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Background
Abdominal surgical site infections, often defined as organ/space surgical site infections (OSI), and postoperative pancreatic fistula (POPF) account for the majority of the postoperative morbidity after pancreatoduodenectomy [1, 2]. POPF correlates with 72–80% of the OSI after pancreatoduodenectomy, whereas isolated (non-POPF) OSI occur in 7–18% of the patients [2, 3]. Contaminated bile during pancreatoduodenectomy is present in the vast majority of patients with preoperative biliary drainage (± 95%) or an ampullary malignancy (± 90%) [3, 4]. As contaminated bile is associated with OSI and clinically relevant (grade B/C) POPF following pancreatoduodenectomy, appropriate antibiotic prophylaxis is presumed to reduce OSI and grade B/C POPF in these patients [1, 4, 5–6].
The updated Enhanced Recovery After Surgery protocol recommends considering pre-emptive antibiotic treatment in patients that have contaminated bile [7]. In a survey amongst all surgical centres of the Dutch Pancreatic Cancer Group (n = 15, 100% response rate), we found that seven centres (47%) only used perioperative antibiotic prophylaxis for pancreatoduodenectomy, and eight centres (53%) used perioperative and pre-emptive antibiotic treatment following pancreatoduodenectomy (Fig. 1A). Pre-emptive antibiotic treatment was indicated for all patients undergoing pancreatoduodenectomy in three centres (37.5%) and only for patients after preoperative biliary drainage in five centres (62.5%, Fig. 1A). The antibiotic agents used as pre-emptive antibiotic treatment varied substantially (Fig. 1B). Also, the duration of pre-emptive antibiotic course ranged from 48 h in one centre (12.5%), 72 h in three centres (33.3%) to 5 days in four centres (50%, Fig. 1C). Altogether, the antibiotic prophylactic regimes for pancreatoduodenectomy vary remarkably between Dutch centres, and a clinical equipoise exists regarding the evidence and consensus on the effectiveness of pre-emptive antibiotic treatment.
Fig. 1 [Images not available. See PDF.]
Pre-emptive antibiotic treatment after pancreaticoduodenectomy in 15 Dutch pancreatic surgery centres. The use of pre-emptive treatment for pancreatoduodenectomy in the Netherlands. A Use of only perioperative antibiotic prophylaxis versus pre-emptive antibiotic treatment in centres and the indication for pre-emptive antibiotic treatment. B Type of antibiotic agent used as pre-emptive antibiotic treatment. C Duration of pre-emptive antibiotic treatment
The effect of pre-emptive antibiotic treatment for pancreatoduodenectomy was evaluated in a meta-analysis demonstrating a 42 to 21% decrease in both abdominal and wound infections in patients receiving antibiotic prophylaxis based on previously obtained bile cultures [8]. As bile...