• Ryan J Ellis, Brian C Brajcich, Kimberly A Bertens, ChanCarlos H FCHFUniversity of Iowa Hospitals and Clinics, Iowa City, IA., CastilloCarlos Fernandez-DelCFMassachusetts General Hospital, Boston, MA., Paul J Karanicolas, Shishir K Maithel, Bradley N Reames, Sharon M Weber, Roberto J Vidri, Henry A Pitt, Vanessa M Thompson, Mithat Gonen, Susan K Seo, Adam C Yopp, Clifford Y Ko, and Michael I D'Angelica.
• Memorial Sloan Kettering Cancer Center, New York, NY.
• Ann. Surg. 2023 Sep 1; 278 (3): 310319310-319.

ObjectiveTo establish the association between bactibilia and postoperative complications when stratified by perioperative antibiotic prophylaxis.BackgroundPatients undergoing pancreatoduodenectomy experience high rates of surgical site infection (SSI) and clinically relevant postoperative pancreatic fistula (CR-POPF). Contaminated bile is known to be associated with SSI, but the role of antibiotic prophylaxis in mitigation of infectious risks is ill-defined.MethodsIntraoperative bile cultures (IOBCs) were collected as an adjunct to a randomized phase 3 clinical trial comparing piperacillin-tazobactam with cefoxitin as perioperative prophylaxis in patients undergoing pancreatoduodenectomy. After compilation of IOBC data, associations between culture results, SSI, and CR-POPF were assessed using logistic regression stratified by the presence of a preoperative biliary stent.ResultsOf 778 participants in the clinical trial, IOBC were available for 247 participants. Overall, 68 (27.5%) grew no organisms, 37 (15.0%) grew 1 organism, and 142 (57.5%) were polymicrobial. Organisms resistant to cefoxitin but not piperacillin-tazobactam were present in 95 patients (45.2%). The presence of cefoxitin-resistant organisms, 92.6% of which contained either Enterobacter spp. or Enterococcus spp., was associated with the development of SSI in participants treated with cefoxitin [53.5% vs 25.0%; odds ratio (OR)=3.44, 95% CI: 1.50-7.91; P =0.004] but not those treated with piperacillin-tazobactam (13.5% vs 27.0%; OR=0.42, 95% CI: 0.14-1.29; P =0.128). Similarly, cefoxitin-resistant organisms were associated with CR-POPF in participants treated with cefoxitin (24.1% vs 5.8%; OR=3.45, 95% CI: 1.22-9.74; P =0.017) but not those treated with piperacillin-tazobactam (5.4% vs 4.8%; OR=0.92, 95% CI: 0.30-2.80; P =0.888).ConclusionsPreviously observed reductions in SSI and CR-POPF in patients that received piperacillin-tazobactam antibiotic prophylaxis are potentially mediated by biliary pathogens that are cefoxitin resistant, specifically Enterobacter spp. and Enterococcus spp.Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.

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