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Antibiotic prophylaxis and infection treatment in cephalic duodenopancreatectomy : case series from a tertiary hospital in Portugal (2017-2020) and protocol proposal
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Resumo(s)
Apesar dos avanços na técnica cirúrgica da duodenopancreatectomia cefálica, as complicações peri-operatórias continuam a ser uma causa major de morbimortalidade nestes doentes. As infeções são como as mais comuns e requerem, muitas vezes, longos
cursos de antibioterapia, prolongando os internamentos e custos inerentes. Este trabalho visa analisar a casuística do Hospital de Santa Maria entre 2017 e 2020, por forma a traçar o perfil microbiológico e o padrão de resistência das bacteriobilias e das infeções e os fatores preditores de infeção nestes doentes, nomeadamente no que concerne a meios complementares de diagnóstico invasivos. Interpretando os dados, pretendemos definir novas estratégias para adequar a profilaxia cirúrgica e o tratamento empírico das complicações infecciosas, ajustando-os à epidemiologia local,
conforme já sugerido em estudos anteriores. De acordo com o nosso estudo, a
Colangiopancreatografia Retrógrada Endoscópica aumenta a taxa de bacteriobilia. A
profilaxia cirúrgica preconizada nas guidelines internacionais tem uma taxa de eficácia
de 5.9%. Propomos a colheita de amostras de bílis pós-manipulação em CPRE e estudo de colonização retal de Enterobacterales produtoras de carbapenemases e/ou Enterococci resistentes à vancomicina, para ajuste da profilaxia cirúrgica no âmbito de uma consulta pré-operatória de Infecciologia (integrada no Programa de Prevenção e Controlo de Infeções e Resistência aos Antimicrobianos nacional). Se estes dados não estiverem disponíveis, sugerimos profilaxia cirúrgica com piperacilina/tazobactam (e tigeciclina se fatores de risco associados). Sugerimos ainda a colheita de amostras de bílis durante a cirurgia e tratamento da bacteriobilia. As infeções deverão ser tratadas de acordo com os agentes isolados na bacteriobilia ou, se indisponível, com meropenem, amicacina e vancomicina, até estarem disponíveis os resultados culturais.
Despite the advances in the surgical technique of cephalic duodenopancreatectomy, perioperative complications remain a major cause of morbimortality in these patients. The most common complications are infectious and usually require long courses of antibiotics as well as long hospital stays, which have huge costs. This work aims to analyze the cases of Hospital de Santa Maria between 2017 and 2020 to outline the microbiological profile and resistance patterns of both the bacteriobilias and the infections in these patients. We also analyzed predictive factors of infection, namely invasive procedures. After analyzing the data, we plan to define new strategies to tailor antibiotic prophylaxis and empirical treatment of infectious complications, according to local epidemiological data, which had been suggested in previous studies already. According to our data, it seems Endoscopic Retrograde Cholangiopancreatography increases the rate of bacteriobilia. Surgical prophylaxis advocated in international guidelines has an efficacy rate of 5.9%. We suggest routine collection of bile samples after ERCP procedures and, combined with rectal colonization of the patients (for carbapenemase-producing Enterobacterales and/or Vancomycin-resistant Enterococci), later adjustment of surgical prophylaxis in a pre-operative Infectious Disease Consultation integrated in the National Program for Infection Control and Prevention of Antimicrobial Resistance. If these data are unavailable, then patients should receive prophylaxis with piperacillin/tazobactam (plus tigecycline depending on the risk factors). Additionally, we suggest routinely collection of bile samples intra-operatively and later treatment of bacteriobilia. Infectious complications should be treated according to bacteriobilia isolates or, if unavailable, with meropenem plus amikacin and vancomycin, until culture results are available.
Despite the advances in the surgical technique of cephalic duodenopancreatectomy, perioperative complications remain a major cause of morbimortality in these patients. The most common complications are infectious and usually require long courses of antibiotics as well as long hospital stays, which have huge costs. This work aims to analyze the cases of Hospital de Santa Maria between 2017 and 2020 to outline the microbiological profile and resistance patterns of both the bacteriobilias and the infections in these patients. We also analyzed predictive factors of infection, namely invasive procedures. After analyzing the data, we plan to define new strategies to tailor antibiotic prophylaxis and empirical treatment of infectious complications, according to local epidemiological data, which had been suggested in previous studies already. According to our data, it seems Endoscopic Retrograde Cholangiopancreatography increases the rate of bacteriobilia. Surgical prophylaxis advocated in international guidelines has an efficacy rate of 5.9%. We suggest routine collection of bile samples after ERCP procedures and, combined with rectal colonization of the patients (for carbapenemase-producing Enterobacterales and/or Vancomycin-resistant Enterococci), later adjustment of surgical prophylaxis in a pre-operative Infectious Disease Consultation integrated in the National Program for Infection Control and Prevention of Antimicrobial Resistance. If these data are unavailable, then patients should receive prophylaxis with piperacillin/tazobactam (plus tigecycline depending on the risk factors). Additionally, we suggest routinely collection of bile samples intra-operatively and later treatment of bacteriobilia. Infectious complications should be treated according to bacteriobilia isolates or, if unavailable, with meropenem plus amikacin and vancomycin, until culture results are available.
Descrição
Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2021
Palavras-chave
Duodenopancreatectomia Profilaxia Antibióticos Infeção Bacteriobilia