hospital. However, its
mortality has been significantly reduced while its overall
mortality is 2% [1]. Increased mortality is still observed in
subgroups of patients including the elderly patients, those
with more numerous and more severe coexisting conditions
(particularly obesity) [6,7], those in whom hospital acquired
infections develop [8], and those with severe episodes of AP
[characterized by persistent failure of one or more organ sys-
tems or infected pancreatic necrosis (IPN)] [4].
The most commonly used classification system for AP is
the 2012 revision of the Atlanta classification and definitions
based on international consensus [9]. AP evolves into severe
necrotizing pancreatitis with transient or permanent organ
failure at a rate of 15–20%. In severe acute necrotizing
70% the necrosis will remain sterile with a 10% mortality,
while at a rate of 30% it will become infected and will evolve
into critical AP with a mortality approaching 30% [4,10].
There are two overlapping phases in this dynamic disease
process [9]. The first phase, which usually lasts for the first
week, is the phase of systemic inflammatory response syn-
drome (SIRS) where cytokine cascades (especially interleukin
6) are activated by the pancreatic inflammation. This is the
time period that may occur transient organ failure. The SIRS
of the early phase may be followed by a compensatory, anti-
inflammatory response syndrome (CARS) that may contribute
to an increased risk of infection with interleukin 10 as a
major mediator. This second later phase is characterized by
the presence of local complications [peripancreatic fluid col-
lections, pancreatic pseudocyst, pancreatic necrosis (PN),
peripancreatic necrosis, acute necrotic collection, walled-off
necrosis, portal vein thrombosis, colonic necrosis] and there
is an increased risk of contamination of pancreatic and peri-
pancreatic necrotic tissue. Systemic complications and/or
persistent organ failure may also occur during the same
period of time.
Mortality in AP has two peaks [1,6–8]: in the first week
and is due to SIRS and organ failure, and then in the third
week and is due to sepsis and complications of the disease.
Actually, approximately 25–40% of patients with severe AP
(SAP) will develop infectious complications. The immune

CONTACT Vasiliki Soulountsi vsoulou@yahoo.gr 1st Department of Intensive Care Medicine, George Papanikolaou General Hospital, G. Papanikolaou
Avenue, Exochi, Thessaloniki 57010, Greece
ß 2020 Informa UK Limited, trading as Taylor & Francis Group
2 V. SOULOUNTSI AND T. SCHIZODIMOS
deficiency associated with AP and the bacterial translocation
as a result of multiple organ failure contribute to infection
susceptibility in patients with AP.
Infections in AP
Infections in AP can be distinguished into two categories:
pancreatic and non-pancreatic. The contamination of PN is
the main representative of pancreatic infections. Non-pancre-
atic infections include mostly pneumonia, bacteremia, central
venous catheter infection, urinary tract infection and cholan-
gitis. Actually, in a data analysis of a cohort study [11] which
involved 731 patients with SAP showed that the main infec-
tions developed were pneumonia and bacteremia in the first
week of the disease and the contamination of PN after the
third week. De Waale et al. [12] analyzed data derived from
the EPIC II study for the infections and the use of antibiotics
(ABs) in patients admitted for SAP. In this study [12], 5% of
patients with intra-abdominal infection had SAP [13].
Infectious complications in these patients occurred in the
first week or after the third week. Patients with infectious
complications had a longer length of stay in intensive care
unit (ICU) and higher mortality. In the same study, 84% of
patients with SAP received antibiotic (AB) treatment, which
in 24% of cases was prophylactic.
Use of ABs in SAP
Current guidelines do not endorse the use of ABs in the
management of AP [14,15]. Indeed, the mild form of AP
(interstitial edematous pancreatitis), characterized by the
absence of organ failure and local or systemic complications,
is usually self-limiting. Short-term hospitalization including
moderate fluid resuscitation, pain and nausea management,
and early oral feeding results in rapid clinical improvement
[15]. On the contrary, the literature has been conflicting
regarding the role of ABs in SAP. Most studies have a lot of
limitations such as low number of patients, involvement of a
substantial number of patients with mild pancreatitis, use of
different ABs and different administration time. Ideal anti-
biotic stewardship in AP will optimize antimicrobial use to
achieve the best clinical outcomes while minimizing adverse
events and limiting selective pressures that drive the emer-
gence of resistance and may also reduce excessive costs
attributable to suboptimal antimicrobial use. We conducted
a literature search on MEDLINE/PubMed, Google Scholar and
Cochrane Library for studies completed in the last twenty
years using the terms ‘acute pancreatitis’ and ‘antibiotics in
acute pancreatitis’. We have also included the latest guide-
lines from all established societies regarding pancreatitis and
its management. The purpose of this review is to detail
through ten questions which is the ideal approach in AP in
terms of ABs with the recent pooled evidence, what is and
what should be the daily clinical practice nowadays. Also,
our aim is to provide a therapeutic strategy for antibiotic
stewardship in AP based on an algorithm useful to guide
clinicians’ decisions (Figure 1).
Prophylactic AB treatment
1. Does prophylactic AB treatment have a role in SAP?
Prophylactic AB therapy in SAP and in sterile PN is still a
matter of controversy in the literature [16]. There remains a
big debate as to whether prophylactic AB therapy in SAP is
associated with better clinical outcomes regarding mortality,
the contamination of PN, the development of extrapancreatic
infection and the need for surgical intervention in patients
with necrosis [16] (Table 1).
Several studies are against prophylactic AB therapy. In
particular, the two double-blind, randomized controlled trials
(RCTs) in the literature [17,18], several later meta-analyses
[19–23] and Cochrane analyses [24,25] concluded that
prophylactic AB use did not reduce the likelihood of infec-
tion in PN, mortality or the requirement for surgical interven-
tion (Table 1). There is a little evidence that the prophylactic
AB therapy may reduce SIRS manifestation, extrapancreatic
infections [21] or may benefit the subgroup of patients with
a large extent of necrosis (>30%) [17,23] and multiple organ
failure [23]. Additionally, the use of imipenem (a beta-lactam)
has been associated with a significantly decrease in pancre-
atic infection [24].
However, in the literature there are studies favoring
prophylactic AB therapy as it improves several outcomes.
Indeed, in a meta-analysis involving 10 RCTs with 1279
patients, Dambrauskas et al. [26] reported that patients with
ANP should receive effective AB prophylaxis (e.g., carbape-
nem iv) to reduce mortality, the risk of necrosis infection,
sepsis and the need for surgical intervention (Table 1).
However, they concluded that further clinical studies regard-
ing the exact indications of prophylactic AB therapy are
required. Subsequently, more recent meta-analyses [27–29]
showed that prophylactic AB treatment reduced occurrence
of IPN [27,28] and mortality [28,29], but did not affect the
need for surgical intervention [27–29] or the development of
extrapancreatic infections [27,28]. However, in the study of
Lim et al. [29], the benefit from the prophylactic use of ABs
in mortality was not confirmed in the isolated analysis of
RCTs. In the latter, benefit was obtained only in terms of the
incidence of extrapancreatic infections.
More recently, accumulated evidence [16,25,30–34] sug-
gested that the use of ABs is not associated with a signifi-
cant decrease in morbidity or mortality. Specifically, Mourad
et al. [16] reported 18 meta-analyses of RCTs identified
between the years 1998 and 2015. Only 6 of these meta-
analyses showed that prophylactic ABs significantly reduced
total mortality, while 4 studies showed that prophylactic ABs
reduced the incidence of PN.
In summary, based on the literature and the latest guide-
lines [14,15,35,36], intravenous AB prophylaxis is not recom-
mended for the prevention of infectious complications in AP
as well as in patients with sterile necrosis to prevent the
development of IPN. However, there is a concern if the use
of prophylactic ABs in subgroup of patients with AP and
increased white blood count or overt clinical signs of sepsis
is justified [16]. Also, in these patients clinicians should be
considered the early administration of ABs, namely within
72 h after onset of symptoms or 48 h after hospital
 SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY 3

Figure 1. Proposed algorithm for the use of antibiotics in severe acute pancreatitis in clinical practice. We provide a step-by-step approach based initially on the
severity of the disease and the CT findings in admission. During the clinical course of the disease, the clinicians should assess continuously the patient for clinical
signs and laboratory tests of sepsis and septic shock and the function of the organs in order to adjust their therapeutic approach in the new data. Antibiotics have
a role only in patients with extended PN (30%) and overt signs of sepsis and septic shock with MOF prophylactically as well as in patients with documented IPN or
extrapancreatic infection. In this way, clinicians could clarify where antibiotics play a key role. CT: Computed tomography, PN: Pancreatic necrosis, MOF: Multiple
organ failure, IPN: Infected pancreatic necrosis, PCT: Procalcitonin, CRP: C-reactive protein, SIRS: Systemic inflammatory response syndrome, FNA: Fine nee-
dle aspiration.

Table 1. Effect of prophylactic antibiotic therapy on main outcomes.

Study Year of the study Infection of pancreatic necrosis Mortality Surgical interventions Extrapancreatic infections
Dambrauskas et al. 2007 # # # #
Yao et al. 2010 # no no no
Ukai et al. 2015 # # no no
Lim et al. 2015 no # no #
except RCTs in RCTs
Mourad et al. 2017 # #
(in 4 studies) (in 6 studies)
Isenmann et al. 2004 no no no –
Dellinger et al. 2007 no no – –
Jafri et al. 2009 no no no –
de Vries et al. 2007 no no – –
Bai et al. 2008 no no – –
Wittau et al. 2011 no no no no
Cochrane analysis (Villatoro et al.) 2010 no (except imipenem) no no no
RCTs: Randomized controlled trials.

admission. According to a recent meta-analysis [28] of 6 may benefit from prophylactic ABs, including those with pre-
RCTs [17,37–41] in this time frame there is a benefit at least dicted SAP or both extensive sterile necrosis and persistent
in occurrence of IPN and mortality. So, there is an imperative organ failure [15], and which is the ideal time frame for the
need for future RCTs to clarify whether specific subgroups administration of the ABs in the course of predicted SAP.
4 V. SOULOUNTSI AND T. SCHIZODIMOS
Another interesting field of investigation is if gut decontam-
ination improves outcomes in patients with predicted SAP
(and possibly other subgroups) [15].
AB therapy in IPN
In contrast to sterile PN, in IPN the use of ABs as well as the
drainage of necrotic collections are necessary based on spe-
cific criteria. Recent systematic review and meta-analysis [42]
concluded that patients with infected necrosis are more than
twice as likely to die compared to patients with sterile necro-
sis. The former had also higher risk for organ failure and
admission to the ICU than the latter.
2. Which patients with PN are at increased risk for IPN?
In general, patients with multiple organ failure, early bacter-
emia, extensive PN (>30%), high C-reactive protein (CRP)
[31,43] and procalcitonin (PCT) values [44–47] and imaging
signs such as presence of gas in peripancreatic collections
(<10%) [9,11,35,48,49] are at an increased risk of IPN.
3. What is the role of PCT in SAP?
Algorithms based on measurement of PCT have emerged as a
means of differentiating bacterial sepsis from SIRS in a wide
range of settings [50]. In terms of PCT in SAP, a reference sys-
tematic review [51] noticed that different cut off values have
been used when its value at predicting the severity of AP and
IPN was evaluated. Nevertheless, researchers found that its sen-
sitivity and specificity for development of SAP were 0.72 and
0.86, respectively (area under the curve [AUC] ¼ 0.87; DOR ¼
14.9; 95% confidence interval [CI] ¼ 5.6–39.8), albeit with a sig-
nificant degree of heterogeneity (Q ¼ 28.56, p < .01). On the
contrary, the sensitivity and specificity of PCT for prediction of
IPN were 0.80 and 0.91 (AUC ¼ 0.91; DOR ¼ 28.3; 95% CI ¼
13.8–58.3) with no significant heterogeneity (Q ¼ 7.83, p ¼ .18).
Thus, serial serum PCT measurements are suggested as they
may be valuable in predicting the severity of AP and the risk of
developing IPN [51]. Most recently, several studies support that
PCT could be a good marker for suspected infection but
patients having sterile necrosis have no benefits from AB ther-
apy [52–55]. An ongoing RCT (PROCAP) aim to prove that a
PCT-based algorithm to guide initiation, continuation and dis-
continuation of ABs in AP will lead to reduced AB use without
an adverse effect upon outcome [56]. Until that is proven, last
guidelines noticed that PCT is the most sensitive laboratory test
for detection of pancreatic infection, and low serum values
appear to be strong negative predictors of IPN [15].
4. What is the role of CRP in SAP?
Several literature data suggest that CRP is an independent
predictor of SAP after 24 h [57–64]. Although the most often
recommended optimal CRP cut off point that predicts com-
plications in AP is 150 mg/L [15,57,65,66], the cut off of
170–190 mg/L evaluating at 48 h after hospital admission
seems to increase the specificity of the test [61]. Most
recently, in a study of 337 patients with a first incidence of
AP, Stirling et al. demonstrated that an interval change in
CRP is a comparable measure to absolute CRP in the prog-
nostication of AP severity. More specifically, they found that
a rise of >90 mg/dL from admission or an absolute value of
>190 mg/dL at 48 h predicts severe disease with the greatest
accuracy [62]. So, similarly with PCT, serial measurements of
CRP during the course of SAP are recommended [32].
5. How do we diagnose an IPN in a patient with ANP in
order to prescribe ABs?
Diagnosis of IPN is a challenge since its clinical signs and
symptoms cannot easily be distinguished from other infec-
tious complications. However, IPN is probable [67] in a
patient with pancreatic or extrapancreatic necrosis who was
previously clinically stable or improving and develops sepsis,
SIRS, organ failure, or imaging signs such as presence of gas
in peripancreatic collections [9,11,35,48,49]. It may occur at
any time during the clinical course of ANP, but usually peaks
between 2 and 4 weeks after presentation [67]. According to
the guidelines, IPN should be considered in patients with
pancreatic or extrapancreatic necrosis who deteriorate or fail
to improve after 7–10 days of hospitalization [14].
In all these patients, contrast enhanced computed tom-
ography (CECT) should be performed in order to evaluate
local complications of AP especially infected (peri)pancre-
atic necrosis [14,68]. If extra luminal gas formations are
observed in (peri)pancreatic necrosis on CECT the clini-
cians should be start at least AB treatment since the
necrosis is considered infected with very high certainty
[68]. In other inconclusive cases, guidelines recommend
strongly either initial CT-guided fine needle aspiration
(FNA) for Gram stain and culture to guide use of appropri-
ate ABs or empiric use of ABs without CT FNA [14,68].
Also, CT-guided FNA is recommended when a fungal infec-
tion is suspected [35], in case of no clinical response to
combination AB therapy. In all these cases it should be
taken into account that there is a risk of false-negative
FNA results in 12–25% of patients with infected necrotiz-
ing pancreatitis [35], while the presence of gas in peri-
pancreatic collections as an evidence of infection is found
in only about half of the patients with IPN (sensitivity 56%,
specificity 97%) [35,48,49]. If sample gram stain and cul-
ture is negative, patient’s supportive care continues and
FNA is repeated every 5–7 days, if clinically indicated [14].
6. What is the therapeutic approach of the patients with
documented IPN with regard to ABs?
If sample gram stain and culture is positive, it is necessary to
start ABs. The efficacy of conservative treatment in IPN was
evaluated in a recent systematic review and meta-analysis
[69]. It was found that conservative management was suc-
cessful for 64% of patients, additional surgery was required
for 26% of patients and the overall mortality rate was 12%.
According to the latest consensus [67], AB therapy alone
could be administered in selected patients with IPN provided
that they are clinically stable, minimally symptomatic and
strictly monitored for clinical deterioration. In addition,

proven IPN can be managed with ABs and supportive care
until the necrotic collections can partially liquefy, wall-off, as
this approach allows safer, more organ-preserving and more
effective interventions [67]. Finally, asymptomatic walled off
necrosis does not mandate intervention regardless of the
size and extension of the collection, and may resolve spon-
taneously over time, even in rare cases of IPN. In case the
patient is clinically unstable and develops multiple organ fail-
ure, surgical intervention is required.
7. Which ABs have a place in AP?
The ideal AB should have good activity against the bacteria
responsible for pancreatic infections, achieve good concen-
trations into pancreatic tissue and peri-pancreatic fluid/exu-
dates, be administered in therapeutic doses based on
minimal inhibitory concentration (MIC), be able to penetrate
the pancreas during AP, and have a clear-cut clinical capacity
to reduce the development of IPN [16]. The choice of the
appropriate AB should be based on the microbiology of the
IPN. Most commonly isolated pathogens are gut bacteria,
namely gram-negative bacteria such as Enterobacteriaceae,
Enterobacter species, gram-positive aerobic bacteria such as
Enterococcus faecalis and Enterococcus faecium and anae-
robes [12,70]. Anaerobic bacteria have been cultured in
8–15% of patients, while fungal infections are present in
5–8% before AB treatment, rising to 20–30% when pro-
longed treatment with multiple broad-spectrum ABs is pre-
scribed [71–73]. The recommended ABs that have good
penetration in pancreatic tissue and bactericidal activity
include carbapenems, piperacillin-tazobactam, fluoroquino-
lones combined with an anti-anaerobic drug such as metro-
nidazole, and to a lesser extent third generation
cephalosporins [74–80]. In contrast, penicillins, first-gener-
ation cephalosporins, aminoglycosides and tetracyclines
should be avoided because of ineffectiveness in AP [75,76].
However, it should always be taken into account that no ABs
effectively penetrate necrotic tissue (where pancreatic infec-
tion usually occurs) without blood supply [16]. This makes
pancreatic infections sometimes very resistant to ABs.
In terms of antifungals agents, according to the latest
guidelines, their routine administration along with prophylac-
tic or therapeutic ABs is not recommended [14]. On the
other hand, as fungal infection is a serious complication and
indicate patients with a higher risk of mortality in long term
[81], the latest IDSA guidelines [82] for invasive candidiasis
suggest that empiric antifungal therapy should be consid-
ered for patients with ANP. Echinocandin or fluconazole
administration is recommended if there is no prior exposure
to azoles or no colonization with azole-resistant Candida spe-
cies [82].
8. What is the role of ABs in extrapancreatic infection?
According to the latest guidelines, ABs should be given for a
confirmed extrapancreatic infection (such as cholangitis or
pneumonia) which are reported in 14–37.4% [11,83–85]. All
these infections should be treated according to the current
international guidelines for each infection [86–89]. However,
SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY 5
once no source of infection is identified, ABs should be dis-
continued [14].
9. What is the daily clinical practice worldwide in terms
of the use of ABs in PN?
Discriminating between pancreatic infection and inflamma-
tion is difficult, with neither clinical assessment nor markers
of inflammation (such as leukocyte count or C-reactive pro-
tein) being sufficiently accurate. Similarly, the distinction
between prophylaxis and treatment remains relatively
unclear. In this way, according to recent literature data,
many patients continue to receive prophylactic ABs in mild
and SAP as well as in sterile PN [90], on the contrary with
the guidelines practice [91,92] and the conclusions of other
studies [93–96]. So, according to the latest systematic review
[52] there is a worldwide overuse of AB therapy with the
highest rates noticed in Asia and Eastern Europe whereas
the lowest observed in Western Europe. More specifically,
clinicians eagerness to initiate AB therapy increases with the
severity of AP, with the 90% of AB therapy started in the first
3 days of AP.
10. What should be the daily clinical practice with regard
to ABs?
Accumulated evidence [42,97,98] showed that in patients
with AP the absolute influence of organ failure and IPN on
mortality and the risk of admission to the ICU [42] is compar-
able and thus the presence of either indicates severe disease.
Moreover, the risk of organ failure and the risk of admission
to the ICU is significantly higher for patients with IPN com-
pared to patients with sterile necrosis [42]. Considering all of
the above, the clinicians should balance between the devas-
tating effects of delayed administration of appropriate and
effective AB therapy on the one hand (aggravate survival)
and the prolonged or needless use of antibiotics on the
other hand (development of multidrug resistance bacterial
and fungal infection, long hospital stay and poor out-
come) [16].
Thus, AB treatment is not indicated in cases of mild AP,
but is required in SAP with documented IPN and confirmed
extrapancreatic infection. Early diagnosis, appropriate and
timely AB therapy and early source control are the corner-
stones of the treatment of IPN [99–101]. In SAP and sterile
PN clinicians should follow the guidelines [4] and clinical
judgment. The individualized approach supported in modern
medical practice is also suggested in ANP due to the limita-
tions of the trials (low number of patients, involvement of a
substantial number of patients with mild pancreatitis, use of
different ABs and different administration time) [101]. In this
way, after the second week, empirical AB therapy is required
for the treatment of PN if sepsis persists or the patient does
not recover. The choice of AB should be based on the most
likely microorganisms with their locally determined resistance
levels as well as its ability to obtain adequate drug levels at
the site of infection. This management may help prevent the
need for surgical necrosectomy. But percutaneous or endo-
scopic drainage or other surgical interventions should be
6 V. SOULOUNTSI AND T. SCHIZODIMOS
considered in case patients with AP deteriorate with on-
going organ failure [15] or signs of unresolved septic shock.
Conclusion
AP leads to a systemic inflammatory response. Clinicians
should outline the situations where antibiotics may have a
definite role and should be used and where should be
avoided (Figure 1). Recent surviving sepsis campaign guide-
lines [102] recommend against sustained systemic antimicro-
bial prophylaxis in patients with severe inflammatory states
of non-infectious diseases such as severe pancreatitis.
Pancreatic infection is a rare event in AP (around 5%) and
extrapancreatic infections are reported in only 14–37.4% of
the cases. In this way, administration of ABs is justified in
20–40% of SAP. But in the literature a significantly higher
rate of unjustified AB treatment [52] is reported. A profound
explanation of this policy is the fear of the clinicians that
death rate can increase from 2 to 35% due to bacterial infec-
tion of the necrotic pancreatic tissue as well as that organ
failure alone is associated with a mortality of around 20%.
In our opinion, bearing in mind accumulated evidence,
three suggestions may improve the use of ABs in SAP: (i)
high-quality multicenter RCTs (power calculation of ideal
sample size, same class of selected ABs, same administration
time) to determine whether prophylactic ABs have a role in
specific groups of patients with predicted SAP and necrotiz-
ing pancreatitis (ii) a biomarker(s), which can predict infec-
tion without bacterial culture test (iii) local administration of
ABs in the necrosis in a proven pancreatic infection, as the
penetrability of systemic ABs is doubtful.
Disclosure statement
No potential conflict of interest was reported by the author(s).
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