Influence of bacteriobilia on postoperative complications in patients with periampullary tumors

BACKGROUND

Periampullary tumours (PAT) may cause obstruction of distal choledochus. The bile stasis is a risk factor for microbial colonisation of bile (bacteriobilia), cholangitis, hepatic insufficiency and coagulopathy. PAT obstruction can be managed surgically or non-operatively - by inserting a biliary drain or stent (BDS). Although BDS allows for adequate bile drainage, liver function restitution and coagulopathy, increased bacteriobilia has been reported and this is associated with an increased incidence of postoperative complications.

METHODS

A monocentric, prospective, comparative study including 100 patients operated with PAT. The effects of bacteriobilia and the presence of a drain in the biliary tract on the development of postoperative complications were evaluated.

RESULTS

Positive microbial findings in bile were found in 67% of patients. It was 98% in the biliary drain group vs. 36% in non-drained patients (p = 0.0001). In 68% 2 or more different bacterial strains were simultaneously present (p = 0.0001). Patients with a positive microbial finding in bile had more frequent incidence of infectious complications 40.2% (27) vs. 9.1% (3); p = 0.0011. The most frequent infectious complication was wound infection 29.8% (20) vs. 3.03% (1); p = 0.0014. Similarly, a higher incidence of postoperative infectious complications occurred in patients with BDS - 36% (18) vs. 24% (12); p = 0.2752.

CONCLUSION

The presence of a drain or stent in the biliary tract significantly increases the microbial colonisation of bile. It is associated with a significant increase in infectious complications, especially infections in the wound.

Effect of Intraoperatively Detected Bacteriobilia on Surgical Outcomes After Pancreatoduodenectomy: Analysis of a Prospective Database in a Single Institute

BACKGROUND

Bacteriobilia, the colonization of bacteria in bile, can be caused by obstructive cholangitis or preoperative biliary drainage (PBD), and is not uncommon condition in patients undergoing pancreatoduodenectomy (PD). This study aims to investigate the effect of intraoperatively detected bacteriobilia on surgical outcomes after PD.

METHODS

For patients who underwent PD in Samsung Medical Center between 2018 and 2020, an intraoperative bile culture was performed prospectively, and their clinicopathological data were retrospectively reviewed. Surgical outcomes were compared between the patients, classified according to PBD and bacteriobilia. Logistic regression analysis was performed to identify factors increasing postoperative complications.

RESULTS

A total of 382 patients were included, and 202 (52.9%) patients had PBD (PBD group). Bacteriobilia was significantly more common in PBD group comparing to non-PBD group (31.1% vs 75.2%, P < 0.001), but there was no difference in postoperative complications. Among PBD group, there were more patients with major complications and CR-POPF in endoscopic drainage group comparing to percutaneous drainage group (37.9% vs 14.6%, P = 0.002; 17.0% vs 4.2%, P = 0.025, respectively). In multivariable analysis, bacteriobilia increased the risk of wound complications (P = 0.041), but not the risks of other short-term adverse outcomes.

CONCLUSION

Bacteriobilia itself does not exacerbate short-term postoperative outcomes after PD except for wound complication. Therefore, surgery could be performed as planned regardless of bacteriobilia, without the need to wait for negative cultures.

Bacterial flora in the bile: Clinical implications and sensitivity pattern from a tertiary care centre

BACKGROUND

Though preoperative biliary drainage (PBD) has been suggested to be linked with increased perioperative morbidity it is still practiced commonly. We studied the association of PBD and positive biliary culture with surgical site infection and also analysed the common pathogens and their antibiotic sensitivity spectrum.

METHODS

Prospectively maintained data of patients who underwent various pancreatobiliary surgeries from 2017 to 2019 was analysed. Patients whose intraoperative bile culture reports were available were included in the study. Various factors associated with surgical site infection (SSI), microbial spectrum of bile culture and their sensitivity pattern were analysed.

RESULTS

Out of 68 patients whose bile culture report were available, PBD was done in 65% (n = 44). Among patients with infected bile (n = 51), biliary stent was present in 78.4% (n = 40). On univariate analysis, the factors associated with SSI were low albumin level (<3.5 mg%), long operative time (>6 h), duration of abdominal drain (>4 days), length of hospital stay, intraoperative bile spillage and infected bile. However, on multivariate analysis, only presence of drain for >4 days (p = 0.04) and positive bile culture (p = 0.02) was linked with increased risk of SSI. Most common organism isolated was E coli (73.2%), with 100% sensitivity to Colistin and Tigecycline shown by gram negative isolates.

CONCLUSION

Preoperative biliary stenting alone did not increase the risk of SSI, but the positive bile culture correlated with SSI irrespective of PBD. Most biliary pathogens were resistant to commonly used antibiotics and intraoperative bile culture will aid in providing appropriate antibiotic coverage.

Antibiotic prophylaxis in acute cholecystectomy revisited: results of a double-blind randomised controlled trial

Purpose

Evidence supporting the value of preoperative antibiotic prophylaxis (PAP) in surgery for acute cholecystitis is lacking. This study aimed to shed light on whether PAP in acute cholecystectomy for cholecystitis reduces the postoperative infectious complication (PIC) rate. Secondary outcomes were the prevalence of bacteriobilia, CRP values and leucocyte counts.

Methods

The study was performed as a single-centre, double-blinded, placebo-controlled, randomised study. Patients with acute cholecystitis amenable for acute laparoscopic cholecystectomy were randomly assigned to either PAP (piperacillin/ tazobactam) or placebo, and the subsequent clinical course was followed.

Results

A total of 106 patients were enrolled, 16 of whom were excluded due to protocol violation. PIC developed in 22 of the 90 patients included with no significant difference between the PAP and placebo groups (8 patients in the PAP group and 14 in the placebo arm, p = 0.193). The PIC rate was significantly higher in patients with a raised CRP at randomisation and on the day of surgery and in cases of conversion to an open procedure (p = 0.008, 0.004 and 0.017, respectively) but with no differences between the study groups.

Conclusion

PAP does not affect the risk for PIC in patients with acute cholecystitis. The major risk factors determining PIC in these patients need defining, in particular, the impact of bacteriobilia.

Trial registration

The study was registered at clinicaltrials.gov (NCT02619149) December 2, 2015.

Bacteriobilia resistance to antibiotic prophylaxis increases morbidity after pancreaticoduodenectomy: a monocentric retrospective study of 128 patients

Several studies attempted to determine whether there is a relationship between the use of preoperative biliary drainage and morbidity after pancreaticoduodenectomy (PD). We retrospectively evaluated post-PD outcome in patients with and without preoperative biliary drainage and the role of bacteriobilia and antibiotic prophylaxis in post-operative complications. Data relating to the PDs performed at the Hepato-Bilio-Pancreatic Surgical Department of Treviso Hospital between 2010 and 2017 were retrospectively evaluated. Morbidity and intra-hospital mortality related to preoperative biliary stent were the primary outcomes. Between 2010 and 2017, 128 patients (mean age 68 years) underwent PD; 72 were treated with early surgery (ES) and 56 underwent preoperative biliary drainage (PBD). Overall morbidity was 50% in the ES cohort and 43% in the PBD (ns, p = 0.43). In the PBD group, bacteriobilia was found in the 100% of the bile cultures (48; 8 unavailable). The microbiota was represented by: Klebsiella spp (48%), Enterococcus spp (29%), E. coli (27%) and Candida spp (21%). In 52% of cases, at least one of the isolated bacteria was resistant to the perioperative antibiotic prophylaxis (69% of cases Amoxicillin-Clavulanic Ac.). The majority of postoperative surgical complications occurred in patients with prophylaxis-resistant bacteriobilia (68% vs 39%; p = 0.04). Antibiotic resistance is a determining factor in morbidity after PD. We therefore propose to pay particular attention to the preoperative prophylaxis, diversifying it between drained and non-drained patients. In fact, in the former, appropriate broad spectrum preoperative antibiotic coverage is strongly suggested.

Bacterobilia in pancreatic surgery-conclusions for perioperative antibiotic prophylaxis

BACKGROUND

Jaundice or preoperative cholestasis (PC) are typical symptoms of pancreatic masses. Approximately 50% of patients undergo preoperative biliary drainage (PBD) placement. PBD is a common cause of bacterobilia (BB) and is a known surgical site infection risk factor. An adjustment of preoperative antibiotic prophylaxis (PAP) may be reasonable according to the profile of BB. For this, we examined the microbiological findings in routine series of patients.

AIM

To investigate the incidence and profile of biliary bacterial colonization in patients undergoing pancreatic head resections.

METHODS

In the period from January 2009 to December 2015, 285 consecutive pancreatic head resections were performed. Indications for surgery were malignancy (71%), chronic pancreatitis (18%), and others (11%). A PBD was in 51% and PC was in 42%. The standard PAP was ampicillin/sulbactam. Intraoperatively, a smear was taken from the hepatic duct. An analysis of the isolated species and resistograms was performed. Patients were categorized according to the presence or absence of PC (PC+/PC-) and PBD (PBD+/PBD-) into four groups. Antibiotic efficiency was analyzed for standard PAP and possible alternatives.

RESULTS

BB was present in 150 patients (53%). BB was significantly more frequent in PBD+ (n =120) than in PBD- (n = 30), P < 0.01. BB was present both in patients with PC and without PC: (PBD-/PC-: 18%, PBD-/PC+: 30%, PBD+/PC-: 88%, PBD+/PC+: 80%). BB was more frequent in malignancy (56%) than in chronic pancreatitis (45%). PBD, however, was the only independent risk factor in multivariate analysis. In total, 357 pathogens (342 bacteria and 15 fungi) were detected. The five most common groups (n = 256, 74.8%) were Enterococcus spp. (28.4%), Streptococcus spp. (16.9%), Klebsiella spp. (12.6%), Escherichia coli (10.5%), and Enterobacter spp. (6.4%). A polymicrobial BB (PBD+: 77% vs PBD-: 40%, P < 0.01) and a more frequent detection of Enterococcus (P < 0.05) was significantly associated with PBD+. In PBD+, the efficiency of imipenem and piperacillin/tazobactam was significantly higher than that of the standard PAP (P < 0.01).

CONCLUSION

PBD-/PC- and PBD-/PC+ were associated with a low rate of BB, while PBD+ was always associated with a high rate of BB. In PBD+ patients, BB was polymicrobial and more often associated with Enterococcus. In PBD+, the spectrum of potential bacteria may not be covered by standard PAP. A more potent alternative for prophylactic application, however, was not found.

Evaluation of Streptococcus pneumoniae in bile samples: A case series review

Although Streptococcus pneumoniae is an important pathogen of humans, pneumococcal cholangitis is rare because of the rapid autolysis of S. pneumoniae. The aim of this case series was to review patients with bile cultures positive for S. pneumoniae. This study was a single center retrospective case series review of patients with S. pneumoniae in their bile at a tertiary-care cancer center between September 2002 and August 2015. Subjects consisted of all patients in whom S. pneumoniae was isolated in their bile during the study period. Bile specimens for culture were obtained from biliary drainage procedures such as endoscopic retrograde biliary drainage, endoscopic nasobiliary drainage, and percutaneous transhepatic biliary drainage. There were 20 patients with bile cultures positive for S. pneumoniae during the study period. All patients presented with extrahepatic obstructive jaundice due to hepatopancreatobiliary tumors. Nineteen of 20 patients underwent the placement of plastic intrabiliary tubes. The mean time between the first-time drainage and the positive culture was 26 days (range 0-313 days). Although 12 of 20 patients met our definition of cholangitis, 5 were clinically treated with antibiotics based on a physician's assessment of whether there was a true infection. The present study is the largest case series of patients with S. pneumoniae in their bile. Based on our findings, the isolation of S. pneumoniae from bile may be attributed to the placement of biliary drainage devices.

Risk factors of organ failure in cholangitis with bacteriobilia

AIM: To identify the risk factors for organ failure (OF) in cholangitis with bacteriobilia.

METHODS: This study included 182 patients with acute cholangitis who underwent percutaneous transhepatic biliary drainage between January 2005 and April 2013. We conducted a retrospective analysis of comprehensive clinical and laboratory data.

RESULTS: There were 24 cases (13.2%) of OF and five deaths (2.7%). Bile culture was positive for microbial growth in 130 out of 138 (94.2%) patients. In multivariate analysis of 130 patients with positive bile cultures, significant predictive factors for OF were the presence of extended-spectrum beta-lactamase (ESBL) organisms in blood cultures, pre-existing renal dysfunction, and choledocholithiasis as an etiology, with odds ratios of 15.376, 6.319, and 3.573, respectively. We developed a scoring system with a regression coefficient of each significant variable. The OF score was calculated using the following equation: (2.7 × ESBL organisms in blood cultures) + (1.8 × pre-existing renal dysfunction) + (1.3 × choledocholithiasis). This scoring system for predicting OF was highly specific (99.1%) and had a positive predictive value of 86.2%.

CONCLUSION: ESBL organisms in blood cultures, pre-existing renal dysfunction, and choledocholithiasis are risk factors for OF in cholangitis with bacteriobilia. The OF scoring system may aid clinicians to identify a poor prognosis group.

Microbial profile and antibiotic sensitivity pattern in bile cultures from endoscopic retrograde cholangiography patients

AIM: To identify the frequency of bacterial growth, the most commonly grown bacteria and their antibiotic susceptibility, and risk factors for bacterial colonization in bile collected from patients with different biliary diseases.

METHODS: This prospective study was conducted between April 2010 and August 2011. Patients with various biliary disorders were included. Bile was aspirated by placing a single-use, 5F, standard sphincterotome catheter into the bile duct before the injection of contrast agent during endoscopic retrograde cholangiopancreaticography (ERCP). Bile specimens were transported to the microbiology laboratory in blood culture bottles within an anaerobic transport system. Bacteria were cultured and identified according to the standard protocol used in our clinical microbiology laboratory. The susceptibilities of the organisms recovered were identified using antimicrobial disks, chosen according to the initial gram stain of the positive cultures.

RESULTS: Ninety-one patients (27% male, mean age 53.7 ± 17.5 years, range: 17-86 years) were included in the study. The main indication for ERCP was benign biliary disease in 79 patients and malignant disease in 12 patients. The bile culture was positive for bacterial growth in 46 out of 91 (50.5%) patients. The most frequently encountered organisms were Gram-negative bacteria including Escherichia coli (28.2%), Pseudomonas (17.3%) and Stenotrophomonas maltophilia (15.2%). There were no significant differences between patients with malignant and benign disease (58% vs 49%, P = 0.474), patients with acute cholangitis and without acute cholangitis (52.9% vs 50%, P = 0.827), patients who were empirically administered antibiotics before intervention and not administered (51.4% vs 60.7%, P = 0.384), with regard to the bacteriobilia. We observed a large covering spectrum or low resistance to meropenem, amikacin and imipenem.

CONCLUSION: We did not find a significant risk factor for bacteriobilia in patients with biliary obstruction. A bile sample for microbiological analysis may become a valuable diagnostic tool as it leads to more accurate selection of antibiotics for the treatment of cholangitis.