Infections and the use of antibiotics A quarter of patients with acute pancreatitis develop infectious complication [11]. Patients with severe acute pancreatitis are more susceptible to develop infections [11]. Patients with organ dysfunctions have higher incidence of bacterial translocation [34]. They also have impaired immune system [7]. The majority of infections are extrapancreatic such as bacteremia and pneumonia. The half of these infections develop within the first week post admission [11]. Diagnosis of infected pancreatic necrosis is usually done significantly later, the peak incidence is between selleck chemicals the third and fourth week from the onset of symptoms [11, 47].

However, the actual

contamination of necrosis happens probably much earlier [48]. Organ failure, early bacteremia and the extent of pancreatic necrosis are associated with increased risk of infected necrosis [11]. Diagnosis of MG-132 clinical trial infected pancreatic necrosis is challenging. Clinical signs of sepsis are too unspecific for definitive diagnosis and CT-scan shows gas bubbles in the necrotic collection in less than ten percent of patients [49]. Fine needle aspiration with bacterial culture has a substantial rate (20-25%) of false negative results, and thus, is not reliable to rule out infection [50]. Prophylactic antibiotics have been studied in many randomized trials with conflicting Nintedanib (BIBF 1120) results and according to several meta-analyses and systematic reviews there is no evidence that patients benefit from prophylactic antibiotics [14, 51, 52]. However, there has been a nonsignificant trend for lower mortality and reduced number of infections, especially extrapancreatic infections in patients treated with prophylactic antibiotics. The randomized trials have been conducted with small samples sizes and some studies included a substantial number of patients with mild pancreatitis [53] with minimal risk of mortality and low risk of infectious complications. Although

trials have not provided evidence that prophylactic antibiotic are effective they have not proved that they are not effective [54]. Taken together the limitations of the trials and the fact that patients with organ failure are susceptible to infections, we believe that the use of prophylactic antibiotic in patients with severe pancreatitis is justified. High incidence of infections in patients with severe pancreatitis and worse survival in patients who develop infection supports this policy. Indication for initiation of prophylactic antibiotics should be based on clinical judgment. Systemic inflammatory response syndrome (SIRS) [4], signs of organ dysfunction, presence of IAH [55], hyperglycemia, low plasma calcium or high creatinine [56] could be helpful in predicting severe disease.