Perioperative Broad-spectrum Antibiotics are Associated With Decreased Surgical Site Infections Compared to 1st–3rd Generation Cephalosporins After Open Pancreaticoduodenectomy in Patients With Jaundice or a Biliary Stent

Abstract

Objective: Compare the effectiveness of 1st-3rd generation cephalosporins (1st-3rdCE) to broad-spectrum antibiotics in decreasing surgical site infections (SSI) after pancreatectomy. Summary of Background Data: SSI is one of the most common complications after pancreatic surgery. Various antibiotic regimens are utilized nationwide with no clear guidelines for pancreatectomy. As we await results of a recently initiated prospective trial, this study retrospectively evaluates over 15,000 patients using the same administrative data abstraction tools as in the trial. Methods: All relevant clinical variables were collected from the 2016-2018 targeted-pancreatectomy database from the American College of Surgeon National Surgical Quality Improvement Program. Preoperative antibiotics were initially collected as first-generation cephalosporin, second or thirdgeneration cephalosporin, and broad-spectrum antibiotics (Broad-abx). Results: Of the 15,182 patients who completed a pancreatic surgery between 2016 and 2018, 6114 (40%) received a first-generation cephalosporin, 4097 (27%) received a second or third-generation cephalosporin, and 4971 (33%) received Broad-abx. On multivariate analysis, Broad-abx was associated with a decrease in all-type SSI compared to 1st-3rdCE (odds ratio ¼ 0.73-0.77, P < 0.001) after open pancreaticoduodenectomy (PD). There was no difference in SSI between antibiotic-types after distal pancreatectomy. Subgroup multivariate analysis of open PD revealed decrease in all-type SSI with Broad-abx amongst patients with jaundice and/or biliary stent only, regardless of wound protector use (odds ratio ¼ 0.69-0.70, P < 0.001). Propensity score matching of open PD patients with jaundice and/or biliary stent confirmed a decrease in all-type SSI (19% vs 24%, P ¼ 0.001), and organ-space SSI (12% vs 16%, P < 0.001). Conclusion: Broad-abx are associated with decreased SSI after open PD and may be preferred specifically for patients with preoperative biliary stent and/ or jaundice.

The Role of Targeted Versus Standard Antibiotic Prophylaxis in Pancreatoduodenectomy in Reducing Postoperative Infectious Complications

“…48 Among those who underwent biliary instrumentation or had preoperative jaundice, broad-spectrum antibiotics was associated with a decrease on overall rates of SSIs (24% vs 19%, P ¼ 0.001). 48 Together, these studies suggest that targeted broadspectrum antibiotics may be particularly important in those undergoing PBD.…”

“…Furthermore, Okamura and colleagues 28 demonstrated a reduction in postoperative SSIs in those receiving targeted antibiotics ( P = 0.012) despite this group having more patients with preoperative cholangitis. In addition, a recent retrospective study comparing the use of cephalosporins versus other broad-spectrum antibiotics found that patients without biliary drainage have similar rates of SSIs regardless of antibiotic choice 48 . Among those who underwent biliary instrumentation or had preoperative jaundice, broad-spectrum antibiotics was associated with a decrease on overall rates of SSIs (24% vs 19%, P = 0.001) 48 .…”

“…In addition, a recent retrospective study comparing the use of cephalosporins versus other broad-spectrum antibiotics found that patients without biliary drainage have similar rates of SSIs regardless of antibiotic choice 48 . Among those who underwent biliary instrumentation or had preoperative jaundice, broad-spectrum antibiotics was associated with a decrease on overall rates of SSIs (24% vs 19%, P = 0.001) 48 . Together, these studies suggest that targeted broad-spectrum antibiotics may be particularly important in those undergoing PBD.…”

Cefotaxime resistance in bile samples is an independent predictor of deep infectious complications after pancreaticoduodenectomy in patients with endoprosthesis

“…Krüger et al found that the prevalence of resistance in bacteriobilia was 50% for cefotaxime vs 26% for piperacillin‐tazobactam 34 . A study from the American College of Surgeons National Surgical Quality Improvement Program database analyzing 15 182 pancreatic surgeries found that patients with biliary endoprosthesis who received perioperative prophylaxis with broad‐spectrum antibiotics had a decreased risk of postoperative complications than patients who received 1st‐ to 3rd‐generation cephalosporins 35 . A randomized controlled trial comparing cefoxitin and piperacillin‐tazobactam as antibiotic prophylaxis in all patients undergoing pancreaticoduodenectomy is ongoing (NCT03269994).…”

“…34 A study from the American College of Surgeons National Surgical Quality Improvement Program database analyzing 15 182 pancreatic surgeries found that patients with biliary endoprosthesis who received perioperative prophylaxis with broad-antibiotics had a risk of postoperative complications than patients who received 1st-to 3rd-generation cephalosporins. 35 A randomized controlled trial comparing cefoxitin and piperacillintazobactam as antibiotic prophylaxis in all patients undergoing pancreaticoduodenectomy is ongoing (NCT03269994). The composition of gut microbiome may be associated with increased risk of surgical complications, including anastomotic fistula or adhesions.…”