Published online Nov 7, 2019. doi: 10.3748/wjg.v25.i41.6238
Peer-review started: July 12, 2019
First decision: August 18, 2019
Revised: October 10, 2019
Accepted: October 17, 2019
Article in press: October 17, 2019
Published online: November 7, 2019
Processing time: 120 Days and 12.7 Hours
Preoperative biliary drainage (PBD) is a common cause of bacterobilia (BB) and is a known surgical site infection risk factor, especially in pancreatoduodenectomies.
An adjustment of preoperative antibiotic prophylaxis (PAP) may be reasonable according to the profile of BB. However, current guidelines do not recommend an adoption of the PAP according to the PBD status.
The objective of this study was to analyze the bacterial profile in routine patients undergoing pancreatic surgery and to find out, if our PAP is adequate for our patients. Antibiotic efficiency was analyzed for standard PAP and possible alternatives.
In the period from January 2009 to December 2015, 285 consecutive pancreatic head resections were performed. Indications for surgery were malignancy (71%), chronic pancreatitis (18%), and others (11%). A PBD was in 51% and preoperative cholestasis (PC) was in 42%. The standard PAP was ampicillin/sulbactam. Intraoperatively, a smear was taken from the hepatic duct. Patients were categorized according to the existence or lack of PC (PC+/PC-) and PBD (PBD+/PBD-).
BB was present in 150 patients (53%). BB was significantly more frequent in PBD+ (n = 120) than in PBD- (n = 30), P < 0.01. BB was more frequent in malignancy (56%) than in chronic pancreatitis (45%). PBD, however, was the only independent risk factor for BB in multivariate analysis (P < 0.01). The five most common groups (n = 256, 74.8%) were Enterococcus spp. (28.4%), Streptococcus spp. (16.9%), Klebsiella spp. (12.6%), Escherichia coli (10.5%), and Enterobacter spp. (6.4%). A polymicrobial BB (PBD+: 77% vs PBD-: 40%, P < 0.01) and a more frequent detection of Enterococcus (P < 0.05) was significantly associated with PBD+. In PBD+, the efficiency of imipenem and piperacillin/tazobactam was significantly higher than that of the standard PAP (P < 0.01).
PBD-/PC- and PBD-/PC+ were associated with a low rate of BB, while PBD+ was always associated with a high rate of BB. In PBD+ patients, BB was polymicrobial and more often associated with Enterococcus. In PBD+, the spectrum of potential bacteria may not be covered by standard PAP. A more potent alternative for prophylactic application, however, was not found.
The perspective of this study is to show more differentiated ways of perioperative antibiotic prophylaxis and to stratify patient groups according to PBD and PC status. As patients with PBD+ are not full covered by standard PAP, these patients have a well-known high risk for infectious complications. A more proper PAP is required. In these selected patients a primary antibiotic treatment adopted to the (suspected) resistogramm.