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Hepato-pancreato-biliary

E203: SSI Prophylaxis with 1st Generation Cephalosporins is Non-inferior to Broad-spectrum Antibiotics in Distal Pancreatectomy

Introduction: Recent research supports broad-spectrum antibiotic (BSA) prophylaxis in pancreatoduodenectomy. Surgical site infection (SSI) rates are lower for distal pancreatectomy (DP) with higher rates of minimally invasive surgery (MIS) and the optimal antibiotic prophylaxis choice for MIS and open DP remain poorly understood. Our objective is to characterize perioperative antibiotic use and SSI occurrence among open and MIS PD patients.

Methods: The 2015-2020 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) pancreatectomy participant data use file was queried for open and MIS DP cases. Patients were excluded if preoperative antibiotic was coded as none, other or unknown. The MIS and open DP cohorts were compared for baseline characteristics and SSI rates using chi squared and multivariable logistic regression.

Results:

Of 10844 patients, 5776 (53%) underwent open DP and 5086 (47%) underwent MIS DP. In the open group, antibiotics included 1st generation (gen) cephalosporin in 45%, 2nd/3rd gen cephalosporin in 30%, and BSA in 24%. In the MIS group, antibiotics included 1st gen cephalosporin in 50%, 2nd/3rd gen cephalosporin in 20%, and BSA in 29%. On univariate analysis, rates of SSI were higher in the open cohort, including those with 1st gen cephalosporins (14% vs. 11%), 2nd/3rd gen cephalosporins (16% vs. 13%) and broad spectrum (15% vs. 12%, all p≤0.05). SSI rates did not differ significantly by antibiotic between open and MIS groups.

 

On multivariate analyses for any SSI, MIS was associated with lower odds of any-SSI compared to the open approach (OR 0.8, 95% CI 0.7-0.8), but antibiotic choice was not significant. Significantly higher odds of SSI were also observed for those with obesity with body mass index (BMI) 30-40 kg/m2 (OR 1.4, CI 1.2-1.7) and severe obesity with BMI > 40 kg/m2 (OR 1.8, CI 1.5-2.1) compared to normal BMI, as well as those with a biliary stent versus no stent (OR: 2.1, 1.7-2.7). Subgroup univariate analysis within the high-risk group with BMI > 30 kg/m2 showed no decreased association of SSI with BSA (Table 1).

Conclusions:

In contrast to prophylaxis for Whipples, broad-spectrum antiobiotic coverage was not associated with lower SSI rates for DP. Routine antibiotic prophylaxis with a 1st generation cephalosporin provides adequate coverage for DP. Overuse of BSA may increase antibiotic resistance and should be avoided. Although patients with biliary stents and BMI > 30 are at higher risk for SSI, there was no evidence that broader coverage in these patient was associated with lower SSI rates.

Learning Objectives:

  • Upon completion, participants will be able to describe variations in utilization of antibiotic prophylaxis among patients undergoing a distal pancreatectomy.
  • Upon completion, participants will be able to recognize that preoperative prophylaxis with broad spectrum antibiotics may not provide the same benefit in distal pancreatectomy patients as in those undergoing pancreatoduodenectomy.
  • Upon completion, participants will be able to recognize patients that are higher risk for surgical site infections among patients undergoing distal pancreatectomy.