Antibiotic treatment in acute pancreatitis

Severe acute pancreatitis is characterized by a poor prognosis with local and systemic complications, high morbidity and mortality. From the morphological standpoint, almost all patients suffering from severe forms of acute pancreatitis present various degree of pancreatic necrosis. In these patients the occurrence of infection of pancreatic necrosis certainly represents a very important prognostic factor as it has worldwide accepted as the leading cause of death. In addition, the discovery of an infected necrosis represents a crucial point in the treatment of these patients as it is the only clear-cut shift from medical to surgical treatment in necrotizing pancreatitis. Over the last years, earlier and more precise identification of pancreatic necrosis together with availability of new classes of antibiotics with documented activity against the most commonly involved bacteria and able to reach in therapeutic concentration the pancreatic necrosis give us the opportunity to perform some important controlled clinical trials on antibiotic prophylaxis in necrotizing acute pancreatitis. The great majority of these studies showed the usefulness of a prophylactic regimen (using antibiotics such as fluoroquinolones and carbapenems) in terms of reduction of pancreatic and extrapancreatic infections in comparison with untreated controls. Nevertheless, some questions on this topic still present controversial aspects such as the antibiotic of choice, the duration of treatment, the possible opportunistic infections with fungi and/or resistant strains. Antibiotics may prove very useful in patients with documented infected necrosis and high anaesthesiological risk unfit for surgical debridement and drainage; some initial experiences show the possibility that antibiotic treatment may be curative without surgery in these selected cases.