[Antibiotics for pancreatitis--still controversial?]

Summary. Infection frequently complicates the course of severe acute pancreatitis and might manifest as infected pancreatic necrosis, pancreatic abscess or an infected peripancreatic fluid collection. Pancreatic necrosis occurs in roughly 21% of all cases of pancreatitis. In patients with necrosis involving more than one-half of the pancreas, the incidence of subsequent infection is as high as 40%-70%. More than 50% of these infection yield a polymicrobial isolate with predominance of enteric bacteria but recently, the microbiologic pattern has shifted toward more resistant gram-negative bacilli, gram-positive cocci and yeast, a reflection of exposure to broad-spectrum antimicrobial agents. Given the morbidity associated with infection, many commentators have advocated prophylactic antimicrobial therapy in patients with necrosis to the point that this measure has been incorporated into routine practice. However, there is controversy over the risks and potential benefit. Currently, advise against the routine use of prophylactic systemic antibiotics and antifungals (side-effect selection of resistant microbes and fungi). However, there may be some patients who benefit from prophylaxis, and additional studies and investigations are ongoing. Antibiotics should not be given early in the disease course because most symptoms are due to the inflammatory response, not an infectious etiology. Antibiotics are indicated when CT scans indicate a pancreatic phlegmon, empirically in the case of severe pancreatitis associated with septic shock, or with documented fine - needle aspiration biopsy identification of bacteria. Under those circumstances, antibiotic coverage is warranted to prevent systemic gram-negative sepsis. Infected pancreatic necrosis should be treated with carbapenems because they can effectively penetrate pancreatic tissue. Other conditions, such as biliary pancreatitis associated with cholangitis, mandate antibiotic coverage.