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Discordance Between Perioperative Antibiotic Treatment and Wound Infection Cultures in Patients Undergoing Pancreaticoduodenectomy: a Multicenter 5-Year Study
Zhi Ven Fong*1, Matthew T. McMillan2, Giovanni Marchegiani3, Klaus Sahora1, Giuseppe Malleo3, Matteo De Pastena3, Cristina R. Ferrone1, Claudio Bassi3, Keith D. Lillemoe1, Charles M. Vollmer2, Carlos Fernandez-Del Castillo1
1General Surgery, Massachusetts General Hospital, Boston, MA; 2Surgery, University of Pennsylvania, Philadelphia, PA; 3Surgery, University of Verona, Verona, Italy
Introduction: Wound infections after pancreaticoduodenectomy (PD) are common, and the antibiotic prophylaxis given to prevent them is often done with cephalosporin. However, these measures are rarely guided by microbiology data pertinent to PD, particularly in patients with biliary stents, and its effectiveness is largely unknown.
Methods: The pancreatic resection databases of 3 institutions were queried for patients undergoing PD over a 5-year period, and patients with wound infections identified. Perioperative variables and microbiology data were analyzed.
Results: A total of 1623 patients who underwent PD were identified. The predominant perioperative antibiotics used at institution A, B and C were Cefoxitin, Cefazolin/Metronidazole and Ampicillin/Sulbactam respectively. The wound infection rate was 8.2%, and was not different across institutions. Of the 133 wound infections, 67% were deep tissue infection, occurring at a median of 8 days after PD. Up to 40% of wound infections required home visiting nurse services on discharge, and almost 30% of all PD readmissions were attributed to wound infection. Preoperative biliary manipulation was the strongest predictor of postoperative wound infection (OR 2.2, p=0.03). There was marked institutional variation in the type of microorganisms cultured from the wound infection (Table 1, p=0.001). Similarly, antibiotic resistance patterns varied (p<0.001).
Conclusion: To our knowledge, this is the first study reporting on microbiology data of wound infections in patients undergoing PD. Based on institution-specific microorganism predominance and antibiotic resistance patterns, all 3 institutions are not using effective antibiotic prophylaxis. Institution-specific internal reviews should amend current protocols for antibiotic prophylaxis to reduce the incidence of wound infections following PD.
Microorganism predominance and resistance patterns across 3 institutions.
| Institution | Microorganism | Resistance | | Enterococcus | Enterobacter | Staphylococcus | E.Coli | Klebsiella | Ampicillin | Cefazolin | Penicillin | Cefoxitin | | A | 51%* | 46%* | 23% | 14% | 11.4% | 56%* | 41%* | 15% | 7% | | B | 7% | 14% | 43% | 14% | 21%* | 69%* | 43%* | 21% | 14% | | C | 36%* | 11% | 9% | 37%* | 19% | 61% | 66%* | 73%* | 66%* |
*, denotes the 2 most common microorganism and resistance pattern in the institution.
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