Advertisement

The utility of bile juice culture analysis for the management of postoperative infection after pancreaticoduodenectomy

Published:December 20, 2022DOI:https://doi.org/10.1016/j.surg.2022.11.021

      Abstract

      Background

      Surgical site infections are common after pancreaticoduodenectomy. Our institution routinely performs intraoperative bile culture with pancreaticoduodenectomy. Herein we examined whether antibiotic selection based on bile culture analysis reduced the surgical site infection risk after pancreaticoduodenectomy.

      Methods

      A total of 349 patients underwent pancreaticoduodenectomy with intraoperative bile cultures in our institution between 2008 and 2019. Patients were categorized into “group A” (196 patients who underwent pancreaticoduodenectomy between 2008 and 2013) or “group B” (153 patients who underwent pancreaticoduodenectomy between 2018 and 2019). Group A received cefazoline perioperatively and for 2 days postoperatively, whereas group B received piperacillin-tazobactam instead based on the bile culture findings in group A.

      Results

      In group A, 91 (46.4%) intraoperative bile cultures were positive, and surgical site infections occurred in 61 patients (31.1%). A total of 32 patients had both positive bile culture and surgical site infection, of whom 23 (71.9%) exhibited the same microorganisms in the biliary and surgical site infection cultures. Due to the common finding of cefazoline-resistant Enterococcus spp. and Enterobacter spp. in group A, group B received piperacillin-tazobactam. Surgical site infection incidence in group B was 18.3% (n = 28), which was significantly lower than in group A (P = .006). Cefazoline-resistant Enterococcus spp. and Enterobacter spp., respectively, were cultured in 69.8% and 24.3% of patients with preoperative biliary drainage, compared with 32.2% and 9.7% of patients without preoperative biliary drainage.

      Conclusion

      The perioperative selection of antibiotics based on bile culture findings at pancreaticoduodenectomy can reduce the incidence of surgical site infection.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Povoski S.P.
        • Karpeh Jr., M.S.
        • Conlon K.C.
        • Blumgart L.H.
        • Brennan M.F.
        Association of preoperative biliary drainage with postoperative outcome following pancreaticoduodenectomy.
        Ann Surg. 1999; 230: 131-142
        • Sudo T.
        • Murakami Y.
        • Uemura K.
        • et al.
        Specific antibiotic prophylaxis based on bile cultures is required to prevent postoperative infectious complications in pancreatoduodenectomy patients who have undergone preoperative biliary drainage.
        World J Surg. 2007; 31: 2230-2235
        • Donald G.W.
        • Sunjaya D.
        • Lu X.
        • et al.
        Perioperative antibiotics for surgical site infection in pancreaticoduodenectomy: does the SCIP-approved regimen provide adequate coverage?.
        Surgery. 2013; 154: 190-196
        • Sugawara G.
        • Ebata T.
        • Yokoyama Y.
        • et al.
        The effect of preoperative biliary drainage on infectious complications after hepatobiliary resection with cholangiojejunostomy.
        Surgery. 2013; 153: 200-210
        • Fujii T.
        • Yamada S.
        • Suenaga M.
        • et al.
        Preoperative internal biliary drainage increases the risk of bile juice infection and pancreatic fistula after pancreatoduodenectomy: a prospective observational study.
        Pancreas. 2015; 44: 465-470
        • Greenblatt D.Y.
        • Kelly K.J.
        • Rajamanickam V.
        • et al.
        Preoperative factors predict perioperative morbidity and mortality after pancreaticoduodenectomy.
        Ann Surg Oncol. 2011; 18: 2126-2135
        • Keenan J.E.
        • Speicher P.J.
        • Thacker J.K.M.
        • Walter M.
        • Kuchibhatla M.
        • Mantyh C.R.
        The preventive surgical site infection bundle in colorectal surgery: an effective approach to surgical site infection reduction and health care cost savings.
        JAMA Surg. 2014; 149: 1045-1052
        • Konishi T.
        • Watanabe T.
        • Kishimoto J.
        • Nagawa H.
        Elective colon and rectal surgery differ in risk factors for wound infection: results of prospective surveillance.
        Ann Surg. 2006; 244: 758-763
        • Kagawa Y.
        • Yamada D.
        • Yamasaki M.
        • et al.
        The association between the increased performance of laparoscopic colon surgery and a reduced risk of surgical site infection.
        Surg Today. 2019; 49: 474-481
        • Kent T.S.
        • Sachs T.E.
        • Callery M.P.
        • Vollmer Jr., C.M.
        The burden of infection for elective pancreatic resections.
        Surgery. 2013; 153: 86-94
        • Ceppa E.P.
        • Pitt H.A.
        • House M.G.
        • et al.
        Reducing surgical site infections in hepatopancreatobiliary surgery.
        HPB. 2013; 15: 384-391
        • Schweizer M.L.
        • Cullen J.J.
        • Perencevich E.N.
        • Vaughan Sarrazin M.S.
        Costs associated with surgical site infections in Veterans Affairs hospitals.
        JAMA Surg. 2014; 149: 575-581
        • Akita H.
        • Takahashi H.
        • Gotoh K.
        • et al.
        Closure method for thick pancreas stump after distal pancreatectomy: soft coagulation and polyglycolic acid felt with fibrin glue.
        Langenbecks Arch Surg. 2015; 400: 843-848
        • Yamada D.
        • Takahashi H.
        • Hama N.
        • et al.
        The clinical impact of splenic artery ligation on the occurrence of digestive varices after pancreaticoduodenectomy with combined portal vein resection: a retrospective study in two institutes.
        Langenbecks Arch Surg. 2021; 406: 1469-1479
        • Rosenberger L.H.
        • Politano A.D.
        • Sawyer R.G.
        The surgical care improvement project and prevention of post-operative infection, including surgical site infection.
        Surg Infect. 2011; 12: 163-168
        • Sano S.
        • Sugiura T.
        • Kawamura I.
        • et al.
        Third-generation cephalosporin for antimicrobial prophylaxis in pancreatoduodenectomy in patients with internal preoperative biliary drainage.
        Surgery. 2019; 165: 559-564
        • Scheufele F.
        • Aichinger L.
        • Jäger C.
        • et al.
        Effect of preoperative biliary drainage on bacterial flora in bile of patients with periampullary cancer.
        Br J Surg. 2017; 104: e182-e188
        • Gavazzi F.
        • Ridolfi C.
        • Capretti G.
        • et al.
        Role of preoperative biliary stents, bile contamination and antibiotic prophylaxis in surgical site infections after pancreaticoduodenectomy.
        BMC Gastroenterol. 2016; 16: 43
        • Sutton T.L.
        • O’Grady J.
        • Martindale R.
        • Mayo S.C.
        • Gilbert E.W.
        • Sheppard B.C.
        Intraoperative bile culture in pancreaticoduodenectomy: teaching old dogma new tricks.
        J Gastrointest Surg. 2022; 26: 30-38
        • Fong Z.V.
        • McMillan M.T.
        • Marchegiani G.
        • et al.
        Discordance between perioperative antibiotic prophylaxis and wound infection cultures in patients undergoing pancreaticoduodenectomy.
        JAMA Surg. 2016; 151: 432-439
        • Mangram A.J.
        • Horan T.C.
        • Pearson M.L.
        • Silver L.C.
        • Jarvis W.R.
        Guideline for prevention of surgical site infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee.
        Am J Infect Control. 1999; 27 (quiz 133–134; discussion 96): 97-132
        • Bassi C.
        • Marchegiani G.
        • Dervenis C.
        • et al.
        The 2016 update of the International Study Group (ISGPS) definition and grading of postoperative pancreatic fistula: 11 years after.
        Surgery. 2017; 161: 584-591
        • Dindo D.
        • Demartines N.
        • Clavien P.-A.
        Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
        Ann Surg. 2004; 240: 205-213
        • Ng Z.Q.
        • Suthananthan A.E.
        • Rao S.
        Effect of preoperative biliary stenting on post-operative infectious complications in pancreaticoduodenectomy.
        Ann Hepatobiliary Pancreat Surg. 2017; 21: 212-216
        • Krüger C.M.
        • Adam U.
        • Adam T.
        • et al.
        Bacterobilia in pancreatic surgery-conclusions for perioperative antibiotic prophylaxis.
        World J Gastroenterol. 2019; 25: 6238-6247
        • Povoski S.P.
        • Karpeh Jr., M.S.
        • Conlon K.C.
        • Blumgart L.H.
        • Brennan M.F.
        Preoperative biliary drainage: impact on intraoperative bile cultures and infectious morbidity and mortality after pancreaticoduodenectomy.
        J Gastrointest Surg. 1999; 3: 496-505
        • Hodul P.
        • Creech S.
        • Pickleman J.
        • Aranha G.V.
        The effect of preoperative biliary stenting on postoperative complications after pancreaticoduodenectomy.
        Am J Surg. 2003; 186: 420-425
        • Pisters P.W.
        • Hudec W.A.
        • Hess K.R.
        • et al.
        Effect of preoperative biliary decompression on pancreaticoduodenectomy-associated morbidity in 300 consecutive patients.
        Ann Surg. 2001; 234: 47-55
        • Kone L.B.
        • Torres C.
        • Banulescu M.
        • Maker V.K.
        • Maker A.V.
        Perioperative broad-spectrum antibiotics are associated with decreased surgical site infections compared to 1st-3rd generation cephalosporins after open pancreaticoduodenectomy in patients with jaundice or a biliary stent.
        Ann Surg. 2022; 275: 1175-1183
        • Sourrouille I.
        • Gaujoux S.
        • Lacave G.
        • et al.
        Five days of postoperative antimicrobial therapy decreases infectious complications following pancreaticoduodenectomy in patients at risk for bile contamination.
        HPB. 2013; 15: 473-480
        • Fathi A.H.
        • Jackson T.
        • Barati M.
        • Eghbalieh B.
        • Siegel K.A.
        • Siegel C.T.
        Extended perioperative antibiotic coverage in conjunction with intraoperative bile cultures decreases infectious complications after pancreaticoduodenectomy.
        HPB Surg. 2016; 2016: 3031749
        • Sugimachi K.
        • Iguchi T.
        • Mano Y.
        • Morita M.
        • Mori M.
        • Toh Y.
        Significance of bile culture surveillance for postoperative management of pancreatoduodenectomy.
        World J Surg Oncol. 2019; 17: 232