Surgical prophylaxis in pancreatoduodenectomy: Is cephalosporin still the drug of choice in patients with biliary stents in situ?

• Published in: Pancreatology : official journal of the International Association of Pancreatology (IAP) ... [et al.] 2024-09, Vol.24 (6), p.960-965
• Main Authors: Hung, Kai Chee, Chung, Shimin Jasmine, Kwa, Andrea Layhoon, Lee, Winnie Hui Ling, Koh, Ye Xin, Goh, Brian K.P.
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; Anti-Bacterial Agents - therapeutic use; Antibiotic prophylaxis; Antibiotic Prophylaxis - methods; Bile; Ceftriaxone - therapeutic use; Cephalosporins - therapeutic use; Escherichia coli - drug effects; Female; Humans; Male; Metronidazole - therapeutic use; Middle Aged; Pancreaticoduodenectomy; Pancreatoduodenectomy; Piperacillin, Tazobactam Drug Combination - therapeutic use; Retrospective Studies; Stents; Surgical site infections; Surgical Wound Infection - prevention & control
• ISSN: 1424-3903; 1424-3911; 1424-3911
• DOI: 10.1016/j.pan.2024.07.004

Universal surgical prophylaxis for pancreatoduodenectomy (PD) is practiced, with cephalosporins recommended in most guidelines. Recent studies suggest piperacillin-tazobactam (PTZ) prophylaxis in biliary-stented patients is superior in preventing surgical site infections (SSIs). This study aims to refine surgical prophylaxis recommendations based on the local microbial profile and evaluate the clinical outcomes of biliary-stented compared with non-stented patients. This was a retrospective study of all consecutive PD patients at Singapore General Hospital between January 2013 to December 2019. The primary outcome was post-operative SSI rates. Secondary outcomes included rates of ceftriaxone-resistant Klebsiella pneumoniae, Escherichia coli, and Enterococcus species from intraoperative bile cultures and 30-day mortality. There were 130 biliary-stented and 211 non-stented patients included. Majority of biliary-stented patients received ceftriaxone ± metronidazole prophylaxis (83/130, 63.8 %) while 30/130 (23.8 %) received PTZ. Most non-stented patients received ceftriaxone ± metronidazole prophylaxis (163/211, 77.3 %). Between biliary-stented and non-stented patients, post-operative SSIs (40.8 % vs 38.4 %, p = 0.662), and 30-day mortality rates (1.5 % vs 1.4 %, p = 1.000) were comparable. The adjusted odds of post-operative SSIs was significantly lower in biliary-stented patients prescribed PTZ as compared to non-PTZ prophylaxis (0.29, 95 % CI (0.10–0.79), p = 0.015). Ceftriaxone-resistant Klebsiella spp. and/or Escherichia coli (27.6 % vs 3.8 %, p