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

Abstract

Introduction: Infectious complications are common after pancreatoduodenectomy, which in turn are associated with preoperative biliary drainage. Current guidelines recommend a first-generation cephalosporin as perioperative antibiotic prophylaxis. However, some studies support the use of targeted antibiotics. The aim of this systematic review and meta-analysis is to evaluate the role of prophylactic targeted antibiotics compared to standard antibiotics in reducing postoperative infections after pancreatoduodenectomy. Methods: A search from MEDLINE, EMBASE, and Cochrane library from 1946 to July 2020 was conducted. Studies were included if they compared targeted antibiotics with standard perioperative antibiotics while including outcome data on surgical site infections (SSI). Targeted therapy was defined as perioperative antibiotics targeting organisms prevalent in bile instrumentation or by culture data obtained from the patient or institution. Outcomes assessed were the rate of SSIs and their microbiology profile. Analyses included demographic data, perioperative antibiotics, postoperative outcomes including microbiology data, and meta-analysis was performed where applicable. Results: Seven studies were included, with a total of 849 patients undergoing pancreatoduodenectomy. Targeted antibiotics were associated with a significantly lower rate of postoperative SSI compared to standard antibiotic therapy [21.1% vs 41.9%; risk ratios (RR) 0.55, 95% confidence interval 0.37-0.81]. Wound/incisional site infections and organ space infections were lower in patients receiving targeted antibiotic prophylaxis (RR 0.33, P ¼ 0.0002 and RR 0.54, P ¼ 0.0004, respectively). Enterococcus species were the most common bacteria reported. Conclusion: There was a significant reduction in overall SSI rates when targeted antibiotics was used. Current standard antibiotic prophylaxis is inadequate in covering microbes prevalent in postoperative infections developing after pancreatoduodenectomy.

Implementation of intraoperative wound irrigation with aqueous 10% povidone–iodine and triclosan‐coated sutures is not effective for reducing the incidence of incisional surgical site infection after major hepato‐biliary‐pancreatic surgery in patients with preoperative biliary drainage

“…Among the organisms that were isolated from incisional SSI, the leading isolates were Enterococcus and Enterobacter species, a result that was also in line with the findings of previous studies. 4,9,10,11,23 Generally, whether or not Enterococcus species are pathogenic for incisional SSI is dubious, 4,11 so ampicillin and vancomycin were not routinely administered as perioperative antibiotics prophylaxis when Enterococcus species were isolated from bile of PBD in this series.…”

“…Antibiotic prophylaxis was divided into standard and broad‐spectrum antibiotic prophylaxis. First‐ and second‐generation cephalosporins were used as standard antibiotic prophylaxis, whereas broad‐spectrum antibiotics prophylaxis included third‐ and fourth‐generation cephalosporins, cefoperazone/sulbactam, piperacillin/tazobactam, and the use of vancomycin in addition to other antibiotics 23 …”

“…First-and second-generation cephalosporins were used as standard antibiotic prophylaxis, whereas broad-spectrum antibiotics prophylaxis included third-and fourth-generation cephalosporins, cefoperazone/sulbactam, piperacillin/tazobactam, and the use of vancomycin in addition to other antibiotics. 23 This study was approved by the Institutional Review Board of Saitama Medical Center, Jichi Medical University (S22-023) and conducted in accordance with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.…”

Understanding risk factors and microbial trends implicated in the development of Whipple-related surgical-site infections

“…24,25 Controversy remains over the choice of preoperative antibiotic therapy as the effectiveness of antibiotic classes is debated, and emerging evidence suggests that institution-specific and/or targeted therapy is more effective in lowering SSI risk than any single antibiotic choice. [26][27][28][29] Intrabdominal surgery most commonly uses early-generation cephalosporins and broad-spectrum antibiotics to cover for gram-positives and/or enterococci and coliform bacteria. Moreover, coverage varies by regional resistance patterns, though antibiotic choices may be limited by patient-specific characteristics (ie, drug reactions, renal insufficiency, or liver disease).…”

Association Between Biliary Pathogens, Surgical Site Infection, and Pancreatic Fistula

“…The notion that bactibilia and resistant organisms drive postoperative SSI led to multiple retrospective series 13,14 and recently a multicenter, phase III clinical trial comparing piperacillin-tazobactam with standard-of-care cefoxitin for use as routine antibiotic prophylaxis in patients undergoing PD 15,16 . This trial demonstrated significant reduction in both SSI and CR-POPF in patients administered piperacillin-tazobactam compared with standard-of-care cefoxitin which was particularly robust in patients with preoperative biliary stents 16 .…”