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Microbiology of pancreatoduodenectomy and recommendations for antimicrobial prophylaxis
Christopher D Swan1, Christopher Nahm2,3, Jaswinder S Samra2,3,4,5,6,7
1Department of Microbiology and Infectious Diseases, Royal North Shore Hospital, Sydney, New South Wales, Australia.
Background:
The microbiology of pancreatoduodenectomy is challenging and published guidelines regarding perioperative antimicrobial prophylaxis are variable with poor adherence.
Methods:
A retrospective analysis of the microbiological results of 294 consecutive patients who underwent pancreatoduodenectomy was performed. Intraoperative specimen culture results were available for 50 patients and their medical records were reviewed to determine the following demographics and factors; age; sex; tumour location, histopathology, grade and stage; neoadjuvant chemotherapy and radiotherapy; preoperative biliary stenting; surgeon; surgery type and antimicrobial prophylaxis coverage. Outcomes assessed included; post-operative infections, mortality (all and 90-day), and intensive care unit and hospital admission durations. Univariate analysis with chi-squared testing was performed.
Results:
Intraoperative specimen cultures were positive in 48 (96%) patients and polymicrobial in 45 (90%) patients with a predominance of Enterobacteriaceae (38/76%), Enterococcus species (27/54%), and Candida species (25/50%). Isolates were potentially susceptible to the current perioperative antimicrobial prophylaxis regimen of ceftriaxone with or without metronidazole in only six patients. However, only neoadjuvant radiotherapy was associated with statistically significant increased intensive care unit and hospital admission durations.
Conclusion:
Although this study was probably underpowered to detect any statistically significant associations, perioperative antimicrobial prophylaxis coverage of the operative field microbiological milieu of pancreatoduodenectomy is logical and current guidelines may be inadequate.
Insights
Microbiology during pancreatoduodenectomy is complex, with most intraoperative cultures showing polymicrobial infections. Current antimicrobial prophylaxis may be inadequate, suggesting a need for updated guidelines for this challenging surgery.
Area of Science:
- Surgical Microbiology
- Oncology
- Infectious Diseases
Background:
- Pancreatoduodenectomy presents significant microbiological challenges.
- Existing guidelines for perioperative antimicrobial prophylaxis are inconsistent and poorly followed.
Purpose of the Study:
- To analyze the microbiological findings from pancreatoduodenectomy specimens.
- To evaluate the appropriateness of current antimicrobial prophylaxis regimens.
Main Methods:
- Retrospective analysis of 294 patients undergoing pancreatoduodenectomy.
- Review of intraoperative cultures and patient medical records for 50 patients.
- Univariate analysis using chi-squared testing to assess factors and outcomes.
Main Results:
- 96% of intraoperative cultures were positive, with 90% being polymicrobial.
- Predominant organisms included Enterobacteriaceae, Enterococcus, and Candida species.
- Only 6% of isolates were susceptible to the current prophylaxis regimen; neoadjuvant radiotherapy correlated with longer hospital stays.
Conclusions:
- Perioperative antimicrobial prophylaxis should logically cover the identified microbiological milieu.
- Current guidelines for antimicrobial prophylaxis in pancreatoduodenectomy may be insufficient.
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