Association between biliary pathogens, surgical site infection, and pancreatic fistula: Results of a randomized trial of perioperative antibiotic prophylaxis in patients undergoing pancreatoduodenectomy Journal Article

   

Authors:	Ellis, R. J.; Brajcich, B. C.; Bertens, K. A.; Chan, C. H. F.; Castillo, C. F. D.; Karanicolas, P. J.; Maithel, S. K.; Reames, B. N.; Weber, S. M.; Vidri, R. J.; Pitt, H. A.; Thompson, V. M.; Gonen, M.; Seo, S. K.; Yopp, A. C.; Ko, C. Y.; D'Angelica, M. I.
Article Title:	Association between biliary pathogens, surgical site infection, and pancreatic fistula: Results of a randomized trial of perioperative antibiotic prophylaxis in patients undergoing pancreatoduodenectomy
Abstract:	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. © 2023 Lippincott Williams and Wilkins. All rights reserved.
Keywords:	controlled study; retrospective studies; clinical trial; pancreaticoduodenectomy; randomized controlled trial; retrospective study; antiinfective agent; anti-bacterial agents; surgical infection; phase 3 clinical trial; antibiotic prophylaxis; pancreatic fistula; piperacillin plus tazobactam; surgical wound infection; pancreas fistula; procedures; humans; human; pancreatoduodenectomy; cefoxitin; piperacillin, tazobactam drug combination
Journal Title:	Annals of Surgery
Volume:	278
Issue:	3
ISSN:	0003-4932
Publisher:	Lippincott Williams & Wilkins
Date Published:	2023-09-01
Start Page:	310
End Page:	319
Language:	English
DOI:	10.1097/sla.0000000000005955
PUBMED:	37314221
PROVIDER:	scopus
PMCID:	PMC10838195
DOI/URL:	https://www.scopus.com/inward/record.uri?eid=2-s2.0-85167841966&doi=10.1097%2fSLA.0000000000005955&partnerID=40&md5=cbdf61bea549d17f4b19b4a51e7e4938
Notes:	The MSK Cancer Center Support Grant (P30 CA008748) is acknowledged in PubMed and PDF -- Corresponding author is MSK author: Michael I. D’Angelica -- Source: Scopus

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