A role for prophylactic antibiotics in necrotizing pancreatitis? Why we may never know the answer

The use of prophylactic antibiotics in patients with severe acute pancreatitis remains an intensely debated topic. Although animal studies consistently demonstrated an advantage of antibiotic prophylaxis, the only two blinded randomized controlled trials could not confirm these findings. Translation of the experimental models in human clinical practice is hampered by a number of fundamental differences between experimental pancreatitis and human disease, and therefore it is highly unlikely that the pronounced benefit found in experimental pancreatitis will ever be demonstrated in human disease. Early and accurate risk stratification to identify the patient at risk for infection early in the course of the disease seems to be the greatest challenge. Until we are able to demonstrate an advantage of antibiotic prophylaxis in a high-risk human population, the absence of proven benefit and potential side effects of this strategy should be acknowledged and the use of antibiotics should be limited to the treatment of documented infection.