Antibiotics, probiotics and enteral nutrition: Means to prevent infected necrosis in AP

Mortality in severe acute pancreatitis (AP) is predominantly associated with secondary infection of (peri-)pancreatic necrosis and other infectious complications. Suggested prophylactic strategies are antibiotics, probiotics and enteral nutrition. We performed a literature review on the prophylactic treatment with antibiotics, probiotics and enteral nutrition in A P. The 2 most recent double blind placebo-controlled randomized trials and 2 meta-analyses on systemic antibiotic prophylaxis in AP did not demonstrate a significant reduction of infected (peri-)pancreatic necrosis. The earlier findings that probiotics are effective in preventing infections in AP were not confirmed by a recent multicenter placebo-controlled randomized controlled trial. Unexpectedly, mortality was significantly higher in patients receiving probiotics. Enteral nutrition, when compared to parenteral nutrition, reduces infectious complications and mortality in A P. The magnitude of the effect may depend on timing of the start of enteral feeding. Current evidence does not support the use of prophylactic antibiotics or probiotics in patients with severe A P. Enteral nutrition should be preferred over parenteral nutrition. Optimal timing of commencement of enteral nutrition should be investigated in randomized studies.