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Master of Public Health

Prophylactic Antibiotic Duration and Infectious Complications in Pancreatoduodenectomy Patients with Biliary Stents: Opportunity for De-Escalation

AUTHORS

Boyev A , Arvide EM , Newhook TE , Prakash LR , Bruno ML , Dewhurst WL , Kim MP , Maxwell JE , Ikoma N , Snyder RA , Lee JE , Katz MHG , Tzeng CD , . Annals of surgery. 2023 7 3; ().

ABSTRACT

OBJECTIVE: This study’s aim was to compare infectious complications in pancreatoduodenectomy (PD) patients with biliary stents treated with short, medium, or long durations of prophylactic antibiotics.

SUMMARY/BACKGROUND DATA: Pre-existing biliary stents have historically been associated with higher infection risk after PD. Patients are administered prophylactic antibiotics, but the optimal duration remains unknown.

METHODS: This single-institution retrospective cohort study included consecutive PD patients from October 2016 to April 2022. Antibiotics were continued past the operative dose per surgeon discretion. Infection rates were compared by short (≤24 h), medium (>24 but ≤96 h) and long (>96 h) duration antibiotics. Multivariable regression analysis was performed to evaluate associations with a primary composite outcome of wound infection, organ-space infection, sepsis, or cholangitis.

RESULTS: Among 542 PD patients, 310 (57%) had biliary stents. The composite outcome occurred in 28% (34/122) short, 25% (27/108) medium, and 29% (23/80) long duration (P=0.824) antibiotic patients. There were no differences in other infection rates or mortality. On multivariable analysis, antibiotic duration was not associated with infection rate. Only postoperative pancreatic fistula (OR 33.1, P<0.001) and male sex (OR 1.9, P=0.028) were associated with the composite outcome.

CONCLUSIONS: Among 310 PD patients with biliary stents, long duration prophylactic antibiotics were associated with similar composite infection rates to short and medium durations but were used almost twice as often in high-risk patients. These findings may represent an opportunity to de-escalate antibiotic coverage and promote risk-stratified antibiotic stewardship in stented patients by aligning antibiotic duration with risk-stratified pancreatectomy clinical pathways.

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