Preoperative surveillance rectal swab is associated with an increased risk of infectious complications in pancreaticoduodenectomy and directs antimicrobial prophylaxis: an antibiotic stewardship strategy?

Pastena, Matteo De; Paiella, Salvatore; Azzini, Anna Maria; Marchegiani, Giovanni; Malleo, Giuseppe; Ciprani, Debora; Mazzariol, Annarita; Secchettin, Erica; Bonamini, Deborah; Gasparini, Clizia; Concia, Ercole; Bassi, Claudio; Salvia, Roberto

doi:10.1016/j.hpb.2017.12.002

Cited by 25 publications

(26 citation statements)

References 48 publications

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“…This study documents the microbiological milieu of the surgical field in patients undergoing pancreatoduodenectomy. We observed a predominance of Enterobacteriaceae and Enterococcus species, which is concordant with other studies with similar methodologies . Candida species were cultured in half of the patients whilst other studies report a prevalence of Candida species of 0–26% in intraoperative bile specimens .…”

Section: Discussionsupporting

confidence: 92%

“…We observed a predominance of Enterobacteriaceae and Enterococcus species, which is concordant with other studies with similar methodologies . Candida species were cultured in half of the patients whilst other studies report a prevalence of Candida species of 0–26% in intraoperative bile specimens . One multicentre retrospective study compared the results of intraoperative bile and surgical site infection cultures from patients undergoing pancreatoduodenectomy at Massachusetts General Hospital in the USA and the University of Verona Hospital in Italy and demonstrated variability in the isolates between centres, although the prevalence of Candida albicans in intraoperative bile cultures was similar at approximately 13% …”

Section: Discussionsupporting

confidence: 92%

“…Surgical site infections occurred in nine of 44 (20%) patients, which lies within the broad range of incidence reported in the literature of 6–50% . Blood culture and surgical site infection site culture isolates correlated with at least one intraoperative specimen culture isolate in seven of 10 (70%) patients, which is comparable to the correlation rate of 30–59% reported in other studies …”

Section: Discussionsupporting

confidence: 84%

“…Intraoperative specimen cultures were positive in the majority (96%) of patients, which is significantly higher than the rate of 58–87% reported in the literature . This probably reflects the high prevalence of preoperative biliary stenting in our patient cohort as most of the operative specimens from which cultures were obtained were biliary stents rather than swabs or tissue.…”

Section: Discussioncontrasting

confidence: 50%

“…The mean duration of perioperative antimicrobial prophylaxis was 4.3 days with a range of 1–14 days . Established risk factors for surgical site infection complicating hepatobiliary and pancreatic surgeries include; American Society of Anesthesiologists score ≥3, cardiac disease, massive intraoperative bleeding, overweight or underweight, preoperative biliary drainage or stenting, post‐operative pancreatic fistula, and prolonged surgery . Several recent studies have also suggested that failure of perioperative antimicrobial prophylaxis coverage of microorganisms colonizing the bile duct is also a risk factor for surgical site infection.…”

Section: Introductionmentioning

confidence: 99%

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Microbiology of pancreatoduodenectomy and recommendations for antimicrobial prophylaxis

Swan

Nahm

Samra

et al. 2019

ANZ Journal of Surgery

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Background The microbiology of pancreatoduodenectomy is challenging and published guidelines regarding perioperative antimicrobial prophylaxis are variable with poor adherence. Methods A retrospective analysis of the microbiological results of 294 consecutive patients who underwent pancreatoduodenectomy was performed. Intraoperative specimen culture results were available for 50 patients and their medical records were reviewed to determine the following demographics and factors; age; sex; tumour location, histopathology, grade and stage; neoadjuvant chemotherapy and radiotherapy; preoperative biliary stenting; surgeon; surgery type and antimicrobial prophylaxis coverage. Outcomes assessed included; post‐operative infections, mortality (all and 90‐day), and intensive care unit and hospital admission durations. Univariate analysis with chi‐squared testing was performed. Results Intraoperative specimen cultures were positive in 48 (96%) patients and polymicrobial in 45 (90%) patients with a predominance of Enterobacteriaceae (38/76%), Enterococcus species (27/54%), and Candida species (25/50%). Isolates were potentially susceptible to the current perioperative antimicrobial prophylaxis regimen of ceftriaxone with or without metronidazole in only six patients. However, only neoadjuvant radiotherapy was associated with statistically significant increased intensive care unit and hospital admission durations. Conclusion Although this study was probably underpowered to detect any statistically significant associations, perioperative antimicrobial prophylaxis coverage of the operative field microbiological milieu of pancreatoduodenectomy is logical and current guidelines may be inadequate.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionsupporting

confidence: 92%

Section: Discussionsupporting

confidence: 84%

Section: Discussioncontrasting

confidence: 50%

Section: Introductionmentioning

confidence: 99%

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Microbiology of pancreatoduodenectomy and recommendations for antimicrobial prophylaxis

Swan

Nahm

Samra

et al. 2019

ANZ Journal of Surgery

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Piperacillin-Tazobactam Compared With Cefoxitin as Antimicrobial Prophylaxis for Pancreatoduodenectomy

D’Angelica

Ellis

Liu

et al. 2023

JAMA

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ImportanceDespite improvements in perioperative mortality, the incidence of postoperative surgical site infection (SSI) remains high after pancreatoduodenectomy. The effect of broad-spectrum antimicrobial surgical prophylaxis in reducing SSI is poorly understood.ObjectiveTo define the effect of broad-spectrum perioperative antimicrobial prophylaxis on postoperative SSI incidence compared with standard care antibiotics.Design, Setting, and ParticipantsPragmatic, open-label, multicenter, randomized phase 3 clinical trial at 26 hospitals across the US and Canada. Participants were enrolled between November 2017 and August 2021, with follow-up through December 2021. Adults undergoing open pancreatoduodenectomy for any indication were eligible. Individuals were excluded if they had allergies to study medications, active infections, chronic steroid use, significant kidney dysfunction, or were pregnant or breastfeeding. Participants were block randomized in a 1:1 ratio and stratified by the presence of a preoperative biliary stent. Participants, investigators, and statisticians analyzing trial data were unblinded to treatment assignment.InterventionThe intervention group received piperacillin-tazobactam (3.375 or 4 g intravenously) as perioperative antimicrobial prophylaxis, while the control group received cefoxitin (2 g intravenously; standard care).Main Outcomes and MeasuresThe primary outcome was development of postoperative SSI within 30 days. Secondary end points included 30-day mortality, development of clinically relevant postoperative pancreatic fistula, and sepsis. All data were collected as part of the American College of Surgeons National Surgical Quality Improvement Program.ResultsThe trial was terminated at an interim analysis on the basis of a predefined stopping rule. Of 778 participants (378 in the piperacillin-tazobactam group [median age, 66.8 y; 233 {61.6%} men] and 400 in the cefoxitin group [median age, 68.0 y; 223 {55.8%} men]), the percentage with SSI at 30 days was lower in the perioperative piperacillin-tazobactam vs cefoxitin group (19.8% vs 32.8%; absolute difference, −13.0% [95% CI, −19.1% to −6.9%]; P &lt; .001). Participants treated with piperacillin-tazobactam, vs cefoxitin, had lower rates of postoperative sepsis (4.2% vs 7.5%; difference, −3.3% [95% CI, −6.6% to 0.0%]; P = .02) and clinically relevant postoperative pancreatic fistula (12.7% vs 19.0%; difference, −6.3% [95% CI, −11.4% to −1.2%]; P = .03). Mortality rates at 30 days were 1.3% (5/378) among participants treated with piperacillin-tazobactam and 2.5% (10/400) among those receiving cefoxitin (difference, −1.2% [95% CI, −3.1% to 0.7%]; P = .32).Conclusions and RelevanceIn participants undergoing open pancreatoduodenectomy, use of piperacillin-tazobactam as perioperative prophylaxis reduced postoperative SSI, pancreatic fistula, and multiple downstream sequelae of SSI. The findings support the use of piperacillin-tazobactam as standard care for open pancreatoduodenectomy.Trial RegistrationClinicalTrials.gov Identifier: NCT03269994

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Use of an intraoperative wound protector to prevent surgical-site infection after pancreatoduodenectomy: randomized clinical trial

Pastena¹,

Marchegiani²,

Paiella³

et al. 2020

British Journal of Surgery

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Background Surgical-site infection (SSI) increases treatment costs, duration of hospital stay and readmission rate after pancreatic surgery. This study aimed to assess whether a wound protector could reduce the risk of superficial incisional SSI after pancreatoduodenectomy. Methods This RCT included patients undergoing pancreatoduodenectomy at Verona University Hospital, between 2017 and 2018. The experimental group had a dual-ring wound protector, whereas the control group had standard surgical drapes. The groups were stratified by preoperative biliary stent placement. The primary outcome was the overall rate of superficial SSI. Results An interim analysis was conducted after 212 patients had been enrolled; 22 patients (10·4 per cent) were excluded owing to inability to complete the pancreatoduodenectomy, or the need for postoperative reintervention. Some 94 patients (49·5 per cent) had a wound protector and 96 (50·5 per cent) had standard drapes. There were no differences between groups in demographics, or in intraoperative findings, pathological data or surgical outcomes. The overall superficial SSI rate was 7·4 per cent, which did not differ between groups (7 per cent in each group; P = 0·585). Subanalysis of patients with a preoperative biliary stent showed a similar outcome (superficial SSI rate 9 versus 8 per cent with wound protector versus surgical drapes respectively; P = 0·536). The trial was stopped prematurely on the grounds of futility. Conclusion Use of a wound protector did not reduce the rate of superficial SSI after pancreatoduodenectomy. Registration number: NCT03820648 (http://www.clinicaltrials.gov).

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Preoperative surveillance rectal swab is associated with an increased risk of infectious complications in pancreaticoduodenectomy and directs antimicrobial prophylaxis: an antibiotic stewardship strategy?

Abstract: Preoperative surveillance RS-culture's positivity correlates to biliary colonization that occurs after PBD. IC and mortality after PD are associated with RS+. Preoperative RS can direct antibiotic prophylaxis to reduce morbidity and mortality after PD.

Cited by 25 publications

References 48 publications

Microbiology of pancreatoduodenectomy and recommendations for antimicrobial prophylaxis

Microbiology of pancreatoduodenectomy and recommendations for antimicrobial prophylaxis

Piperacillin-Tazobactam Compared With Cefoxitin as Antimicrobial Prophylaxis for Pancreatoduodenectomy

Use of an intraoperative wound protector to prevent surgical-site infection after pancreatoduodenectomy: randomized clinical trial

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