Microbial Pathogen Spectrum in Anastomotic Leaks after Ivor-Lewis Esophagectomy

Background: Anastomotic leaks after esophagectomy cause significant morbidity and mortality. In addition to their early detection and prompt endoscopic or surgical management, providing adequate antimicrobial agents is a fundamental aspect of therapy. In this study, different types of microbiological samples were analyzed to provide insight into the microbial pathogen spectrum of anastomotic leaks after esophagectomy. Methods: We retrospectively reviewed patients who developed anastomotic leak after Ivor-Lewis esophagectomy at a German high-volume center between 2016 and 2018. Results of microbiological cultures from surgical samples, chest tube fluid, endoscopic aspirates, and blood cultures were analyzed to determine species and antimicrobial susceptibility. Results: Out of 513 consecutive patients undergoing esophagectomy, 74 developed an anastomotic leak. About 88%-100% of positive samples showed growth of gram-positive bacteria, mainly viridians streptococci but also enterococci. Gram-negative bacteria were found in 48%-82% of positive samples, mainly enterobacterales. Yeasts were found in 43%-64%. The prevalance of multidrug-resistant bacteria was low in our patient population. Expected failure of empiric antibiotic treatment was <10% for piperacillin-tazobactam, meropenem, and tigecycline (each combined with an echinocandin) but not for ampicillin-sulbactam, ceftriaxone plus metronidazole, moxifloxacin, or gentamicine plus clindamycin. Conclusions: There is a broad microbial pathogen spectrum in anastomotic leaks after esophagectomy. Implications for empiric antimicrobial treatment arise from enterobacterales, enterococci, and yeasts.