Prophylactic antibiotics for severe acute pancreatitis: The beginning of an era

Death from acute severe pancreatitis results from infection and multiple or gan system failure occurring late in the course of illness. Patients with n ecrotizing pancreatitis involving at least one-third of the organ are at hi ghest risk of secondary infection and death. We conducted a MEDLINE search to identify human trials of prophylactic antibiotics in acute pancreatitis. Results of early studies of prophylactic ampicillin to avoid secondary inf ection and death were negative, but the studies included patients with mild disease who are at low risk for infection. Antibiotics were beneficial in four recently completed studies: imipenem significantly reduced pancreatic and nonpancreatic sepsis (p less than or equal to 0.01); cefuroxime reduced all infectious complications (p<0.01) and deaths (p=0.0284); a regimen of ceftazidime, amikacin, and metronidazole reduced all infectious complicatio ns (p<0.03); and protocol use of imipenem significantly reduced pancreatic infection compared with nonprotocol antibiotics (p=0.04) and no antibiotics (p<0.001). Based on these results, we suggest early antibiotic prophylaxis in patients with necrotizing pancreatitis, but the best drug and duration of therapy are unknown.