An Antimicrobial Stewardship Program in Pancreatic Surgery Reduces the Infectious Risk of Colonized Bile, Reducing the Predictive Value of the Intraoperative Bile Culture: A Before-after Study on 1638 Pancreatoduodenectomies.

Abstract

To evaluate the pancreatic surgery-specific antimicrobial stewardship (AMS) program on surgical site infections (SSIs), focusing on bile microbiology and colonization. Colonized bile is well known to increase the risk of SSIs after pancreatoduodenectomy. However, AMS programs seem to reduce their occurrence. This observational before-after study included patients who underwent pancreatoduodenectomy from 2015 to 2022 at a high-volume pancreatic center (#NCT04199494). Pre-AMS data spanned from January 2015 to November 2019, and post-AMS data from December 2019 to October 2022. Intraoperative bile samples were analyzed for microbiology. The AMS program involved preoperative rectal screening for multidrug-resistant bacteria to guide personalized surgical antibiotic prophylaxis (SAP). Tailored SAP was used for patients colonized with resistant pathogens. SSI rates, length of stay, major and pancreatic surgery-specific complications, and mortality were assessed using standard statistics. Of 1638 patients included, 1321 (80.6%) had intraoperative bile sampling, with 909 samples (68.8%) testing positive for colonization. The most common bacteria were Enterobacterales (75%), 18% extended-spectrum beta-lactamase-producing, and Enterococci (60%), 4% of which were vancomycin-resistant. Colonized bile was associated with male sex, jaundice, biliary stenting, and positive rectal screening ( P < 0.05). Before AMS, colonized bile correlated with higher SSI rates (38% vs 31%, P = 0.008). Post-AMS, no significant difference was observed (29% vs 28%, P = 0.5). Tailored SAP reduced overall SSI (34% reduction, P = 0.002) and superficial SSI (59% reduction, P = 0.011). Pancreatic surgery-specific AMS with tailored SAP reduces SSIs and diminishes the predictive value of colonized bile for SSIs. Intraoperative bile cultures remain valuable for postoperative management.