Patients with severe pancreatitis fulfill the criteria of severe sepsis in case of infection and there is no rapid and reliable

diagnostic method available to rule out infection. Delayed administration of antibiotics has been shown to worsen survival in patients with severe sepsis with or without septic shock [57]. After the end of the second week, empiric antibiotics may be needed for treatment of infected pancreatic necrosis if sepsis continues or the patient does not recover. Empiric antibiotics at this stage should cover potential pathogens including gram negative rods and gram positive cocci [47]. The role of empiric antifungals is not clear. Fine needle aspiration for microbiological samples should be taken if infected necrosis is suspected, although negative samples do not rule out infection [50]. Positive samples help in selection of antimicrobials and initiation of possible antifungal selleck therapy. Prophylactic

or empiric antibiotic should be discontinued when the patient recovers from organ dysfunctions and there is no evidence of infection. Surgery for infected necrosis Infected pancreatic or peripancreatic necrosis has traditionally been considered an indisputable indication for surgical debridement [58]. Infected necrosis is a significant source of sepsis and removal of devitalized tissue is believed to be necessary for control of sepsis. However, infection usually continues after necrosectomy, especially if necrotic tissue is left in place. Before demarcation of necrosis develops, usually after Caspase inhibitor 4 weeks from disease onset, it is impossible to remove all necrotic tissue without causing hemorrhage. Early surgical debridement has been associated with high risk of hemorrhage leading to increased organ dysfunction and death. If necrosectomy for infected pancreatic necrosis is done within the first two weeks the mortality rate is 75%, but gradually

decreases to 5% when done later than four weeks after the onset of symptoms [15, 50, 59]. Multiple organ dysfunction increases mortality risk considerably in patients with infected necrosis. The mortality rate increases in proportion to the number of failed organs [50]. Infected pancreatic necrosis does not cause significant PDK4 risk of death in absence of organ dysfunction [12, 50]. Because high mortality is associated with early surgery and multiple organ dysfunction, it is recommended that surgery for infected necrosis should be postponed as late as possible, preferable later than four week from disease onset. Percutaneus drainage of the liquid component of the infected acute necrotic collection may serve as a bridge to surgery [16]. Sterile collections do not need drainage. Placement of a drain into a sterile necrotic collection can result in secondary infection, and a prolonged drainage may increase the risk further [60, 61].