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©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
Bacterobilia in pancreatic surgery-conclusions for perioperative antibiotic prophylaxis
Colin Markus Krüger, Ulrich Adam, Thomas Adam, Axel Kramer, Claus D Heidecke, Frank Makowiec, Hartwig Riediger
Colin Markus Krüger, Department of Surgery, Immanuel Hospital Rüdersdorf, Berlin 15562, Germany
Ulrich Adam, Hartwig Riediger, Department of General Surgery, Vivantes-Humboldt hospital, Berlin 13503, Germany
Thomas Adam, Department of Microbiology, Labor Berlin GmbH, Berlin 13353, Germany
Axel Kramer, Institute of Hygiene and Environmental Medicine, University Medicine Greifswald, Greifswald 17495, Mecklenburg Vorpommern, Germany
Claus D Heidecke, Department of Surgery, Clinic of General, Visceral, Vascular and Thoracic Surgery, University Medicine Greifswald, Greifswald 17475, Mecklenburg Vorpommern, Germany
Frank Makowiec, Section of clinical risk assessment, University hospital of Freiburg, Freiburg 79106, Baden-Württemberg, Germany
Author contributions: Krueger CM contributed to design of the study, acquisition and analysis of data, and writing of manuscript; Adam U contributed to performing of procedures, acquisition of data, and critical review of manuscript; Adam T contributed to acquisition of data and critical review of manuscript; Kramer A contributed to design of the study, analysis of data, interpretation of data, writing of manuscript, and reviewing the manuscript; Heidecke CD contributed to interpretation of data and critical review of manuscript; Makowiec F contributed to interpretation of data and critical review of manuscript; Riediger H contributed to design of the study, performing of procedures, analysis and interpretation of data, and writing of manuscript.
Institutional review board statement: The study was only reviewed and approved by the Review Board of Brandenburg Medical School.
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: All authors declare no conflicts-of-interest related to this article.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Colin Markus Krüger, FACS, MD, PhD, Chief Physician, Postdoc, Surgeon, Department of Surgery, Immanuel Hospital Rüdersdorf, Seebad 82/83, Berlin 15562, Germany. cm.krueger@immanunel.de
Telephone: +49-1718-151480
Received: July 12, 2019
Peer-review started: July 12, 2019
First decision: August 18, 2019
Revised: October 10, 2019
Accepted: October 17, 2019
Article in press: October 17, 2019
Published online: November 7, 2019
ARTICLE HIGHLIGHTS
Research background
Preoperative biliary drainage (PBD) is a common cause of bacterobilia (BB) and is a known surgical site infection risk factor, especially in pancreatoduodenectomies.
Research motivation
An adjustment of preoperative antibiotic prophylaxis (PAP) may be reasonable according to the profile of BB. However, current guidelines do not recommend an adoption of the PAP according to the PBD status.
Research objectives
The objective of this study was to analyze the bacterial profile in routine patients undergoing pancreatic surgery and to find out, if our PAP is adequate for our patients. Antibiotic efficiency was analyzed for standard PAP and possible alternatives.
Research methods
In the period from January 2009 to December 2015, 285 consecutive pancreatic head resections were performed. Indications for surgery were malignancy (71%), chronic pancreatitis (18%), and others (11%). A PBD was in 51% and preoperative cholestasis (PC) was in 42%. The standard PAP was ampicillin/sulbactam. Intraoperatively, a smear was taken from the hepatic duct. Patients were categorized according to the existence or lack of PC (PC+/PC-) and PBD (PBD+/PBD-).
Research results
BB was present in 150 patients (53%). BB was significantly more frequent in PBD+ (n = 120) than in PBD- (n = 30), P < 0.01. BB was more frequent in malignancy (56%) than in chronic pancreatitis (45%). PBD, however, was the only independent risk factor for BB in multivariate analysis (P < 0.01). The five most common groups (n = 256, 74.8%) were Enterococcus spp. (28.4%), Streptococcus spp. (16.9%), Klebsiella spp. (12.6%), Escherichia coli (10.5%), and Enterobacter spp. (6.4%). A polymicrobial BB (PBD+: 77% vs PBD-: 40%, P < 0.01) and a more frequent detection of Enterococcus (P < 0.05) was significantly associated with PBD+. In PBD+, the efficiency of imipenem and piperacillin/tazobactam was significantly higher than that of the standard PAP (P < 0.01).
Research conclusions
PBD-/PC- and PBD-/PC+ were associated with a low rate of BB, while PBD+ was always associated with a high rate of BB. In PBD+ patients, BB was polymicrobial and more often associated with Enterococcus. In PBD+, the spectrum of potential bacteria may not be covered by standard PAP. A more potent alternative for prophylactic application, however, was not found.
Research perspectives
The perspective of this study is to show more differentiated ways of perioperative antibiotic prophylaxis and to stratify patient groups according to PBD and PC status. As patients with PBD+ are not full covered by standard PAP, these patients have a well-known high risk for infectious complications. A more proper PAP is required. In these selected patients a primary antibiotic treatment adopted to the (suspected) resistogramm.
