TY - JOUR
T1 - Association between Biliary Pathogens, Surgical Site Infection, and Pancreatic Fistula
T2 - Results of a Randomized Trial of Perioperative Antibiotic Prophylaxis in Patients Undergoing Pancreatoduodenectomy
AU - Ellis, Ryan J.
AU - Brajcich, Brian C.
AU - Bertens, Kimberly A.
AU - Chan, Carlos H.F.
AU - Castillo, Carlos Fernandez Del
AU - Karanicolas, Paul J.
AU - Maithel, Shishir K.
AU - Reames, Bradley N.
AU - Weber, Sharon M.
AU - Vidri, Roberto J.
AU - Pitt, Henry A.
AU - Thompson, Vanessa M.
AU - Gonen, Mithat
AU - Seo, Susan K.
AU - Yopp, Adam C.
AU - Ko, Clifford Y.
AU - D'Angelica, Michael I.
N1 - Funding Information:
Funded in part through the NIH/NCI Cancer Center Support Grant P30 CA008748. No external funds were used for the conduct of the trial. The AHPB Foundation provided material support for trial conduct and had no role in data collection, analysis, interpretation, writing of the manuscript, or the decision to submit. The ACS provided no funding for the conduct of the trial but did allow linkage of the existing ACS-NSQIP registry mechanism at participating institutions at no additional cost.
Publisher Copyright:
© 2023 Lippincott Williams and Wilkins. All rights reserved.
PY - 2023/9/1
Y1 - 2023/9/1
N2 - Objective: To establish the association between bactibilia and postoperative complications when stratified by perioperative antibiotic prophylaxis. Background: Patients undergoing pancreatoduodenectomy experience high rates of surgical site infection (SSI) and clinically relevant postoperative pancreatic fistula (CR-POPF). Contaminated bile is known to be associated with SSI, but the role of antibiotic prophylaxis in mitigation of infectious risks is ill-defined. Methods: Intraoperative bile cultures (IOBCs) were collected as an adjunct to a randomized phase 3 clinical trial comparing piperacillin-tazobactam with cefoxitin as perioperative prophylaxis in patients undergoing pancreatoduodenectomy. After compilation of IOBC data, associations between culture results, SSI, and CR-POPF were assessed using logistic regression stratified by the presence of a preoperative biliary stent. Results: Of 778 participants in the clinical trial, IOBC were available for 247 participants. Overall, 68 (27.5%) grew no organisms, 37 (15.0%) grew 1 organism, and 142 (57.5%) were polymicrobial. Organisms resistant to cefoxitin but not piperacillin-tazobactam were present in 95 patients (45.2%). The presence of cefoxitin-resistant organisms, 92.6% of which contained either Enterobacter spp. or Enterococcus spp., was associated with the development of SSI in participants treated with cefoxitin [53.5% vs 25.0%; odds ratio (OR)=3.44, 95% CI: 1.50-7.91; P=0.004] but not those treated with piperacillin-tazobactam (13.5% vs 27.0%; OR=0.42, 95% CI: 0.14-1.29; P=0.128). Similarly, cefoxitin-resistant organisms were associated with CR-POPF in participants treated with cefoxitin (24.1% vs 5.8%; OR=3.45, 95% CI: 1.22-9.74; P=0.017) but not those treated with piperacillin-tazobactam (5.4% vs 4.8%; OR=0.92, 95% CI: 0.30-2.80; P=0.888). Conclusions: Previously observed reductions in SSI and CR-POPF in patients that received piperacillin-tazobactam antibiotic prophylaxis are potentially mediated by biliary pathogens that are cefoxitin resistant, specifically Enterobacter spp. and Enterococcus spp.
AB - Objective: To establish the association between bactibilia and postoperative complications when stratified by perioperative antibiotic prophylaxis. Background: Patients undergoing pancreatoduodenectomy experience high rates of surgical site infection (SSI) and clinically relevant postoperative pancreatic fistula (CR-POPF). Contaminated bile is known to be associated with SSI, but the role of antibiotic prophylaxis in mitigation of infectious risks is ill-defined. Methods: Intraoperative bile cultures (IOBCs) were collected as an adjunct to a randomized phase 3 clinical trial comparing piperacillin-tazobactam with cefoxitin as perioperative prophylaxis in patients undergoing pancreatoduodenectomy. After compilation of IOBC data, associations between culture results, SSI, and CR-POPF were assessed using logistic regression stratified by the presence of a preoperative biliary stent. Results: Of 778 participants in the clinical trial, IOBC were available for 247 participants. Overall, 68 (27.5%) grew no organisms, 37 (15.0%) grew 1 organism, and 142 (57.5%) were polymicrobial. Organisms resistant to cefoxitin but not piperacillin-tazobactam were present in 95 patients (45.2%). The presence of cefoxitin-resistant organisms, 92.6% of which contained either Enterobacter spp. or Enterococcus spp., was associated with the development of SSI in participants treated with cefoxitin [53.5% vs 25.0%; odds ratio (OR)=3.44, 95% CI: 1.50-7.91; P=0.004] but not those treated with piperacillin-tazobactam (13.5% vs 27.0%; OR=0.42, 95% CI: 0.14-1.29; P=0.128). Similarly, cefoxitin-resistant organisms were associated with CR-POPF in participants treated with cefoxitin (24.1% vs 5.8%; OR=3.45, 95% CI: 1.22-9.74; P=0.017) but not those treated with piperacillin-tazobactam (5.4% vs 4.8%; OR=0.92, 95% CI: 0.30-2.80; P=0.888). Conclusions: Previously observed reductions in SSI and CR-POPF in patients that received piperacillin-tazobactam antibiotic prophylaxis are potentially mediated by biliary pathogens that are cefoxitin resistant, specifically Enterobacter spp. and Enterococcus spp.
KW - antibiotic prophylaxis
KW - pancreatoduodenectomy
KW - surgical infection
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U2 - 10.1097/SLA.0000000000005955
DO - 10.1097/SLA.0000000000005955
M3 - Article
C2 - 37314221
AN - SCOPUS:85167841966
SN - 0003-4932
VL - 278
SP - 310
EP - 319
JO - Annals of surgery
JF - Annals of surgery
IS - 3
ER -