Significance of Antimicrobial Prophylaxis for the Prevention of Early-Onset Pneumonia After Radical Esophageal Cancer Resection: A Retrospective Analysis of 356 Patients Undergoing Thoracoscopic Esophagectomy

Abstract

Background. Postoperative pneumonia is a common complication after esophagectomy and is associated with a high mortality rate. Although many randomized, controlled trials have been conducted on the prevention of postoperative pneumonia, little attention has been paid to the efficacy of antimicrobial prophylaxis. The purpose of this study was to investigate the impact of antimicrobial prophylaxis on the prevention of postoperative pneumonia. Methods. Data of patients with esophageal cancer who underwent thoracoscopic esophagectomy between 2016 and 2020 were collected. Early-period patients received cefazolin (CEZ) per protocol as antimicrobial prophylaxis (n = 250), and later-period patients received ampicillin/sulbactam (ABPC/SBT) (n = 106) because of the unavailability of CEZ in Japan. The incidence of pneumonia was compared between treatments in this quasiexperimental setting. Pneumonia detected by routine computed tomography (CT) on postoperative Days 5-6 was defined as early-onset pneumonia, and pneumonia that developed later was defined as late-onset pneumonia.Results. The incidence of early-onset pneumonia was significantly lower (3.8% vs. 13.6%, P = 0.006), and the median length of postoperative hospital stay was significantly shorter (17 vs. 20 days, P \ 0.001) in the ABPC/ SBT group than in the CEZ group. The incidence of lateonset pneumonia was similar between groups (9.4% vs. 10.0%, P = 0.870). The incidence of Clostridioides difficile infections and the incidence of multidrug-resistant organisms were similar between groups. Multivariate analyses consistently showed the superiority of ABPC/SBT to CEZ in preventing early-onset pneumonia (odds ratio: 0.20, P = 0.006). Conclusions. ABPC/SBT after esophagectomy was better at preventing early-onset pneumonia compared with CEZ and was feasible regarding the development of antimicrobial resistance.

Antimicrobial Prophylaxis with Ampicillin-sulbactam Compared with Cefazolin for Esophagectomy

“…A single-center study of lung surgery (n=445) demonstrated similar results; amoxicillin-clavulanate was associated with a lower risk of postoperative pneumonia compared with cefamandole 11 . In addition, a previous before and after study reported that ABPC/SBT could reduce pneumonia that is likely to occur on POD 2–3 after esophagectomy compared with CEZ 16 . Antimicrobial prophylaxis covering oral bacteria (both aerobic and anaerobic) may have reduced the risk of respiratory failure and complications caused by silent aspiration in the acute phase after esophagectomy.…”

“…According to previous studies, CEZ, ABPC/SBT, second-generation cephalosporins, and CEZ plus metronidazole have been used worldwide for antimicrobial prophylaxis in esophagectomy 7,15–18,36,37 . In the absence of evidence specific to esophagectomy, the choice of agents for antimicrobial prophylaxis varied among hospitals and across study periods; consequently, the regimens depended on hospital policies or regional guidelines 14 .…”

“…Some hospitals prefer the combination of ampicillin-sulbactam (ABPC/SBT) targeting both aerobic and anaerobic oral bacteria 16–18 in accordance with guideline recommendations in head, neck, and lung surgery 6 . A recent single-center study of esophagectomy (n=360) showed that the risk of early-onset pneumonia [diagnosed using routine computed tomography on postoperative days (POD) 5–6] was lower with ABPC/SBT compared with CEZ 16 . In addition, the use of ABPC/SBT was associated with a lower incidence of SSI and anastomotic leakage than that with CEZ, although the difference lacked statistical significance.…”

Construction of a prognostic model for radical esophagectomy based on immunohistochemical prognostic markers combined with clinicopathological factors

“…Among them, the most common are esophageal anastomotic leakage, esophageal stricture, pulmonary infection and recurrent laryngeal nerve injury. [27][28][29] The occurrence of these complications seriously affects the quality of life of patients and may lead to non-tumor death of patients. A study showed that the median survival of patients with postoperative esophageal fistula and fistula formation was only 11 and 3.63 months, respectively.…”

Predictive model of postoperative pneumonia after neoadjuvant immunochemotherapy for esophageal cancer

“…treated by drugs, and airway clearance techniques(45) and hand-assisted expectoration (46) used to assist excretion.If the prognosis of patients is known early, a focus on high-risk patients could improve their prognosis. Before surgery, strengthening the optimization of respiratory function(47), the preventative use of antibiotics(48), preoperative oral care(49), and nutritional support (50) can reduce postoperative pulmonary complications of…”