Extrapancreatic Infections Research Articles

The role of extra-pancreatic infections in the prediction of severity and local complications in acute pancreatitis

The role of extra-pancreatic infections in the prediction of severity and local complications in acute pancreatitis

Evaluating Appropriate Use of Antibiotics in Acute Pancreatitis - Need for Antibiotic Stewardship

Introduction: Acute pancreatitis (AP) is a common condition within gastroenterology. The American College of Gastroenterology consensus guidelines for acute pancreatitis recommend that antibiotics be only used in infected necrotizing disease. Despite these recommendations, antibiotics are often inappropriately administered in these patients. Although previous studies have shown that antibiotics are overused in severe pancreatitis, there is limited data on use of antibiotics in mild pancreatitis. Methods: We designed a quality improvement project to evaluate and improve the use of antibiotics in patients with mild AP. Patients admitted with AP between April 1, 2017 to September 30, 2017 were included. Exclusion criteria included patients transferred from an outside hospital to our facility and patients with moderate-severe or severe pancreatitis, and BISAP score > 3. Baseline characteristics including age, race, gender, comorbid conditions, body mass index, admitting service were noted. Mild pancreatitis was defined as AP without organ failure and/or pancreatic necrosis and BISAP score < 2. Our primary outcome was adherence to appropriate guidelines in the use of antibiotics in patients admitted for AP. We defined appropriate use of antibiotics as administration in suspected extra-pancreatic infection or infected necrosis of the pancreas. Results: A total of 85 patients were admitted with AP. Mean age of these patients was 52.0 years (S. D= 15.8) and 53 % were males. The etiology of AP was: Alcohol 40%, gallstone 32%, idiopathic 21%, and other 7%. 89% of our patients (76) had mild AP. Of those with mild AP, 43% received antibiotics. The most commonly used antibiotic was PiperacillinTazobactam followed by floroquinolones. Of the patients that received antibiotics, 47% were for documented extrapancreatic infection, and 53% of patients received antibiotics without true indication. Conclusion: Our retrospective analysis is congruent with previous studies documenting the overuse of antibiotics in patients with AP. Our study highlights that overuse of antibiotics is common in patients with mild disease as well. We are developing a multidisciplinary acute pancreatitis antibiotic stewardship program including internal medicine resident and faculty, gastroenterology fellow and faculty, hepatobiliary surgery faculty and clinical pharmacy. We plan to reexamine adherence and outcomes post implementation of Pancreatitis-Antibiotic Stewardship Program.

The role of extra-pancreatic infections in the prediction of severity and local complications in acute pancreatitis

The role of extra-pancreatic infections in the prediction of severity and local complications in acute pancreatitis

The role of extra-pancreatic infections in the prediction of severity and local complications in acute pancreatitis

BackgroundThe aim of our study was to determine the risk factors for extrapancreatic infection (EPI) occurrence and its predictive power for assessing severity and local complications in acute pancreatitis including infected pancreatic necrosis (IPN). MethodsClinical data of 176 AP patients prospectively enrolled were analysed. EPI analysed were bacteraemia, lung infection, urinary tract infection and catheter line infection. Risk factors analysed were: Leukocyte count, C-reactive protein, liver function test, serum calcium, serum glucose, Blood urea nitrogen, mean arterial pressure at admission, total parenteral nutrition (TPN), enteral nutrition, hypotension, respiratory, cardiovascular and renal failure at admission, persistent systemic inflammatory response (SIRS) and intrapancreatic necrosis. Severity outcomes assessed were defined according to the Atlanta Criteria definition for acute pancreatitis. The predictive accuracy of EPI for morbidity and mortality was measured using area-under-the-curve (AUC) receiver-operating characteristics. ResultsForty-four cases of EPI were found (25%). TPN (OR:9.2 CI95%: 3.3–25.7), APACHE-II>8 (OR:6.2 CI95%:2.48–15.54) and persistent SIRS (OR:2.9 CI95%: 1.1–7.8), were risk factors related with EPI. Bacteraemia, when compared with others EPI, showed the best accuracy in predicting significantly persistent organ failure (AUC:0.76, IC95%:0.64–0.88), ICU admission (AUC:0.80 IC95%:0.65–0.94), and death (AUC:0.73 CI95%:0.54–0.91); and for local complications including IPN (AUC:0.72 CI95%:0.53–0.92) as well. Besides, it was also needed for an interventional procedure against necrosis (AUC:0.74 IC95%: 0.57–0.91). When bacteraemia and IPN occurs, bacteraemia preceded infected necrosis in all cases. On multivariate analysis, risk factor for IPN were lung infection (OR:6.25 CI95%1.1-35.7 p = 0.039) and TPN (OR:22.0CI95%:2.4–205.8, p = 0.007), and for mortality were persistent SIRS at first week (OR: 22.9 CI95%: 2.6–203.7, p = 0.005) and Lung infection (OR: 9.7 CI95%: 1.7–53.8). ConclusionIn our study, EPI, played a role in predicting the severity and local complications in acute pancreatitis.

Impact of Antibiotic-Resistant Bacterial and Fungal Infections in Outcome of Acute Pancreatitis.

The knowledge about pathogens and their antibiotic susceptibility patterns is essential to select an appropriate antibiotic. We investigated the microbiological profile in pancreatic and extrapancreatic infections, and antibiotic sensitivity pattern in patients with acute pancreatitis. Of 556 patients with acute pancreatitis, only 189 developed bacterial infection; however, bacteremia was present in 42 patients (7.6%). Culture-proven infected pancreatic necrotic collection was present in 161 patients (29%). Escherichia coli and Klebsiella pneumoniae were the most common organisms. Among the bacterial infection cohort, 164 patients developed multidrug-resistant bacterial infection. Infection with multidrug-resistant bacteria, especially at multiple sites, increased mortality. Nearly 50% of patients (n = 94) acquired extremely drug-resistant bacterial infection at some time and emerged as key reason for prolonged hospital and intensive care unit stay. Colistin resistance and tigecycline resistance were documented in 2.1% and 17.2% of the specimens at admission and in 4.6% and 21% of specimens during the hospital stay. Of 556 patients, 102 patients developed fungal infection and 28 patients had only fungal infection without bacterial infection. Colistin and tigecycline are best reserved as last-resort antibiotics. Fungal infection was found to be associated with increased mortality, median hospital stay, and intensive care unit stay.

The optimal timing of enteral nutrition and its effect on the prognosis of acute pancreatitis: A propensity score matched cohort study

BackgroundEarly enteral nutrition (EN) can improve the prognosis of acute pancreatitis (AP), but the optimal initiation time is unknown. In this study, the optimal time of early EN was analyzed to disclose the application of early EN in AP. MethodsData of 104 patients with AP were prospectively collected. With secondary infection (infected pancreatic necrosis and extrapancreatic infection) as the primary outcome variable, receiver operating characteristic (ROC) curve was used to calculate the optimal cut-off time of early EN. Propensity score matching was used to adjust for covariates. Secondary outcomes include acute gastrointestinal injury (AGI) grades, serum albumin level, and EN-related complications. ResultsThe ROC curve analysis showed that the third day after hospital admission was the best cut-off time of early EN (with the area under the curve of 0.744). After PS matching, the proportion of secondary infection in the early EN group was significantly lower than the late EN group (8.6% vs. 36.5%, P < 0.05). Regression analysis showed that early EN was a protective factor against secondary infection (OR 0.161, 95%CI 0.036–0.718, P < 0.05). The AGI grades and serum albumin levels were better improved in the early EN group (AGI F = 4.468, P < 0.05; serum albumin F = 3.794, P < 0.05).The proportion of EN-related abdominal distension in the early EN group was significantly lower (8.8% vs. 38.5%, P < 0.05). ConclusionsEarly EN initiated within three days could reduce the risk of secondary infection and improve the nutritional status of patients with acute pancreatitis, with a better tolerance.

Is nasogastric or nasojejunal enteral feeding more appropriate in severe acute pancreatitis?

Early enteral nutrition (EN) can improve the prognosis of acute pancreatitis (AP), but the optimal initiation time is unknown. In this study, the optimal time of early EN was analyzed to disclose the application of early EN in AP.Data of 104 patients with AP were prospectively collected. With secondary infection (infected pancreatic necrosis and extrapancreatic infection) as the primary outcome variable, receiver operating characteristic (ROC) curve was used to calculate the optimal cut-off time of early EN. Propensity score matching was used to adjust for covariates. Secondary outcomes include acute gastrointestinal injury (AGI) grades, serum albumin level, and EN-related complications.The ROC curve analysis showed that the third day after hospital admission was the best cut-off time of early EN (with the area under the curve of 0.744). After PS matching, the proportion of secondary infection in the early EN group was significantly lower than the late EN group (8.6% vs. 36.5%, P < 0.05). Regression analysis showed that early EN was a protective factor against secondary infection (OR 0.161, 95%CI 0.036–0.718, P < 0.05). The AGI grades and serum albumin levels were better improved in the early EN group (AGI F = 4.468, P < 0.05; serum albumin F = 3.794, P < 0.05).The proportion of EN-related abdominal distension in the early EN group was significantly lower (8.8% vs. 38.5%, P < 0.05).Early EN initiated within three days could reduce the risk of secondary infection and improve the nutritional status of patients with acute pancreatitis, with a better tolerance.

Extrapancreatic bacterial infections are common in acute pancreatitis and they are related to organ failure: a population-based study

Extrapancreatic bacterial infections are common in acute pancreatitis and they are related to organ failure: a population-based study

Prophylactic antibiotics in acute pancreatitis: endless debate.

INTRODUCTION The development of pancreatic infection is associated with the development of a deteriorating disease with subsequent high morbidity and mortality. There is agreement that in mild pancreatitis there is no need to use antibiotics; in severe pancreatitis it would appear to be a logical choice to use antibiotics to prevent secondary pancreatic infection and decrease associated mortality. MATERIALS AND METHODS A non-systematic review of current evidence, meta-analyses and randomized controlled trials was conducted to assess the role of prophylactic antibiotics in acute pancreatitis and whether it might improve morbidity and mortality in pancreatitis. RESULTS Mixed evidence was found to support and refute the role of prophylactic antibiotics in acute pancreatitis. Most studies have failed to demonstrate much benefit from its routine use. Data from our unit suggested little benefit of their routine use, and showed that the mortality of those treated with antibiotics was significantly higher compared with those not treated with antibiotics (9% vs 0%, respectively, P=0.043). In addition, the antibiotic group had significantly higher morbidity (36% vs 5%, respectively, P=0.002). CONCLUSIONS Antibiotics should be used in patients who develop sepsis, infected necrosis-related systemic inflammatory response syndrome, multiple organ dysfunction syndrome or pancreatic and extra-pancreatic infection. Despite the many other factors that should be considered, prompt antibiotic therapy is recommended once inflammatory markers are raised, to prevent secondary pancreatic infection. Unfortunately, there remain many unanswered questions regarding the indications for antibiotic administration and the patients who benefit from antibiotic treatment in acute pancreatitis.

Early nasogastric feeding versus parenteral nutrition in severe acute pancreatitis: A retrospective study.

Objective:To compare the efficacy and safety of early nasogastric enteral nutrition (EN) with total parenteral nutrition (TPN) in patients with severe acute pancreatitis (SAP).Methods:From July 2008 to July 2014,185 patients with SAP admitted to our centre were enrolled in this retrospective study. They were divided into EN group (n=89) and TPN group (n=96) based on the nutrition support modes. Patients in EN group received nasogastric EN support, while patients in TPN group received TPN support within 72 hours of disease onset. The medical records were reviewed and clinical factors were retrospectively analyzed.Results:There were no significant differences in baseline characteristics between two groups. EN group had significantly lower incidence of pancreatic infections (P=0.0333) and extrapancreatic infections (P=0.0431). Significantly shorter hospital stay (P=0.0355) and intensive-care stay (P=0.0313) were found in EN group. TPN group was found to have significantly greater incidence of multiple organ dysfunction syndrome (MODS) (P=0.0338) and mortality (P=0.0382). Moreover, the incidence of hyperglycemia was significantly higher in TPN group (P=0.0454).Conclusions:Early nasogastric EN was feasible and significantly decreased the incidence of infectious complications as well as the frequency of MODS and mortality caused by SAP.

Quantifying endoscopic ultrasound (EUS)-guided elastography for the differential diagnosis of solid pancreatic masses: Hue-histogram or strain ratio?

Extra-pancreatic infectious complications in acute pancreatitis increase morbidity, but their incidence and association with infected pancreatic necrosis is unknown. Half of bacterial cultures of pancreatic necrosis are of non-enteric origin, raising the possibility of other sources of infection. The aim of this systematic review was to assess the incidence of extra-pancreatic infectious complications in acute pancreatitis, their timing, and relation to severity of pancreatitis and mortality.A systematic review was performed using Ovid MEDLINE, Embase and Cochrane Libraries, following PRISMA guidelines. Search terms were “Pancreatitis” AND “Infection” AND (“Complication” OR “Outcome”).19 studies with 1741 patients were included. Extra-pancreatic infectious complication incidence was 32% (95% CI 23–41%), with the commonest being respiratory infection (9.2%) and bacteraemia (8.4%). Extra-pancreatic infectious complications were not associated with the predicted severity or the mortality of acute pancreatitis. Only 3 studies reported a relation of timing between extra-pancreatic and pancreatic infectious complications.This is the first systematic review to evaluate the incidence of extra-pancreatic infectious complications in acute pancreatitis, which a third of patients with acute pancreatitis will develop. Implications are vigilance and prompt treatment of extra-pancreatic infection, to reduce possibility of progression to infected pancreatic necrosis.

NFATc1-EGFR loop controls Sox9 promoter for acinar ductal metaplasia

Extra-pancreatic infectious complications in acute pancreatitis increase morbidity, but their incidence and association with infected pancreatic necrosis is unknown. Half of bacterial cultures of pancreatic necrosis are of non-enteric origin, raising the possibility of other sources of infection. The aim of this systematic review was to assess the incidence of extra-pancreatic infectious complications in acute pancreatitis, their timing, and relation to severity of pancreatitis and mortality.A systematic review was performed using Ovid MEDLINE, Embase and Cochrane Libraries, following PRISMA guidelines. Search terms were “Pancreatitis” AND “Infection” AND (“Complication” OR “Outcome”).19 studies with 1741 patients were included. Extra-pancreatic infectious complication incidence was 32% (95% CI 23–41%), with the commonest being respiratory infection (9.2%) and bacteraemia (8.4%). Extra-pancreatic infectious complications were not associated with the predicted severity or the mortality of acute pancreatitis. Only 3 studies reported a relation of timing between extra-pancreatic and pancreatic infectious complications.This is the first systematic review to evaluate the incidence of extra-pancreatic infectious complications in acute pancreatitis, which a third of patients with acute pancreatitis will develop. Implications are vigilance and prompt treatment of extra-pancreatic infection, to reduce possibility of progression to infected pancreatic necrosis.

Interventional endoscopy for the treatment of walled off necrosis: A single center experience

Extra-pancreatic infectious complications in acute pancreatitis increase morbidity, but their incidence and association with infected pancreatic necrosis is unknown. Half of bacterial cultures of pancreatic necrosis are of non-enteric origin, raising the possibility of other sources of infection. The aim of this systematic review was to assess the incidence of extra-pancreatic infectious complications in acute pancreatitis, their timing, and relation to severity of pancreatitis and mortality.A systematic review was performed using Ovid MEDLINE, Embase and Cochrane Libraries, following PRISMA guidelines. Search terms were “Pancreatitis” AND “Infection” AND (“Complication” OR “Outcome”).19 studies with 1741 patients were included. Extra-pancreatic infectious complication incidence was 32% (95% CI 23–41%), with the commonest being respiratory infection (9.2%) and bacteraemia (8.4%). Extra-pancreatic infectious complications were not associated with the predicted severity or the mortality of acute pancreatitis. Only 3 studies reported a relation of timing between extra-pancreatic and pancreatic infectious complications.This is the first systematic review to evaluate the incidence of extra-pancreatic infectious complications in acute pancreatitis, which a third of patients with acute pancreatitis will develop. Implications are vigilance and prompt treatment of extra-pancreatic infection, to reduce possibility of progression to infected pancreatic necrosis.

Pancreatic stellate cells express ZEB1 that is essential for the maintenance of an activated apoptotic-resistant and pro-tumoral phenotype

Extra-pancreatic infectious complications in acute pancreatitis increase morbidity, but their incidence and association with infected pancreatic necrosis is unknown. Half of bacterial cultures of pancreatic necrosis are of non-enteric origin, raising the possibility of other sources of infection. The aim of this systematic review was to assess the incidence of extra-pancreatic infectious complications in acute pancreatitis, their timing, and relation to severity of pancreatitis and mortality.A systematic review was performed using Ovid MEDLINE, Embase and Cochrane Libraries, following PRISMA guidelines. Search terms were “Pancreatitis” AND “Infection” AND (“Complication” OR “Outcome”).19 studies with 1741 patients were included. Extra-pancreatic infectious complication incidence was 32% (95% CI 23–41%), with the commonest being respiratory infection (9.2%) and bacteraemia (8.4%). Extra-pancreatic infectious complications were not associated with the predicted severity or the mortality of acute pancreatitis. Only 3 studies reported a relation of timing between extra-pancreatic and pancreatic infectious complications.This is the first systematic review to evaluate the incidence of extra-pancreatic infectious complications in acute pancreatitis, which a third of patients with acute pancreatitis will develop. Implications are vigilance and prompt treatment of extra-pancreatic infection, to reduce possibility of progression to infected pancreatic necrosis.

Bacteriology of infection in severe acute pancreatitis.

Severe acute pancreatitis is associated with high mortality with infectious complications being the most common cause of mortality. To analyze the prevalence and characteristics of pancreatic and extrapancreatic infection in patients with severe acute pancreatitis. Prospective study over a one-year period. Fifty-one consecutive patients with severe acute pancreatitis. Setting Tertiary care centre, Northern India. The presence of pancreatic and extrapancreatic infections were noted in consecutive patients with severe acute pancreatitis and their effect on disease outcome was assessed. Pancreatic infection was noted in 19 (37.3%) patients; 14 (27.5%) patients had monomicrobial and 5 (9.8%) patients had polymicrobial infections. In the first week of hospitalization, all positive 6/6 (100%) cultures grew Escherichia coli, in the second week 5/8 (62.5%) grew Escherichia coli while after the second week, 2/5 (40.0%) cultures grew Escherichia coli. A total of 32 (62.7%) patients had evidence of extrapancreatic infections, with 53 positive cultures. Fifteen (29.4%) patients had monomicrobial infections while 17 (33.3%) had polymicrobial infections. The most common site was blood together with intravenous site with 21 positive cultures in 16 patients. Staphylococcus aureus was most commonly isolated in the blood cultures. There was a statistically significant increase in mortality with pancreatic (P=0.003) and extrapancreatic (P=0.041) infections. The antibiotic sensitivity pattern showed that most of the bacteria were sensitive to beta lactum antibiotics, aminoglycosides and imipenem. Pancreatic infections are more often monomicrobial with a shift from gram-negative to gram-positive as the pancreatitis progressed. Extrapancreatic infections are more often polymicrobial; most commonly, the blood stream is invaded by gram-positive bacteria.

Position paper: timely interventions in severe acute pancreatitis are crucial for survival

Severe acute pancreatitis has high mortality, but multiple and timely interventions can improve survival. Early in the course of the disease aggressive fluid resuscitation is needed for the prevention and treatment of shock. In conjunction with leaking capillaries this results in increased tissue edema, which may lead to intra-abdominal hypertension and abdominal compartment syndrome. Invasive hemodynamic monitoring is essential for optimizing fluid therapy while monitoring of intra-abdominal pressure is necessary for identification patients at risk of developing abdominal compartment syndrome. Abdominal compartment syndrome develops usually within the first days after hospitalization. Conservative treatment modalities are useful in prevention but also in the treatment of abdominal compartment syndrome. If conservative management fails surgical decompression of abdomen may be needed. Multiple organ dysfunction syndrome and increased intra-abdominal pressure predispose patients with severe pancreatitis to secondary infections. Extrapancreatic infections predominate during the first week of the disease, whereas infection of pancreatic necrosis usually develops later. Early enteral nutrition reduces the risk of infections whereas advantage of prophylactic antibiotics is lacking evidence. Surgery for infected pancreatic necrosis is associated with high mortality when performed within the first two weeks of the disease. Therefore surgery should be postponed as late as possible, preferably later than four weeks after disease onset.

PTU-176 Retrospective Audit of Antibiotic use in Patients admitted to Intensive Care Unit (ICU) with Severe Acute Pancreatitis

IntroductionThe Atlanta classification divides patients with acute pancreatitis (AP) into two groups, mild and severe. The severe form (severe acute pancreatitis, SAP ) is best managed in HDU or ICU...

The Microbiology of Secondary and Postoperative Pancreatic Infections

We reviewed our experience with secondary pancreatic infections with a focus on preemptive intervention and the potential alteration of the recovered microbial flora. The pathogens associated with postoperative pancreatic infections were analyzed with respect to nonenteric organisms, if any, that were recovered. We hypothesized that our findings might alter the antimicrobial management of these patients. Retrospective review. Hospitals affiliated with the University of Tennessee Health Science Center, Memphis. Patients developing secondary and postoperative pancreatic infections following severe acute pancreatitis. Factors examined relative to secondary pancreatitis included preoperative antibiotic use and antecedent extrapancreatic infections potentially implicated in seeding the pancreatic bed. Patients who had elective resection received 24 to 48 hours of antibiotic prophylaxis. Twenty-two patients required surgery for secondary infections following severe acute pancreatitis, with 29 pathogenic isolates being recovered. Of these 22 patients, 14 received vancomycin hydrochloride prior to surgical intervention. Of those 14 patients, 6 had isolates recovered at the time of surgery that were positive for Enterococcus faecalis and 5 of these isolates were vancomycin resistant. Eight of the 22 patients received antifungal prophylaxis with no fungi recovered from intraoperative culture. However, 2 of the 14 patients who did not receive empiric therapy had isolates that were positive for fungi. Five patients who required an urgent operation for sepsis had pathogenic isolates that were similar to those recovered from central lines. Postoperative infections occurred in 40 of 225 patients (17.8%) who had an elective pancreatic resection, with 72 pathogenic isolates being recovered. Of these 40 patients, 22 (55.0%) had polymicrobial infections. Of the 72 pathogenic isolates recovered from patients, 34 (47.2%) were gram-positive organisms, 15 (20.8%) were fungal organisms, and 17 (23.6%) were drug-resistant bacteria. Prolonged vancomycin use in patients with severe acute pancreatitis is associated with the acquisition of vancomycin-resistant enterococci. Empiric antifungal therapy may reduce the incidence of secondary fungal pancreatic infections. Systemic bloodstream infections at extrapancreatic sites can lead to seeding of pancreatic pseudocysts. Postoperative infections frequently include gram-positive, fungal, and drug-resistant organisms, and empiric therapy directed at these pathogens should be utilized until definitive culture results are obtained.

Update in Acute Pancreatitis

Acute pancreatitis is a common cause for hospitalization that carries a substantial burden of disease in the United States and worldwide. Recent reports have encompassed a wide array of topics including new insights into the acinar cell pH microenvironment, signal pathways for acinar cell fate, and the innate immune response. Clinical researchers have reported new methods to assess disease severity, innovative techniques for management of local complications, the importance of early recognition of pancreatic or extrapancreatic infection, and prevention of disease recurrence. Recent data also suggest that specialized centers may be of benefit for the management of severe acute pancreatitis. This review summarizes a number of recent advances in basic and clinical science with an emphasis on findings that are relevant to clinicians who manage patients with acute pancreatitis.

Effect of antibiotic prophylaxis on acute necrotizing pancreatitis: Results of a randomized controlled trial

This study addresses whether antibiotic prophylaxis is beneficial for acute necrotizing pancreatitis. This randomized, controlled trial enrolled 276 patients with severe acute pancreatitis. There were 56 patients with 30% or more necrosis proved by contrast-enhanced computerized tomography who were eligible for randomization: 29 in the study group and 27 in the control group, who received i.v. imipenem-cilastatin (3 x 500 mg/day) within 72 h of the onset of symptoms for 7-14 days, and no antibiotic prophylaxis, respectively. The primary end-point was the incidence of infectious complication. The secondary end-points were mortality, the incidence of necrosectomy for infected necrosis, the incidence of organ complication and hospital courses. Characteristics of baseline data were similar in the two groups. No significant differences were found in the incidence of infected pancreatic necrosis (37% vs 27.6%), mortality (10.3% vs 14.8%) and the incidence of operative necrosectomy (29.6% vs 34.6%) between the study group and the control group (P > 0.05). The incidence of extrapancreatic infections, organ complications and hospital courses between the groups were also not significantly different. However, a significantly increased incidence of fungal infection was observed in the study group versus the control group (36.1% vs 14.2%, P < 0.05). There was no benefit in the outcomes when antibiotic prophylaxis was routinely used in patients with acute necrotizing pancreatitis.